Decompressive craniectomy in head injury

Comparative effectiveness of different surgical procedures for traumatic acute epidural haematoma: study protocol for Prospective, Observational Real-world Treatments of AEDH in Large-scale Surgical Cases (PORTALS-AEDH)

INTRODUCTION

Controversy and variation exist in surgical management for acute epidural haematoma (AEDH). Although craniotomy for AEDH is conventionally employed, no specific evaluation on the necessity of decompressive craniectomy (DC) followed by AEDH evacuation has been performed.

METHODS AND ANALYSIS

This is a multicentre prospective, phase III observational study that evaluates different surgical managements for the AEDH. Patients of both genders, aged 18-65 years, presenting to the emergency room with a clinical and radiological diagnosis of AEDH, complying with other inclusion and exclusion criteria, are enrolled. Clinical information, including diagnosis of AEDH, radiological information, treatment procedures and follow-up data of 1, 3 and 6 months post-injury, is collected on 2000 eligible patients among 263 hospitals in China. Recruitment for the study started in April 2021, and inclusion will be continued until the sample size is obtained, expected is an inclusion period of 24 months. The interventions of concern are surgical treatments for AEDH, including craniotomy and DC. The primary outcome is the Glasgow Outcome Score-Extended 6 months post-injury. Secondary outcomes include the incidence of postoperative cerebral infarction, the incidence of additional craniocerebral surgery and other evaluation indicators within 6 months post-injury.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethics committee and institutional review board of Renji Hospital, School of Medicine, Shanghai Jiao Tong University. All study investigators strictly follow the Declaration of Helsinki and Human Biomedical Research Ethical Issues. Signed written informed consent will be obtained from all enrolled patients. The trial results will be disseminated through academic conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04229966.

Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial

Background

The expeditious surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical options for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted with the decision to evacuate the hematoma with decompressive craniectomy (DC) or craniotomy.

Methods/design

Patients of both sexes, age between 18 and 65 years, who presented to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, were assessed against the inclusion and exclusion criteria to be enrolled in the study. Clinical and radiological information, including diagnosis of AEDH, treatment procedures, and follow-up data at 1, 3, and 6 months after injury, was collected from 120 eligible patients in 51 centers. The patients were randomized into groups of DC versus craniotomy in a 1:1 ratio. The primary outcome was the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes included incidence of postoperative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicators within 6 months post-injury.

Discussion

This study is expected to support neurosurgeons in their decision to evacuate the epidural hematoma with or without a DC, especially in patients with brain herniation, and provide additional evidence to improve the knowledge in clinical practice.

Trial registration

ClinicalTrials.govNCT 04261673. Registered on 04 February 2020

EVALUATION OF THE RADIATION EXPOSURE IN SEQUENTIAL HEAD TOMOGRAPHIC EXAMS OF PATIENTS WITH TRAUMATIC BRAIN INJURY AND DECOMPRESSIVE CRANIECTOMY

Brain trauma patients who underwent decompressive craniectomy make several computed tomography (CT) scans until cranioplasty. Despite several recommendations to avoid unnecessary radiological exposure, few studies systematically analyzed the technical parameters employed. CT exams of 14 patients were retrospectively analyzed to find display field of view (DFOV), dose length product (DLP), volume computed tomography dose index (CTDIvol) and effective dose (ED). The values obtained were: 120 kVp [95% confidence interval (CI) of 0.5], 297 mA (95% CI of 5.6), scan range 20.8 cm (95% CI of 1.3), DFOV 24.5 cm (95% CI of 1.6), CTDIvol 67.5 mGy (95% CI of 10.17), DLP 1404.8 mGy.cm (95% CI of 235.0) and ED 2.9 mSv (95% CI of 0.5). In conclusion, these values were above the recommendations of several guidelines and raise concern for excessive radiological exposure in trauma patients despite being previously reported in the literature.

Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury

BACKGROUND

High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy).

OBJECTIVES

To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP.

SEARCH METHODS

The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts.

SELECTION CRITERIA

We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care.

DATA COLLECTION AND ANALYSIS

We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach.

MAIN RESULTS

We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I² = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I² = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I² value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I² = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I² = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events.

AUTHORS' CONCLUSIONS

Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.

Calvarial fracture patterns on CT imaging predict risk of a delayed epidural hematoma following decompressive craniectomy for traumatic brain injury

BACKGROUND AND PURPOSE

The development of a delayed epidural hematoma as a result of decompressive craniectomy represents an urgent and potentially lethal complication in traumatic brain injury. The goal of this study was to determine the incidence of delayed epidural hematoma and whether patterns of skull fractures on the preoperative CT scan could predict risk of a delayed epidural hematoma.

MATERIALS AND METHODS

We retrospectively evaluated medical records and imaging studies for patients with acute traumatic brain injury who underwent a decompressive craniectomy during a 9-year period. We compared patterns of skull fractures contralateral to the side of the craniectomy with the occurrence of a postoperative delayed epidural hematoma.

RESULTS

In a series of 203 patients undergoing decompressive craniectomy for acute traumatic brain injury, the incidence of a delayed epidural hematoma complication was 6% (12 of 203). All 12 patients who developed a delayed epidural hematoma had a contralateral calvarial fracture on preoperative CT at the site where the delayed epidural hematoma subsequently formed. A contralateral calvarial fracture has perfect sensitivity (100%) for subsequent development of delayed epidural hematoma in our study population. Moreover, a contralateral calvarial fracture involving 2 or more bone plates had an especially high diagnostic odds ratio of 41 for delayed epidural hematoma.

CONCLUSIONS

Recognition of skull fracture patterns associated with delayed epidural hematoma following decompressive craniectomy may reduce morbidity and mortality by prompting early postoperative intervention in high-risk situations.

Technical considerations in decompressive craniectomy in the treatment of traumatic brain injury

Refractory intracranial hypertension is a leading cause of poor neurological outcomes in patients with severe traumatic brain injury. Decompressive craniectomy has been used in the management of refractory intracranial hypertension for about a century, and is presently one of the most important methods for its control. However, there is still a lack of conclusive evidence for its efficacy in terms of patient outcome. In this article, we focus on the technical aspects of decompressive craniectomy and review different methods for this procedure. Moreover, we review technical improvements in large decompressive craniectomy, which is currently recommended by most authors and is aimed at increasing the decompressive effect, avoiding surgical complications, and facilitating subsequent management. At present, in the absence of prospective randomized controlled trials to prove the role of decompressive craniectomy in the treatment of traumatic brain injury, these technical improvements are valuable.

In situ floating resin cranioplasty for cerebral decompression

The purpose of this report is to describe our surgical experiences in the treatment of cerebral decompression with in situ floating resin cranioplasty. We included in this retrospective study 7 patients who underwent in situ floating resin cranioplasty for cerebral decompression between December 2006 and March 2008. Of these patients, 3 patients had traumatic brain injury, 3 cerebral infarction, and one subarachnoid hemorrhage due to aneurysmal rupture. In situ floating resin cranioplasty for cerebral decompression can reduce complications related to the absence of a bone flap and allow reconstruction by secondary cranioplasty without difficulty. Furthermore, it provides cerebral protection and selectively eliminates the need for secondary cranioplasty in elderly patients or patients who have experienced unfavorable outcome.

Bi-occipital decompressive craniectomy in refractory post traumatic intracranial hypertension: first report of one case

Decompressive craniectomy (DC) is considered a 'second tier' therapy to control posttraumatic intracranial hypertension refractory to maximal medical treatment. The authors present a case of refractory intracranial hypertension due to diffuse brain swelling and a large (>25 ml) non-surgically-treatable haematoma of the splenium of the corpus callosum successfully treated with bi-occipital DC and augmentative duraplasty.

Comparison of the effect of decompressive craniectomy on different neurosurgical diseases

BACKGROUND

Many previous studies have reported that decompressive craniectomy has improved clinical outcomes in patients with intractable increased intracranial pressure (ICP) caused by various neurosurgical diseases. However there is no report that compares the effectiveness of the procedure in the different conditions. The authors performed decompressive craniectomy following a constant surgical indication and compared the clinical outcomes in different neurosurgical diseases.

MATERIALS AND METHODS

Seventy five patients who underwent decompressive craniectomy were analysed retrospectively. There were 28 with severe traumatic brain injury (TBI), 24 cases with massive intracerebral haemorrhage (ICH), and 23 cases with major infarction (MI). The surgical indications were GCS score less than 8 and/or a midline shift more than 6 mm on CT. The clinical outcomes were assessed on the basis of mortality and Glasgow Outcome Scale (GOS) scores. The changes of ventricular pressure related to the surgical intervention were also compared between the different disease groups.

FINDINGS

Clinical outcomes were evaluated 6 months after decompressive craniectomy. The mortality was 21.4% in patients with TBI, 25% in those with ICH and 60.9% in MI. A favourable outcome, i.e. GOS 4-5 (moderate disability or better) was observed in 16 (57.1%) patients with TBI, 12 (50%) with ICH and 7 (30.4%) with MI. The change of ventricular pressure after craniectomy and was 53.2 (reductions of 17.4%) and further reduced by 14.9% (with dural opening) and (24.8%) after returning to its recovery room, regardless of the diseases group.

CONCLUSIONS

According to the mortality and GOS scores, decompressive craniectomy with dural expansion was found to be more effective in patients with ICH or TBI than in the MI group. However, the ventricular pressure change during the decompressive craniectomy was similar in the different disease groups. The authors thought that decompressive craniectomy should be performed earlier for the major infarction patients.

Decompressive craniotomy: durotomy instead of duroplasty to reduce prolonged ICP elevation

BACKGROUND

Usually, decompressive craniectomy (DC) in patients with increased intracranial pressure (ICP) is combined with resection of the dura and large-scale duroplasty. However, duroplasty is cumbersome, lengthens operation time and requires heterologous or autologous material. In addition, the swelling brain could herniate into the duroplasty with kinking of the superficial veins at the sharp cutting edges and subsequent ICP exacerbation. Several longitudinal durotomies avoid these limitations, but it remains a matter of discussion if durotomies reduce ICP sufficiently.

METHODS

DC was performed in ten patients (mean age 45 years) with increased ICP after head trauma or subarachnoid hemorrhage. After craniectomy, the dura was opened by three to four durotomies from midline to the temporal base. Duration of surgical procedure and ICP during each surgical step and postoperatively were recorded.

FINDINGS

Mean duration of surgery was 90 +/- 10 min. ICP prior to skin incision was 39 +/- 12 mmHg and dropped to 22 +/- 9 mmHg after craniectomy. During durotomy ICP decreased stepwise and reached stable values of 12 +/- 6 mmHg at the end of surgery. On days 1-10 after surgery, ICP values ranged between 12-17 mmHg.

CONCLUSION

This study showed that durotomy is a fast and easy, but likewise effective method to lower ICP further after craniectomy.

Use of hinge craniotomy for cerebral decompression

✓Decompressive craniectomy to relieve cerebral edema and intracranial hypertension due to traumatic brain injury is a generally accepted practice; however, the procedure remains controversial because of its uncertain effects on outcome, specific complications such as the syndrome of the sinking skin flap, and the need for subsequent cranioplasty. The authors developed a novel craniotomy technique using titanium bone plates in a hinged fashion, which maintains cerebral protection while reducing postoperative complications and eliminating subsequent cranioplasty procedures.

The authors conducted a retrospective review of data obtained in all consecutive patients who had undergone post-traumatic cerebral decompression craniotomy using the hinge technique at a Level I trauma facility between 1990 and 2004.

Twenty-five patients, most of whom were male (88%) and Caucasian (88%) with a mean age of 38.2 ± 16.1 years, underwent the hinge craniotomy. The in-hospital mortality rate was 48%, and good cerebral decompression was achieved. None of the patients required surgery for flap replacement. Long-term follow-up data showed that one patient required subsequent cranioplasty due to infection and one patient presented with cranial deformities. None of the patients presented with bone resorption or sinking flap syndrome.

The hinge technique effectively prevents procedure-related morbidity and the need for subsequent surgical bone replacement otherwise introduced by traditional decompressive craniectomy. A randomized controlled trial is required to substantiate these findings.

Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma

Large cranial defects resulting from decompressive craniectomy performed for refractory intracranial hypertension after head trauma is one of the indications for cranioplasty, and this procedure is commonly performed 3 months after craniectomy. However, the large cranial defect would lead to the kinds of complications early during the phase of these patients' recovery, which would go against rehabilitation. This study retrospectively reviewed 23 patients undergoing early cranioplasty (5-8 weeks after craniectomy) in the last 4 years with a detailed choice of patients, outcome of complications after head trauma and large craniectomy, as well as assessment of prognosis. The early outcome (1 month later) revealed most of the patients who had conscious disturbance before the cranioplasty recovered their consciousness and presented an improved neurologic function. The long-dated prognosis (18 months later) revealed that 17 patients were good (independent patients) in this series (74%), whereas four patients survived with a severe disability (17%) and two remained in a vegetative state (9%). No dead patients or intracranial infection after the procedure were found in this study. Most patients' complications were relieved after the cranioplasty with improvements of symptoms or image of computed tomography scan. In conclusion, we consider that with the appropriate choice of patients and materials, early cranioplasty for large cranial defects after decompressive craniectomy would be safe and helpful for the improvement of patients' neurologic function and prognosis. To our knowledge, this series may be the first detailed report in English about early cranioplasty after decompressive craniectomy. We are going to perform prospective and retrospective contrastive studies to further confirm the effects of this procedure on the patients with large cranial defects after decompressive craniectomy.

[Decompressive craniectomy in children and adolescents with head injury: analysis of seven cases]

INTRODUCTION

Decompressive craniectomy (DC) is a surgical technique used to treat patients with elevated intracranial pressure often found in head injury. Its indication remains a controversial issue in the pediatric population.

OBJECTIVE

To report seven cases managed with this technique.

METHOD

Retrospective study of seven patients, aged from 2 to 17 years, treated with unilateral DC due to increased intracranial pressure (ICP) as a consequence of head injury. All patients had ICP monitored post operatively and the DC classified as ultra-early (<6h), early (6-12h) or late (>24h) according to the time of its application. The minimum follow-up was six months.

RESULTS

Patients were evaluated with CT scans and clinical exams, and graded according the Glasgow Outcome Scale (GOS). Three patients deceased (GOS1), one was in vegetative state (GOS2), two recovered but still requiring nursing care (GOS3 and 4), and one had a full recovery (GOS5) at hospital discharge. After six months the GOS2 and a GOS3 patients achieved full recovery (GOS5). Subdural collection (2), hydrocephalus (1) and superficial infection (1) occurred as complication. Two patients had autologous cranioplasty and the other two heterologous cranioplasty.

CONCLUSION

Decompressive craniectomy remains a feasible treatment method to lower the ICP, but is not safe from complications. A multicentric study should be done for appropriate protocol treatment of pediatric patients.

[Management of severe traumatic brain injury]

Severe brain injuries, most often occurring in young subjects, are a major source of lost work years. These injuries are medical and surgical emergencies. Prehospital management of severe brain injuries requires intubation and mechanical ventilation aimed at normal arterial carbon dioxide pressure. Signs of transtentorial herniation: Uni- or bilateral mydriasis requires immediate perfusion of 20% mannitol or hypertonic sodium chloride. Neurological disorders after head injury justify emergency cerebral computed tomography. The presence of a mass syndrome or signs of transtentorial herniation are in principle indications for surgery. Specialized hospital management is essential. In the case of refractory intracranial hypertension, the cerebral perfusion pressure and osmotherapy should be adapted to the volume of the cerebral contusion. The use of deep hypothermia and barbiturates should be minimized as much as possible. Magnetic resonance imaging makes it possible to identify the cerebral lesions.

Treatment leading to dramatic recovery in acute hemorrhagic leukoencephalitis

The clinical course, neuroimaging, neuropathological features, and management of a 7-year-old girl with acute hemorrhagic leukoencephalitis are reported. Treatment with subtotal bifrontal craniectomies for symptoms of imminent uncal herniation followed by high-dose corticosteroid therapy was associated with dramatic clinical recovery. This report highlights the utility of aggressive intervention in acute hemorrhagic leukoencephalitis, an otherwise fatal disorder.

Neurosurgical history: Comparing the management of penetrating head injury in 1969 with 2005

Penetrating head trauma may present challenging problems in the acute phase (removal of foreign bodies, control of haemorrhage, prevention of infection) and in the management of long-term sequelae (neurological deficit, cognitive impairment, seizures). Two unusual cases demonstrate the progress made in emergency medicine, radiology neurointensive care, and neurosurgical head injury management over 36 years.

Decompressive craniectomy in traumatic brain injury: the randomized multicenter RESCUEicp study (www.RESCUEicp.com)

The RESCUEicp (Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of intracranial pressure) study has been established to determine whether decompressive craniectomy has a role in the management of patients with traumatic brain injury and raised intracranial pressure that does not respond to initial treatment measures. We describe the concept of decompressive craniectomy in traumatic brain injury and the rationale and protocol of the RESCUEicp study.

Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury

BACKGROUND

High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). High ICP is treated by general maneuvers (normothermia, sedation etc) and a set of first line therapeutic measures (moderate hypocapnia, mannitol etc). When these measures fail to control high ICP, second line therapies are started. Among these, second line therapies such as barbiturates, hyperventilation, moderate hypothermia or removal of a variable amount of skull bone (known as decompressive craniectomy) are used.

OBJECTIVES

To assess the effects of secondary decompressive craniectomy (DC) on outcome and quality of life in patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP.

SEARCH STRATEGY

We searched the Cochrane Injuries Group's Trial Register, CENTRAL, MEDLINE, EMBASE, Best Evidence, Clinical Practice Guidelines, PubMed, CINAHL, the National Research Register and Google Scholar. We also handsearched relevant conference proceedings and contacted experts in the field and the authors of included studies.

SELECTION CRITERIA

Randomized or quasi-randomized studies assessing patients over the age of 12 months with a severe TBI who underwent DC to control ICP refractory to conventional medical treatments.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the electronic search results for reports of possibly relevant trials and for retrieval in full. One author applied the selection criteria, performed the data extraction and assessed methodological quality. Study authors were contacted for additional information.

MAIN RESULTS

We found one trial with 27 participants conducted in the pediatric population (>18 years). DC was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72), and RR of 0.54 for death, vegetative status or severe disability 6 to 12 months after injury (95% CI 0.29 to 1.07).

AUTHORS' CONCLUSIONS

There is no evidence to support the routine use of secondary DC to reduce unfavourable outcome in adults with severe TBI and refractory high ICP. In the pediatric population DC reduces the risk of death and unfavourable outcome. Despite the wide confidence intervals for death and the small sample size of the only study identified, this treatment maybe justified in patients below the age of 18 when maximal medical treatment has failed to control ICP. To date, there are no results from randomised trials to confirm or refute the effectiveness of DC in adults. However, the results of non-randomized trials and controlled trials with historical controls involving adults, suggest that DC may be a useful option when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of DC (Rescue ICP and DECRAN) that may allow further conclusions on the efficacy of this procedure in adults.

Traumatic brain injury: physiology, mechanisms, and outcome

PURPOSE OF REVIEW

This review on traumatic brain injury consolidates the substantial current literature available on the pathophysiology, mechanisms, developments, and their subsequent effects on outcome. In particular, it tries to conceptualize why our greatly improved understanding of pathophysiology and neurobiology in traumatic brain injury has not translated into clear outcome improvements.

RECENT FINDINGS

Early cerebral ischaemia has been characterized further, with ischaemic brain volume correlating with 6-month outcome. The Brain Trauma Foundation has revised perfusion pressure targets, and there are additional data on the outcome impact of brain tissue oxygen response and asymmetric patterns of cerebral autoregulation. Mechanistic studies have highlighted the role of inflammation and introduced concepts such as therapeutic vaccination and immune modulation. Experimental neurogenesis and repair strategies show promise. Despite continuing gains in knowledge, the experimental successes have not yet translated to the clinic. Indeed, several major articles have attempted to understand the clinical failure of highly promising strategies such as hypothermia, and set out the framework for further studies (e.g. addressing decompressive craniectomy). High-dose mannitol has shown promise in poor grade patients, while hypertonic saline has shown better intracranial pressure control. Negative results may be the consequence of ineffective therapies. However, there is a gathering body of work that highlights the outcome impact of subtle neurocognitive changes, which may not be quantified adequately by outcome measures used in previous trials. Such knowledge has also informed improved definition of mild traumatic brain injury, and allowed validation of management guidelines.

SUMMARY

The evidence base for current therapies in this heterogeneous patient group is being refined, with greater emphasis on long-term functional outcomes. Improved monitoring techniques emphasize the need for individualization of therapeutic interventions.

Medical management of severe traumatic brain injury

This article reviews the current guidelines for the management of patients with severe traumatic brain injury from presentation in the accident and emergency department, through transfer, to specialist treatment in a neurocritical care unit.