Long-term outcome following decompressive craniectomy: an inconvenient truth?

Decompressive Craniectomy in Patients with Malignant Stroke with Additional Vascular Territory

BACKGROUND

Decompressive craniectomy substantially reduces mortality and disability rates following a malignant stroke. This procedure remains a life-saving option, especially in contexts with little access to mechanical thrombectomy despite downward trends in the performance of decompressive craniectomy due to discussions on the acceptance of living with severe disabilities. However, the outcomes of the surgery in cases involving concomitant occlusion of anterior or posterior cerebral arteries have not been extensively studied.

METHODS

In this retrospective cohort study, spanning January 2010 to December 2022 and including patients who underwent decompressive craniectomy, we compared outcomes between patients with and without additional vascular territory involvement. Independent variables included age, sex, comorbidities, admission National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, time elapsed between stroke and surgery, laterality of the stroke, midline shift, and postoperative infarction volume. Outcomes included mortality and modified Rankin Score at the 3-month follow-up.

RESULTS

Of the 86 patients analyzed, 61 (70.9%) and 25 (29.1%) demonstrated no territory and additional territory involvement, respectively. Patients with involvement of additional territories exhibited lower admission Glasgow Coma Scale scores, higher National Institutes of Health Stroke Scale scores, and larger postoperative infarction volumes. However, these variables were not associated with poor outcomes. Univariate analyses revealed no differences in mortality or severe disability. Even after adjustment, the differences remained insignificant for mortality and severe disability. Age emerged as the sole variable linked to increased mortality.

CONCLUSIONS

Our data suggest that, for patients with malignant stroke undergoing decompressive craniectomy, the outcomes for patients with and without involvement of additional vascular territory are similar.

Analysis of Causes of Complications and Prognostic Factors After Titanium Mesh Ultra-Early Cranioplasty Following Decompressive Craniectomy for Craniocerebral Trauma

OBJECTIVE

Craniocerebral trauma is one of the main causes of death and disability worldwide. Decompressive craniectomy is a common emergency measure in the treatment of craniocerebral trauma, aimed at relieving intracranial pressure. However, cranial bone reconstruction (CP) following this surgery is crucial for the patient's long-term recovery. Despite this, research on complications and prognostic factors after ultra-early cranioplasty remains limited. Therefore, this study aims to explore the complications of ultra-early cranioplasty with titanium mesh and its impact on prognosis.

METHODS

From January 2020 to November 2022, 44 patients with craniocerebral trauma who needed ultra-early CP after decompressive craniectomy were collected. The basic data of the National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale, modified Rankin Scale, and Montreal Cognitive Assessment scores of patients were collected, and the complications and prognosis of patients 3 months after operation were collected. Multivariate logistic regression was used to analyze the prognostic factors.

RESULTS

Compared with preoperative, the postoperative NIHSS score of patients with ultra-early CP decreased, the postoperative Glasgow Coma Scale score increased, the postoperative modified Rankin Scale score decreased (P < 0.05), and the postoperative Montreal Cognitive Assessment score was higher. Postoperative complications occurred in 42 patients with ultra-early CP. There were 37 complications, including 7 cases of hydroaccumulation, 18 cases of hematocele, 11 cases of pneumatosis, 3 cases of scalp swelling, 2 cases of epilepsy, 10 cases of hydrocephalus, and 1 case of intracranial infection, and no incision infection occurred. Age and postoperative NIHSS score were related factors affecting the poor prognosis of ultra-early CP patients (P < 0.05).

CONCLUSIONS

Ultra-early CP can promote the recovery of neurological function, reduce the disturbance of consciousness, improve daily living ability, and improve cognitive function in patients with craniocerebral trauma, but there is a high risk of postoperative complications. In addition, age and postoperative NIHSS score are related factors affecting the poor prognosis of ultra-early CP patients.

Effect of Early Versus Delayed Tracheostomy Strategy on Functional Outcome of Patients With Severe Traumatic Brain Injury: A Target Trial Emulation

OBJECTIVES

Optimal timing of tracheostomy in severe traumatic brain injury (TBI) is unknown due to lack of clinical trials. We emulated a target trial to estimate the effect of early vs. delayed tracheostomy strategy on functional outcome of patients with severe TBI.

DESIGN

Target trial emulation using 1:1 balanced risk-set matching.

SETTING

North American hospitals participating in the TBI Hypertonic Saline randomized controlled trial of the Resuscitation Outcomes Consortium.

PATIENTS

The prematching population consisted of patients with TBI and admission Glasgow Coma Scale less than or equal to 8, who were alive and on mechanical ventilation on the fourth day following trial enrollment, and stayed in the ICU for at least 5 days. Patients with absolute indication for tracheostomy and patients who died during the first 28 days with a decision to withdraw care were excluded.

INTERVENTIONS

We matched patients who received tracheostomy at a certain timepoint (early group) with patients who had not received tracheostomy at the same timepoint but were at-risk of tracheostomy in the future (delayed group). The primary outcome was a poor 6-month functional outcome, defined as Glasgow Outcome Scale-Extended less than or equal to 4.

MEASUREMENTS AND MAIN RESULTS

Out of 1282 patients available for analysis, 275 comprised the prematching population, with 75 pairs being created postmatching. Median time of tracheostomy differed significantly in the early vs. the delayed group (7.0 d [6.0-10.0 d] vs. 12.0 d [9.8-18.3 d]; p < 0.001). Only 40% of patients in the delayed group received tracheostomy. There was no statistically significant difference between groups regarding poor 6-month functional outcome (early: 68.0% vs. delayed: 72.0%; p = 0.593).

CONCLUSIONS

In a target trial emulation, early as opposed to delayed tracheostomy strategy was not associated with differences in 6-month functional outcome following severe TBI. Considering the limitations of target trial emulations, delaying tracheostomy through a "watchful waiting" approach may be appropriate.

Evaluation of Outcomes Among Patients With Traumatic Intracranial Hypertension Treated With Decompressive Craniectomy vs Standard Medical Care at 24 Months: A Secondary Analysis of the RESCUEicp Randomized Clinical Trial

Importance

Trials often assess primary outcomes of traumatic brain injury at 6 months. Longer-term data are needed to assess outcomes for patients receiving surgical vs medical treatment for traumatic intracranial hypertension.

Objective

To evaluate 24-month outcomes for patients with traumatic intracranial hypertension treated with decompressive craniectomy or standard medical care.

Design, Setting, and Participants

Prespecified secondary analysis of the Randomized Evaluation of Surgery With Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) randomized clinical trial data was performed for patients with traumatic intracranial hypertension (>25 mm Hg) from 52 centers in 20 countries. Enrollment occurred between January 2004 and March 2014. Data were analyzed between 2018 and 2021. Eligibility criteria were age 10 to 65 years, traumatic brain injury (confirmed via computed tomography), intracranial pressure monitoring, and sustained and refractory elevated intracranial pressure for 1 to 12 hours despite pressure-controlling measures. Exclusion criteria were bilateral fixed and dilated pupils, bleeding diathesis, or unsurvivable injury.

Interventions

Patients were randomly assigned 1:1 to receive a decompressive craniectomy with standard care (surgical group) or to ongoing medical treatment with the option to add barbiturate infusion (medical group).

Main Outcomes and Measures

The primary outcome was measured with the 8-point Extended Glasgow Outcome Scale (1 indicates death and 8 denotes upper good recovery), and the 6- to 24-month outcome trajectory was examined.

Results

This study enrolled 408 patients: 206 in the surgical group and 202 in the medical group. The mean (SD) age was 32.3 (13.2) and 34.8 (13.7) years, respectively, and the study population was predominantly male (165 [81.7%] and 156 [80.0%], respectively). At 24 months, patients in the surgical group had reduced mortality (61 [33.5%] vs 94 [54.0%]; absolute difference, -20.5 [95% CI, -30.8 to -10.2]) and higher rates of vegetative state (absolute difference, 4.3 [95% CI, 0.0 to 8.6]), lower or upper moderate disability (4.7 [-0.9 to 10.3] vs 2.8 [-4.2 to 9.8]), and lower or upper severe disability (2.2 [-5.4 to 9.8] vs 6.5 [1.8 to 11.2]; χ27 = 24.20, P = .001). For every 100 individuals treated surgically, 21 additional patients survived at 24 months; 4 were in a vegetative state, 2 had lower and 7 had upper severe disability, and 5 had lower and 3 had upper moderate disability, respectively. Rates of lower and upper good recovery were similar for the surgical and medical groups (20 [11.0%] vs 19 [10.9%]), and significant differences in net improvement (≥1 grade) were observed between 6 and 24 months (55 [30.0%] vs 25 [14.0%]; χ22 = 13.27, P = .001).

Conclusions and Relevance

At 24 months, patients with surgically treated posttraumatic refractory intracranial hypertension had a sustained reduction in mortality and higher rates of vegetative state, severe disability, and moderate disability. Patients in the surgical group were more likely to improve over time vs patients in the medical group.

Trial Registration

ISRCTN Identifier: 66202560.

The prevalence and risk factors of posttraumatic cerebral infarction in patients with traumatic brain injury: a systematic review and meta-analysis

Posttraumatic cerebral infarction (PTCI) is a serious complication of traumatic brain injury (TBI), and the prevalence and risk factors of PTCI in TBI patients are in dispute. We systematically searched the literature in the PubMed, Embase, and Cochrane library up to October 2021 to identify studies on the prevalence and risk factors of PTCI in patients with TBI. The quality of observational studies was assessed by the Newcastle-Ottawa scale tool. Random-effects model was conducted. The Higgins` I² statistic was used to measure heterogeneity between trials. Moreover, sensitive analyses were conducted to assess whether the pooled result was credible and robust. Eleven studies (3696 total TBI patients) were included. The pooled prevalence of PTCI in TBI patients was 14% (95% CI, 0.11-0.17; I² = 83.1%). Sensitive analyses showed that the pooled prevalence of PTCI was 13% (95% CI, 0.10-0.15; I² = 69.2%) by omitting Su et al. The prevalence of PTCI was associated with a lower Glasgow Coma Scale (GCS) score (OR, 0.33; 95% CI, 0.14-0.77; I² = 99.2%), pupillary dilation (OR, 4.73; 95% CI, 4.30-5.19; I² = 85.6%), abnormal PT (OR, 1.16; 95% CI,1.05-2.47; I² = 99.2%), hematoma location (OR, 1.16; 95% CI,1.05-2.47; I² = 99.2%) and hematoma volume (OR, 1.16; 95% CI,1.05-2.47; I² = 99.2%). Whereas hypotensive shock, duraplasty, cerebral herniation, and thrombocytopenia were not statistically associated with PTCI. Lower GCS, pupillary dilation, abnormal PT, hematoma location, and hematoma volume were risk factors for PTCI. Considering some limitations, the conclusion of our study should be interpreted with caution.

The intensive care management of acute ischaemic stroke

PURPOSE OF REVIEW

To discuss recent advances in the critical care management of acute ischaemic stroke patients and highlight controversies and consensus.

RECENT FINDINGS

Intravenous thrombolysis and endovascular thrombectomy are standard of care reperfusion therapies that have revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. They can now be delivered in extended time windows and to those previously ineligible for intervention based on advanced neuroimaging criteria. Secondary systemic insults, such as hypo- and hypertension, hyperthermia or hyperglycaemia, which can extend the area of ischaemia must also be prevented or corrected to minimize infarct progression. Meticulous blood pressure management is of central importance, particularly in patients that have undergone reperfusion therapies. Neurological deterioration can occur because of infarct extension, haemorrhagic transformation or worsening cerebral oedema. Transcranial Doppler ultrasonography allows bedside, noninvasive evaluation of cerebral haemodynamics and is increasingly used in acute stroke triage, management and recovery prediction. The management of acute ischaemic stroke raises several ethical issues, and shared decision making is essential to ensure outcomes that are compatible with an individual patient's expectations.

SUMMARY

A bundle of medical, endovascular and surgical strategies implemented by a multidisciplinary team working to locally agreed protocols can improve long-term stroke outcomes.

The role of tranexamic acid in traumatic brain injury

Evidence from recent trials evaluating efficacy of antifibrinolytic agents in the context of traumatic brain injury may lead to changes in the management of patients with traumatic brain injury. Tranexamic acid (TXA) reduces the proteolytic action of plasmin on fibrin clots, resulting in an inhibition of fibrinolysis and stabilisation of established blood clots. There has been significant interest in use of the drug as a therapeutic agent in the context of severe haemorrhage; however, considerable controversies regarding its efficacy remain. A number of trials have demonstrated a small but significant decrease in mortality following its administration, but the results have been somewhat inconsistent and may not be generalisable. The results of the CRASH-3 trial were that there was no statistical difference in the number of traumatic brain injury related deaths (18.5% with TXA and 19.8% with placebo; relative risk [RR] 0·94; 95% confidence interval [CI] 0·86-1·02). Nonetheless, there was a subgroup of patients for whom TXA appeared to provide benefit, and this was in patients with mild and moderate injury (with a Glasgow Coma Score > 8). This is potentially a very important finding that may have huge potential implications; however, we believe it does not currently provide indisputable evidence to support the administration of TXA to all patients with TBI. Further work is required to better define the subset of patients who may benefit as well as to evaluate the long-term functional benefit in order to determine which types of severe traumatic brain injury patients would derive more benefits than harms from TXA.

Decompressive Craniectomy for Traumatic Intracranial Hypertension in Children

OBJECTIVES

Decompressive craniectomy (DC) for control of refractory intracranial pressure (ICP) elevations remains a controversial procedure because of its invasiveness and lack of clearly defined indications, the absence of an established surgical technique, the variability of its outcomes, and the significant risk of complications.

AIM

The purpose of this study was to identify factors for unfavorable outcomes after DC in children with a severe traumatic brain injury (TBI).

METHODS

A longitudinal investigation of correlations was carried out in 64 children (mean age ± 4.8 years) with severe TBI and a Glasgow Coma Scale (GCS) score of 6 ± 2 on admission. The follow-up period was 6 months.

RESULTS

There was good recovery (with a Glasgow Outcome Scale (GOS) score of 4-5) in 45.3% of cases, severe disability in 31.0% of cases (with a GOS score of 3); and a GOS score of 1-2 in 23.4% of cases. Twelve patients (18.7%) died. Unfavorable prognostic signs were a GCS score < 5 (P = 0.0003); dilated, unreactive pupils (P < 0.05); and ICP >40 mmHg (P = 0.0003; P < 0.05). ICP characteristics appeared to be the most sensitive predictor of outcomes after secondary DC (P < 0.05).

CONCLUSION

DC may be effective in preventing dislocation syndrome but futile in cases of cerebral herniation. Outcomes after DC are determined by the severity of the primary and secondary brain injuries.

Outcomes of Traumatic Brain-Injured Patients With Glasgow Coma Scale < 5 and Bilateral Dilated Pupils Undergoing Decompressive Craniectomy

Objective: Decompressive craniectomy (DC) plays an important role in the treatment of patients with severe traumatic brain injury (sTBI) with mass lesions and intractably elevated intracranial hypertension (ICP). However, whether DC should be performed in patients with bilateral dilated pupils and a low Glasgow Coma Scale (GCS) score is still controversial. This retrospective study explored the clinical outcomes and risk factors for an unfavorable prognosis in sTBI patients undergoing emergency DC with bilateral dilated pupils and a GCS score <5. Methods: The authors reviewed the data from patients who underwent emergency DC from January 2012 to March 2019 in a medical center in China. All data, such as patient demographics, radiological findings, clinical parameters, and preoperative laboratory variables, were extracted. Multivariate logistic regression analysis was performed to determine the factors associated with 30-day mortality and 6-month negative neurological outcome {defined as death or vegetative state [Glasgow Outcome Scale (GOS) score 1-2]}. Results: A total of 94 sTBI patients with bilateral dilated pupils and a GCS score lower than five who underwent emergency DC were enrolled. In total, 74 patients (78.7%) died within 30 days, and 84 (89.4%) had a poor 6-month outcome (GOS 1-2). In multivariate analysis, advanced age (OR: 7.741, CI: 2.288-26.189), prolonged preoperative activated partial thromboplastin time (aPTT) (OR: 7.263, CI: 1.323-39.890), and low GCS (OR: 6.162, CI: 1.478-25.684) were associated with a higher risk of 30-day mortality, while advanced age (OR: 8.812, CI: 1.817-42.729) was the only independent predictor of a poor 6-month prognosis in patients undergoing DC with preoperative bilateral dilated pupils and a GCS score <5. Conclusions: The mortality and disability rates are extremely high in severe TBI patients undergoing emergency DC with bilateral fixed pupils and a GCS score <5. DC is more valuable for younger patients.

"Eppur si muove" - Clinical case: evolutionary "saga" during the last 6 years: posttraumatic subdural hematoma, decompressive craniectomy, right hemiplegia and aphasia, cranioplasty, hydrocephalus and porencephaly, post-traumatic encephalopathy - in remission

The case reports a 59-year-old male patient who suffered a severe head injury (affirmative by accidental fall from 3 m) with multiple hemorrhagic lesions (bifrontal, bioccipital, biparieto-temporal) and left cerebral subdural hematoma, requiring a large fronto- temporo-parietal decompressive craniotomy for the mass lesion evacuation. Cranioplasty was performed after 6 months. The paper synthesizes the evolution over six years of follow-up (12 in-patient admissions and 4 out-patient evaluations), like in a neurorehabilitation cinematographic “saga”. The posttraumatic encephalopathy had a peculiar evolution, sugestively compared with the humps of a camel: the brain injury (determined coma, right hemiplegia and mixed aphasia, intense psycho-motor agitation, severe dysphagia for solids and liquids, neurogenic bladder, anemia), was followed by a slowly progressive favorable neuro-psychological evolution (after the decompressive craniectomy). A brutal neurological fall-down was noticed after the cranioplasty, and finally a gradually favorable ascending trend, towards a global neuro-psichological stabilization (with an almost imperceptible sequelary ataxic hemiparesis). The paper discusses the pathophisiological aspects focused on the decompressive craniectomy and cranioplasty, correlated to the patient’s evolution. Complications of each neurosurgical procedures are succinctly depicted. The traumatic encephalopathy was complicated with post-traumatic seizures (therapeutically controlled) and active internal hydrocephalus with interstitial edema and an ischemic lesion. Finally it was a "happyend", with favorable clinical evolution, towards a stable and stationary normotensive asymmetric hydrocephalus, with a gigantic and deforming porencephaly. The paper advocates for a carefully follow-up and prompt intervention in order to prevent recurrences and/ or complications (secondary and tertiary prophylaxis). Keywords: traumatic brain injury, subdural hematoma, decompressive craniectomy; cranioplasty; internal hydrocephalus; post-traumatic encephalopathy; seizures; neurorehabilitation,

Outcomes After Decompressive Craniectomy for Ischemic Stroke: A Volumetric Analysis

BACKGROUND

Decompressive hemicraniectomy (DHC) is a treatment of space-occupying hemispheric infarct. Current surgical guidelines use criteria of age <60 years and surgery within 48 hours of stroke onset.

OBJECTIVE

The purpose of this study was to evaluate the neurologic outcome after DHC and evaluate the relationship of stroke volume and outcomes.

METHODS

A retrospective review was performed of patients undergoing DHC for cerebral infarct from 2016 to 2019. Unfavorable outcome was defined as modified Rankin Scale (mRS) score >3. Patients with precraniectomy magnetic resonance imaging were selected as a subset for volumetric stroke volume analysis using RAPID software (iSchemaView, Redwood City, California), with stroke volume defined as apparent diffusion coefficient <620 on diffusion-weighted imaging.

RESULTS

Fifty-two patients met the inclusion criteria. At 90 days, favorable outcome was achieved in 11 patients (21.2%), and 41 patients (78.8%) had unfavorable outcomes (15 [29%] died). Surgery after 48 hours, age >60 years, and multivessel distribution did not significantly affect 90-day mRS score (P = 0.091, 0.111, and 0.664, respectively). In volumetric subset analysis, 10 patients of 41 (31.3%) achieved favorable outcomes, and no patients with volume of infarct >280 mL had a favorable outcome. There was a trend of lower volumes associated with favorable outcomes, but this did not meet significance (favorable 207 ± 68.7 vs. unfavorable 262 ± 117.1; P = 0.163).

CONCLUSIONS

Outcomes after DHC for malignant hemispheric infarct were not affected by current accepted guidelines. Volume of infarct may have an effect on outcome after DHC. Further research to aid in predicting which patients benefit from decompressive craniectomy is warranted.

Deciding Under Uncertainty: The Case of Refractory Intracranial Hypertension

A challenging clinical conundrum arises in severe traumatic brain injury patients who develop intractable intracranial hypertension. For these patients, high morbidity interventions such as surgical decompression and barbiturate coma have to be considered against a backdrop of uncertain outcomes including prolonged states of disordered consciousness and severe disability. The clinical evidence available to guide shared decision-making is mainly limited to one randomized controlled trial, the RESCUEicp. However, since the publication of this trial significant controversy has been ongoing over the interpretation of the results. Is the mortality benefit from surgery merely a trade off for unacceptable long-term disability? How should treatment options, possible outcomes, and results from the trial be communicated to surrogates? How do we incorporate patient values into forming plans of care? The aim of this article is to sketch an approach based on insights from Decision Theory, and specifically deciding under uncertainty. The mainstream normative decision theory, Expected Utility (EU) theory, essentially says that, in situations of uncertainty, one should prefer the option with greatest expected desirability or value. The steps required to compute expected utilities include listing the possible outcomes of available interventions, assigning each outcome a utility ranking representing an individual patient's preferences, and a conditional probability given each intervention. This is a conceptual framework meant to supplement, and enhance shared decision making by assuring that patient values are elicited and incorporated, the possible range and nature of outcomes is discussed, and finally by attempting to connect best available means to patient-individualized ends.

Long-term follow-up of patients undergoing decompressive hemicraniectomy for malignant stroke: Quality of life and caregiver's burden in a real-world setting

BACKGROUND AND PURPOSE

Decompressive hemicraniectomy is a life-saving procedure for the treatment of space-occupying middle cerebral artery infarctions (malignant stroke); however, patients may survive severely disabled. Comprehensive data on long-term sequelae outside randomized controlled trials are scarce.

METHODS

We retrospectively evaluated the survival rates, quality of life, ability to perform activities of daily living, and caregiver burden of 61 patients (aged from 37 to 83) who had previously undergone decompressive hemicraniectomy for malignant stroke between 2012 and 2017.

RESULTS

The mortality rate was higher among patients older than 60 years than among younger patients (71.0 % vs 36.7 %, p = 0.007; odds ratio 4.222, 95 % confidence interval 1.443-12.355). The mean survival time was 37.9 ± 6.0 months for 19 survivors of the younger group and 22.6 ± 5.7 months for 9 survivors of the older group. Among the 28 surviving patients, 22 (78.6 %) were interviewed, and we found that age was a determining factor for functional outcome (Barthel indices of 65.7 ± 10.6 for younger patients vs 48.0 ± 9.3 for older patients, p < 0.001), but not for quality of life. The caregiver burden was significantly correlated (R = -0.53, p < 0.01) with the severity of disability and age (R = 0.544, p = 0.011) of the patients.

CONCLUSION

Our findings show that the degree of impairment, as well as caregiver burden, is higher in patients older than 60 years than in younger patients.

The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond

PURPOSE OF REVIEW

There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies.

RECENT FINDINGS

Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome.

SUMMARY

Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.

Balancing the short-term benefits and long-term outcomes of decompressive craniectomy for severe traumatic brain injury

Introduction: The role of decompressive craniectomy in the management of neurological emergencies remains controversial. There is evidence available that it can reduce intracranial pressure, but it will not reverse the effects of the pathology that precipitated the neurological crisis, so there has always been concern that any reduction in mortality will result in an increase in the number of survivors with severe disability.Areas covered: The results of recent randomised controlled trials investigating the efficacy of the procedure are analyzed in order to determine the degree to which the short-term goals of reducing mortality and the long-term goals of a good functional outcome are achieved.Expert opinion: Given the results of the trials, there needs to be a change in the clinical decision-making paradigm such that decompression is reserved for patients who develop intractable intracranial hypertension and who are thought unlikely to survive without surgical intervention. In these circumstances, a more patient-centered discussion is required regarding the possibility and acceptability or otherwise of survival with severely impaired neurocognitive function.

Long-term and delayed functional recovery in patients with severe cerebrovascular and traumatic brain injury requiring tracheostomy

OBJECTIVE

Data on long-term functional recovery (LFR) following severe brain injury are essential for counseling of surrogates and for appropriate timing of outcome assessment in clinical trials. Delayed functional recovery (DFR) beyond 3-6 months is well documented following severe traumatic brain injury (sTBI), but there are limited data on DFR following severe cerebrovascular brain injury. The objective of this study was to assess LFR and DFR in patients with sTBI and severe stroke dependent on tracheostomy and tube feeding at the time of discharge from the intensive care unit (ICU).

METHODS

The authors identified patients entered into their tracheostomy database 2008-2013 with sTBI and severe stroke, encompassing SAH, intracerebral hemorrhage (ICH), and acute ischemic stroke (AIS). Eligibility criteria included disease-specific indicators of severity, Glasgow Coma Scale score < 9 at time of tracheostomy, and need for tracheostomy and tube feeding at ICU discharge. Assessment was at 1-3 months, 6-12 months, 12-24 months, and 24-36 months after initial injury for presence of tracheostomy, ability to walk, and ability to perform basic activities of daily living (B-ADLs). Long-term functional recovery (LFR) was defined as recovery of the ability to walk or perform B-ADLs by the 24- to 36-month follow-up. Delayed functional recovery (DFR) was defined as progression in functional milestones between any 2 time points beyond the 1- to 3-month follow-up.

RESULTS

A total of 129 patients met the eligibility criteria. Functional outcomes were available for 129 (100%), 97 (75%), 83 (64%), and 80 (62%) patients, respectively, from assessments at 1-3, 6-12, 12-24 and 24-36 months; 33 (26%) died by 24-36 months. Fifty-nine (46%) regained the ability to walk and 48 (37%) performed B-ADLs at some point during their recovery. Among survivors who had not achieved the respective milestone at 1-3 months, 29/58 (50%) were able to walk and 28/74 (38%) performed B-ADLs at 6-12 months. Among survivors who had not achieved the respective milestone at 6-12 months, 5/16 (31%) were able to walk and 13/30 (43%) performed B-ADLs at 12-24 months. There was no significant difference in rates of LFR or DFR between patients with sTBI and those with severe stroke.

CONCLUSIONS

Among patients with severe brain injury requiring tracheostomy and tube feeding at ICU discharge, 46% regained the ability to walk and 37% performed B-ADLs 2-3 years after injury. DFR beyond 1-3 and 6-12 months was seen in over 30% of survivors, with no significant difference between sTBI and severe stroke.

Role of Decompressive Craniectomy in Ischemic Stroke

Ischemic stroke is one of the leading causes for death and disability worldwide. In patients with large space-occupying infarction, the subsequent edema complicated by transtentorial herniation poses a lethal threat. Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to the vessel occlusion is associated with high mortality. By decompressive craniectomy, a significant proportion of the skull is surgically removed, allowing the ischemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. Several studies have shown that decompressive craniectomy reduces the mortality rate in patients with malignant cerebral artery infarction. However, this is done for the cost of a higher proportion of patients who survive with severe disability. In this review, we will describe the clinical and radiological features of malignant middle cerebral artery infarction and the role of decompressive craniectomy and additional therapies in this condition. We will also discuss large cerebellar stroke and the possibilities of suboccipital craniectomy.

Complications of Decompressive Craniectomy

Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.