Serial Attacks: Contralateral Hematoma Secondary to Decompressive Craniectomy for Traumatic Brain Injury Led to Posttraumatic Cerebral Infarction

The Effect of Controlled Decompression for Severe Traumatic Brain Injury: A Randomized, Controlled Trial

Background: Experimental evidence has indicated the benefits of intraoperative controlled decompression for the treatment of severe traumatic brain injury (sTBI). Intraoperative rapid decompression (conventional decompression) for the treatment of sTBI may result in intra- and post-operative complications. Controlled decompression may reduce these complications. Previous clinical trials in China have not yielded conclusive results regarding controlled decompression for sTBI. Therefore, we explored whether controlled decompression treatment decreases the rates of complications and improves the outcomes of patients with sTBI.

Methods: We performed this randomized, controlled trial at our hospital. Patients with sTBI aged 18–75 years old were randomly (1:1) divided into controlled decompression surgery (n = 124) or rapid decompression surgery groups (n = 124). The primary outcome measures were the Extended Glasgow Outcome Scale (GOS-E) score at 6 months and 30-days all-cause mortality. The secondary outcomes were the incidences of intraoperative brain swelling, post-traumatic cerebral infarction, and delayed hematoma.

Results: Compared with the rapid decompression group, the controlled decompression group had reduced 30-days all-cause mortality (18.6 vs. 30.8%, P = 0.035) and improved the 6-months GOS-E scores, and the difference was significant. In addition, the patients in the controlled decompression group had a lower intraoperative brain swelling rate (13.3 vs. 24.3%, P = 0.036), a lower delayed hematoma rate (17.7 vs. 29.0%, P = 0.048) and a relatively lower post-traumatic cerebral infarction rate (15.0 vs. 22.4%, P = 0.127) than those in the rapid decompression group.

Conclusions: Our data suggest that controlled decompression surgery significantly improves sTBI outcomes and decreases the rates of sTBI-related complications. However, this was a single-hospital study, and well-designed multicenter randomized controlled trials are needed to evaluate the effects of controlled decompression surgery for the management of patients with sTBI.

Clinical Trial Registration: Chinese Clinical Trial Registry; Date: 14/Dec/2013; Number: ChiCTR-TCC-13004002.

Inhibition of Lats1/p-YAP1 pathway mitigates neuronal apoptosis and neurological deficits in a rat model of traumatic brain injury

AIMS

To investigate the roles of Lats1/p-YAP1 pathway in TBI-induced neuronal apoptosis and neurological deficits in rats.

RESULTS

We found that Lats1 and YAP1 were expressed in cerebral cortex neurons of Sprague-Dawley rats, and the phosphorylation levels of Lats1 and YAP1 in injured regions were significantly increased after TBI. Furthermore, inhibition of Lats1 not only decreased the level of p-YAP1, but also attenuated neuronal apoptosis and neurological impairment.

CONCLUSIONS

Our work demonstrates that inhibition of Lats1/p-YAP1 pathway mitigates neuronal apoptosis and neurological deficits in a rat model of TBI.

Clinical Features and Outcomes of Bilateral Decompression Surgery for Immediate Contralateral Hematoma after Craniectomy Following Acute Subdural Hematoma

Objective

Immediate contralateral epidural hematoma (EDH) and traumatic intracerebral hematoma (T-ICH) after craniectomy for traumatic subdural hematoma (SDH) are rare but devastating post-operative complications. Their clinical features and outcomes are not well studied. In this report, we present the clinical features and outcomes of immediate contralateral acute hematoma cases requiring a second operation.

Methods

This study includes 10 cases of immediate contralateral EDH and T-ICH following bilateral craniectomy for the evacuation of traumatic SDH and contralateral hematoma between 2004 and 2015. Their medical records and radiographic findings were reviewed and analyzed retrospectively.

Results

Ten of the 528 patients (1.89%) who underwent craniectomy for the evacuation of traumatic SDH developed post-operative EDH (n=5), T-ICH (n=5). The trauma was caused by a fall in 5 patients and by a traffic accident in 5 patients. The patients who suffered trauma due to pedestrian accidents died. Seven patients had a low admission Glasgow Coma Scale (GCS; GCS≤8) score in the preoperative state (average admission GCS, 7.7; average discharge GCS, 3.4; and average discharge Glasgow Outcome Scale, 2.0). Severe intra-operative brain swelling was noted in all patients, while skull fracture was observed in 8. Multiple associated injuries and medication for heart disease were characteristic of patients who died.

Conclusion

The prognosis of delayed contralateral hematoma was very poor. Multiple associated injuries, past medical history and traffic accidents, especially pedestrians were seemed to be associated with higher mortality rates. Finally, contralateral skull fractures can indicate high risk of delayed contralateral acute intracranial hematoma.