Late decompressive craniectomyafter traumatic brain injury: neurological outcome at 6 months after ICU discharge

Timing of Decompressive Craniectomy for Ischemic Stroke and Traumatic Brain Injury: A Review

While studies have demonstrated that decompressive craniectomy after stroke or TBI improves mortality, there is much controversy regarding when decompressive craniectomy is optimally performed. The goal of this paper is to synthesize the data regarding timing of craniectomy for malignant stroke and traumatic brain injury (TBI) based on studied time windows and clinical correlates of herniation. In stroke patients, evidence supports that early decompression performed within 24 h or before clinical signs of herniation may improve overall mortality and functional outcomes. In adult TBI patients, published results demonstrate that early decompressive craniectomy within 24 h of injury may reduce mortality and improve functional outcomes when compared to late decompressive craniectomy. In contrast to the stroke data, preliminary TBI data have demonstrated that decompressive craniectomy after radiographic signs of herniation may still lead to improved functional outcomes compared to medical management. In pediatric TBI patients, there is also evidence for better functional outcomes when treated with decompressive craniectomy, regardless of timing. More high quality data are needed, particularly that which incorporates a broader set of metrics into decision-making surrounding cranial decompression. In particular, advanced neuromonitoring and imaging technologies may be useful adjuncts in determining the optimal time for decompression in appropriate patients.

Outcome Determinants of Decompressive Craniectomy in Patients with Traumatic Brain Injury; A Single Center Experience from Southern Iran

OBJECTIVE

To investigate the determinants of outcome in patients with traumatic brain injury (TBI) undergoing decompressive craniectomy (DC) in a large level I trauma center in southern Iran.

METHODS

This retrospective cross-sectional study was conducted during an 18-month period from 2013 to 2014 in Shahid Rajaei hospital, a Level I trauma center in Southern Iran. Patients with TBI who had undergone DC were included and the medical charts were reviewed regarding demographics, clinical, radiological and outcome characteristics. The outcome was determined by extended Glasgow outcome scale (GOS-E) after one year of surgery. The variables were compared between those with favorable and unfavorable outcome to investigate the outcome determinants.

RESULTS

Overall 142 patients with mean age of 34.8 ± 15.5 (ranging from 15 to 85) years were included. There were 127 (89.4%) men and 15 (10.6%) women among the patients. After 1-year, the mortality rate was 58 (40.8%) and 8 (5.6%) patients were persistent vegetative state. The final outcome was found to be unfavorable in 77 (54.2%) patients.  Unfavorable outcome was associated with lower GCS on admission (p<0.001) as well as occurrence of postoperative hydrocephalus (p=0.011). Formation of the postoperative subdural hygroma after the operation was found to be associated with favorable outcome (p=0.019).

CONCLUSION

DC in patients with TBI is associated with favorable outcome in most of them. On admission GCS, postoperative hydrocephalus and presence of postoperative subdural hygroma are among the important predictors of outcome in TBI patients undergoing DC.

Early Decompression of Acute Subdural Hematoma for Postoperative Neurological Improvement: A Single Center Retrospective Review of 10 Years

Objective

This study was conducted to investigate survival related factors, as well as to evaluate the effects of early decompression on acute subdural hematoma (ASDH).

Methods

We retrospectively reviewed cases of decompressive craniectomy (DC) for decade. In total, 198 cases of DC involved ASDH were available for review, and 65 cases were excluded due to missing data on onset time and a delayed operation after closed observation with medical care. Finally, 133 cases of DC with ASDH were included in this study, and various factors including the time interval between trauma onset and operation were evaluated.

Results

In the present study, survival rate after DC in patients with ASDH was shown to be related to patient age (50 years old, p=0.012), brain compression ratio (p=0.042) and brain stem compression (p=0.020). Sex, preoperative mental status, and time interval between trauma onset and operation were not related with survival rate. Among those that survived (n=78), improvements in Glasgow Coma Scale (GCS) score of more than three points, compared to preoperative measurement, were more frequently observed among the early (less than 3 hours between trauma onset and operation) decompressed cases (p=0.013). However, improvements of more than 4 or 5 points on the GCS were not affected by early decompression.

Conclusion

Early decompression of ASDH was not correlated with survival rate, but was related with neurological improvement (more than three points on the GCS). Accordingly, early decompression in ASDH, if indicated, may be of particular benefit.

Comparison of early and late decompressive craniectomy on the long-term outcome in patients with moderate and severe traumatic brain injury: a meta-analysis

BACKGROUND

Several studies have searched whether early decompressive craniectomy (DC) can improve the long-term outcome of patients with moderate and severe traumatic brain injury (TBI). However, the effects of early DC remain unclear. The purpose of this meta-analysis was to assess whether early DC (time to surgery after injury <24 h) is better than late DC (>24 h) after moderate and severe TBI.

METHOD

Two reviewers independently searched Pubmed, Embase, ISI web of science, the Cochrane Library and Scopus databases from inception to 4 November 2014. Studies comparing the long-term outcome of patients following early and late DC after TBI were included. The long-term outcomes were evaluated by Glasgow Outcome Score, Extended Glasgow Outcome Score. Newcastle-Ottawa Scale was used to assess the methodological quality of included studies. Characteristics of the selected studies were extracted. Pooled results were presented by odds ratios (ORs) with 95% CIs. I(2) was used to test heterogeneity. Pearson correlation coefficient was used to detect the relationship between bilateral pupil abnormality and unfavourable outcome.

RESULTS

Five articles were eligible for this meta-analysis. The pooled results of comparison of unfavourable outcome and mortality revealed no significant difference in the early and late groups (ORs: 1.469; 95% CIs: 0.495-4.362; p > 0.05; I(2 )=70.5% and ORs: 1.262; 95% CIs: 0.385-4.137; p > 0.05; I(2 )=77.6%, respectively). Pearson correlation coefficient indicated that bilateral pupil abnormality was positive related to the unfavourable outcomes and mortality (r = 0.833; p < 0.05) (0.829; p < 0.05).

CONCLUSION

Bilateral pupil abnormality is positive related to unfavourable outcome and mortality in the patients following DC after moderate and severe TBI. Early DC may be more helpful to improve the long-term outcome of patients with refractory raised intracranial cerebral pressure after moderate and severe TBI. However, more RCTs with better control of patients with bilateral pupil abnormality divided into the early and late groups are needed in the future.

Prospective randomized evaluation of therapeutic decompressive craniectomy in severe traumatic brain injury with mass lesions (PRECIS): study protocol for a controlled trial

BACKGROUND

For cases of severe traumatic brain injury, during primary operation, neurosurgeons usually face a dilemma of whether or not to remove the bone flap after mass lesion evacuation. Decompressive craniectomy, which involves expansion of fixed cranial cavity, is used to treat intra-operative brain swelling and post-operative malignant intracranial hypertension. However, due to indefinite indication, the decision to perform this procedure heavily relies on personal experiences. In addition, decompressive craniectomy is associated with various complications, and the procedure lacks strong evidence of better outcomes. In the present study, we designed a prospective, randomized, controlled trial to clarify the effect of decompressive craniectomy in severe traumatic brain injury patients with mass lesions.

METHODS

PRECIS is a prospective, randomized, assessor-blind, single center clinical trial. In this trial, 336 patients with traumatic mass lesions will be randomly allocated to a therapeutic decompressive craniectomy group or a prophylactic decompressive craniectomy group. In the therapeutic decompressive craniectomy group, the bone flap will be removed or replaced depending on the emergence of brain swelling. In the prophylactic decompressive craniectomy group, the bone flap will be removed after mass lesion evacuation. A stepwise management of intracranial pressure will be provided according to the Brain Trauma Foundation guidelines. Salvage decompressive craniectomy will be performed for craniotomy patients once there is evidence of imaging deterioration and post-operative malignant intracranial hypertension. Participants will be assessed at 1, 6 and 12 months after randomization. The primary endpoint is favorable outcome according to the Extended Glasgow Outcome Score (5-8) at 12 months. The secondary endpoints include quality of life measured by EQ-5D, mortality, complications, intracranial pressure and cerebral perfusion pressure control and incidence of salvage craniectomy in craniotomy patients at each investigation time point.

DISCUSSION

This study will provide evidence to optimize primary decompressive craniectomy application and assess outcomes and risks for mass lesions in severe traumatic brain injury.

TRIAL REGISTRATION

ISRCTN20139421.

Traumatic Brain Injury pathophysiology and treatments: early, intermediate, and late phases post-injury

Traumatic Brain Injury (TBI) affects a large proportion and extensive array of individuals in the population. While precise pathological mechanisms are lacking, the growing base of knowledge concerning TBI has put increased emphasis on its understanding and treatment. Most treatments of TBI are aimed at ameliorating secondary insults arising from the injury; these insults can be characterized with respect to time post-injury, including early, intermediate, and late pathological changes. Early pathological responses are due to energy depletion and cell death secondary to excitotoxicity, the intermediate phase is characterized by neuroinflammation and the late stage by increased susceptibility to seizures and epilepsy. Current treatments of TBI have been tailored to these distinct pathological stages with some overlap. Many prophylactic, pharmacologic, and surgical treatments are used post-TBI to halt the progression of these pathologic reactions. In the present review, we discuss the mechanisms of the pathological hallmarks of TBI and both current and novel treatments which target the respective pathways.

Traumatic brain injury: pathophysiology, monitoring, and mechanism-based care

Traumatic brain injury, which may be blunt or penetrating, begins altering intracranial physiology at the moment of impact as primary brain trauma. This article differentiates blunt versus penetrating brain trauma, primary versus secondary brain injury, and subsequent intracranial pathophysiology. Discussion and case study correlate intracranial pathophysiology and multisystem influences on evolving brain injury with mechanism-based interventions to modulate brain components (brain, blood, and cerebrospinal fluid volumes). The discussion also explores the effects of controlled ventilation, cardiopulmonary physiology, and global physiologic state on secondary injury, control of intracranial pressure, and recovery.