Effects of unilateral decompressive craniectomy on patients with unilateral acute post-traumatic brain swelling after severe traumatic brain injury

Functional Outcome of Adult Traumatic Brain Injury Patients Treated by Decompressive Craniectomy in an Ethiopian Trauma Center

OBJECTIVE

To describe the long-term functional outcome of traumatic brain injury (TBI) patients treated by decompressive craniectomy (DC).

METHODS

Data was collected on decompressive craniectomy performed on TBI patients admitted between May 1, 2018, and May 1, 2021, using a multi-center, cross-sectional study design. The long-term outcomes of survivors were assessed using a structured extended Glasgow Outcome Scale (GOSE) questionnaire. Descriptive statistics, including frequency, mean, median, and range, were analyzed. Predictors of functional outcomes were determined using multivariate regression analyses.

RESULTS

In this study, 74 patients were examined. The mean age at the time of DC was 33.9 years, with a male:female ratio of 11:1. Primary DC was performed in 93.2% of cases. The in-hospital and overall mortality rates were 24.3% and 36.5% respectively. Overall, a favorable functional outcome (GOSE ≥4) was witnessed in 43 patients (58.1%). Among survivors, 91.5% had favorable outcomes. Age ≥40 years, Glasgow Coma Scale (GCS) score ≤5, chest infections, and noninfectious complications were independent predictors of an unfavorable functional outcome (GOSE<4). Patients with GCS ≤5 fared the worst, with an unfavorable functional outcome rate of 85.7%.

CONCLUSIONS

Our results showed that a significant number of our patients had favorable functional outcome after DC for TBI comparable to results from high-income countries. We found that age, admission GCS, postoperative chest infection, and noninfectious complications were all independent factors predicting unfavorable functional outcome. In particular, patients with GCS ≤5 had a higher rate of mortality and unfavorable outcome.

Comparative Analysis of Duroplasty Techniques in Decompressive Craniectomy: The CANDID Study

BACKGROUND AND OBJECTIVE

At present, there is no consensus regarding the most optimal dural substitute to use for duroplasty in primary decompressive craniectomy (PDC) for traumatic brain injury (TBI). The author's objective was to conduct a retrospective analysis comparing 2 techniques of PDC: duroplasty using anterior-based vascularized galea pericranium (VP group) with synthetic dural substitute duroplasty (SR group).

METHODS

From April 2015 to February 2022, 379 craniotomies were done for TBI. The outcome of eligible 97 consecutive patients receiving PDC treatment were examined. Out of 97, 60 received vascularized galea pericranium and 37 received synthetic dural graft for dural augmentation. Propensity matching generated 28 pairs (56 patients) for analysis. The primary outcome was extended Glasgow Outcome Scale (GOS-E) measured at 6 months after injury. Secondary outcomes included were incidence of surgical complications (neurosurgical site infections, and hemorrhagic and hydrodynamic complications), surgical time, days in intensive care unit, hospital length of stay, hospital mortality, and GOS-E at 1 year after injury.

RESULTS

Patients in VP group, compared with those in SR group had better GOS-E score at 6 months ( P = .011) and 1 year ( P = .026). Hospital mortality ( P = .342), days in intensive care unit ( P = .574), hospital stay ( P = .155), surgical time ( P = .131), medical and surgical complications including neurosurgical infections, and hemorrhagic and hydrodynamic complications did not differ significantly in both groups. Complication of brain abscess was found exclusively in the SR group ( P = .327).

CONCLUSION

In this retrospective study, adults who underwent PDC for TBI using anterior-based vascularized galea pericranial graft were associated with better clinical outcomes at 6 months and 1 year compared with standard repair group using synthetic dural substitute (G patch).

Surgical intervention in traumatic brain injury: a systematic review and meta-analysis of decompressive craniotomy

BACKGROUND

Traumatic brain injury (TBI) is considered a major cause of death globally, resulting from trauma. Decompressive craniectomy (DC) may improve functional outcomes in patients with TBI and its associated complications. This study was designed to determine safety and efficacy of DC in improving clinical outcomes in TBI patients compared to standard therapy.

METHODS

A systematic search was conducted across six electronic databases to identify relevant randomized controlled trials (RCTs) examining decompressive craniotomy (DC) and traumatic brain injury (TBI) from database inception until March 2021. The pooled risk ratio was estimated for categorical outcomes, while the pooled standardized mean difference with a 95% confidence interval was calculated for continuous outcomes. Statistical analysis software, including RevMan 5.4 and STATA version 17, was employed to perform this meta-analysis. The protocol for this study is registered with the OSF registry, ensuring transparency and reproducibility.

RESULTS

A total of 656 studies were screened, and five RCTs involving 665 subjects (334 in the DC group and 331 in the control group) were included in this meta-analysis. Our meta-analysis revealed a non-significant trend towards a higher rate of favorable clinical outcomes in subjects who underwent DC compared to those in the medical treatment (MT) group (risk ratio (RR) 1.20, 95% confidence interval (CI) 0.70 to 2.08, P = 0.50). In contrast, the mortality rate was significantly lower in patients treated with DC compared to those receiving MT alone (RR 0.58, 95% CI 0.47 to 0.73, P < 0.001). Additionally, intracranial pressure (ICP) levels were significantly lower in subjects who underwent DC compared to those receiving MT alone (standardized mean difference (SMD): - 0.87, 95% CI - 1.58 to - 0.16, P = 0.02). Furthermore, there was a statistically significant reduction in the duration of stay in the DC group compared to the MT alone group (SMD: - 1.18, 95% CI - 1.49 to - 0.86, P < 0.001).

CONCLUSION

This study presents evidence suggesting that DC is linked to a lower mortality rate, decreased ICP, and shorter hospital stays among patients with moderate to severe TBI. However, it did not show a significant impact on improving favorable clinical outcomes.

A Comparison of Decompression Size and Craniectomy Speed of Reverse Question Mark Versus Retroauricular Incisions for Decompressive Hemicraniectomy: A Cadaver Study

BACKGROUND AND OBJECTIVES

Decompressive hemicraniectomy is a common emergent surgery for patients with stroke, hemorrhage, or trauma. The typical incision is a reverse question mark (RQM); however, a retroauricular (RA) incision has been proposed as an alternative. The widespread adoption ofthe RA incision has been slowed by lack of familiarity and concerns over decompression efficacy. Our goal is to compare the RA vs RQM incisions regarding decompression safety and to examine skill acquisition among resident neurosurgeons.

METHODS

Six cadaveric heads were randomized to first receive either RQM or RA decompressive hemicraniectomy, which was followed by use of the other incision on the contralateral side. Primary endpoints were decompression circumference and time to bone flap removal. Resident neurosurgeon (postgraduate year 3 through 7) confidence and operative times were compared.

RESULTS

All craniectomies yielded decompression diameters >13 cm (RQM: 13.5-15.5 cm; RA: 13.0-16.5 cm) and residual temporal bone heights <1.5 cm (RQM: 0.5-1.3 cm; RA: 0.5-1.5 cm). There were no differences between the RA and RQM groups in decompression circumference (P = .6605), residual temporal bone height (P = .7121), or time from incision until bone flap removal (P = .8452). There was a nonsignificant trend toward a shorter incision length with RA (RQM: 37.7 ± 0.7 cm vs RA: 35.1 ± 0.9; P = .0729). Regardless of which incision was performed first, operative time significantly improved from the first craniectomy to the second (-174.6 seconds, P = .0186). Surgeon confidence improved more with the RA incision, and there was a linear association with experience and time to bone flap removal in the RQM (P = .04) but not the RA (P = .95) groups.

CONCLUSION

The RA incision may provide adequate operative exposure without significant changes in operative time. Cadaveric labs improve skill acquisition and should be considered during implementation of novel surgical approaches into practice.

Decompressive Craniectomy and Hinged Craniotomy for Traumatic Brain Injury: Experience in Two Centers in a Middle-Income Country

Objective

The goal of a decompressive craniectomy (DC) or a hinge craniotomy (HC), is to treat intracranial hypertension and reduce mortality. Traditionally, the decompression procedure has been performed with cranial bone removal. However, decompression and repositioning the cranial bone, named HC, has been presented as an alternative for certain cases. Our objective is to describe the neuroradiological and clinical preoperative factors and outcomes in traumatic brain injury (TBI) cases treated with both techniques in 2 centers in a Middle-Income country.

Methods

This is a retrospective cross-sectional study of adult patients who underwent decompression surgical treatment for TBI, either with a traditional DC or HC, in 2 centers in Bogotá, Colombia between 2016-2020.

Results

This study involved 30 cases that underwent HC and 20 that underwent DC. 78% were male with an overall mean age of 50.2 years. 66% cases had traumatic subarachnoid hemorrhage (tSAH) and 60% had evidence of acute subdural hematoma ≥10 mm in thickness. The overall mortality rate during hospitalization was 20%. Preoperative pupil impairment differences between the 2 groups were statistically significant (p=0.026).

Conclusion

This study reveals that using a traditional DC or HC depends on the neurosurgeon's intraoperative case-by-case assessment according to the intraoperative brain's vitality and the presence of diffuse edema in the brain parenchyma at the time of surgical closure. Each case requires an individualized evaluation before and during surgery. The preoperative pupil condition can serve as a marker for HC or DC selection.

Decompressive craniectomy in trauma: What you need to know

ABSTRACT

Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.

Intracranial pressure changes in traumatic brain injury patients undergoing unilateral decompressive craniectomy with dural expansion

Background

The aim of this study is to assess the ICP changes induced by a unilateral fronto-temporo-parietal DC with dural expansion after moderate to severe TBI. The effect of different bone flap sizes on ICP and the neurological outcomes were also evaluated after the decompressive surgery.

Methods

52 TBI patients with clinical and radiological evidences of increased ICP were included in this prospective study. All patients received unilateral fronto-temporo-parietal DC with dural expansion and ventriculostomy at contralateral Kocher's point. Postoperatively, ICP values and the largest antero-posterior (AP) diameter of bone flap removed was measured, and the clinical outcomes were assessed using Extended Glasgow Outcome Scale (GOS-E) at discharge and 6 months after DC.

Results

The median ICP significantly decreased with an average of 56.7 % reduction from the initial opening ICP. Similar ICP changes were observed in all groups. This study also found that the large bone flap group (AP diameter >15 cm) demonstrated better postoperative ICP control as compared to the small bone flap group (AP diameter 12-15 cm), although not statistically significant. The SDH and cerebral swelling groups did better in the GOS-E at 6 months after TBI compared with cerebral contusion group.

Conclusion

The ICP reduction in moderate to severe TBI patients undergoing unilateral fronto-temporo-parietal DC with dural expansion occurred in accordance with decompressive steps, regardless of intracranial lesions and the surgical procedure should be performed with the bone flap size of at least 12 cm in AP diameter for adequate and sustained ICP control.

Indications and scientific support for supratentorial unilateral decompressive craniectomy for different subgroups of patients: A scoping review

CONTEXT

Even though supratentorial unilateral decompressive craniectomy (DC) has become the gold standard neurosurgical procedure aiming to provide long term relief of intractable intracranial hypertension, its indication has only been validated by high-quality evidence for traumatic brain injury and malignant middle cerebral artery infarction. This scoping review aims to summarize the available evidence regarding DC for these two recognized indications, but also for less validated indications that we may encounter in our daily clinical practice.

MATERIALS AND METHODS

A scoping review was conducted on Medline / Pubmed database from inception to present time looking for articles focused on 7 possible indications for DC indications. Studies' level of evidence was assessed using Oxford University level of evidence scale. Studies' quality was assessed using Newcastle-Ottawa scale for systematic reviews of cohort studies and Cochrane Risk of Bias Tool for randomized controlled trials.

RESULTS

Two randomized trials (level 1b) reported the possible efficacy of unilateral DC and the mitigated efficiency of bifrontal DC in the trauma setting. Five systematic reviews meta-analyses (level 2a) supported DC for severely injured young patients with acute subdural hematoma probably responsible for intraoperative brain swelling, while one randomized controlled trial (level 1b) showed comparable efficacy of DC and craniotomy for ASH with intraoperative neutral brain swelling. Three randomized controlled trials (level 1b) and two meta-analyses (level 1a and 3a) supported DC efficacy for malignant ischemic stroke. One systematic review (level 3a) supported DC efficacy for malignant meningoencephalitis. One systematic review meta-analysis (level 3a) supported DC efficacy for malignant cerebral venous thrombosis. The mitigated results of one randomized trial (level 1b) did not allow to conclude for DC efficacy for intracerebral hemorrhage. One systematic review (level 3a) reported the possible efficacy of primary DC and the mitigated efficacy of secondary DC for aneurysmal subarachnoid hemorrhage. Too weak evidence (level 4) precluded from drawing any conclusion for DC efficacy for intracranial tumors.

CONCLUSION

To date, there is some scientific background to support clinicians in the decision making for DC for selected cases of severe traumatic brain injury, acute subdural hematoma, malignant ischemic stroke, malignant meningoencephalitis, malignant cerebral venous thrombosis, and highly selected cases of aneurysmal subarachnoid hemorrhage.

Practical pearls for management of cranial injury in the developing world

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality, with approximately 69 million individuals affected globally each year, particularly in low- and middle-income countries (LMICs) where neurosurgical resources are limited. The neurocognitive consequences of TBI range from life-threatening conditions to more subtle impairments such as cognitive deficits, impulsivity, and behavioral changes, significantly impacting patients' reintegration into society. LMICs bear about 70% of the global trauma burden, with causes of TBI differing from high-income countries (HICs). The lack of equitable neurosurgical care in LMICs exacerbates these challenges. Improving TBI care in LMICs requires targeted resource allocation, neurotrauma registries, increased education, and multidisciplinary approaches within trauma centers. Reports from successful neurotrauma initiatives in low-resource settings provide valuable insights into safe, adaptable strategies for managing TBI when "gold standard" protocols are unfeasible. This review discusses common TBI scenarios in LMICs, highlighting key epidemiological factors, diagnostic challenges, and surgical techniques applicable to resource-limited settings. Specific cases, including epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and cerebrospinal fluid leaks, are explored to provide actionable insights for improving neurosurgical outcomes in LMICs.

Decompressive craniectomy: A primer for acute care practitioners

Decompressive craniectomy (DC) involves surgical removal of the skull that overlies swollen, imperiled, brain. This is done to combat intracranial hypertension and mitigate a vicious cycle of secondary brain injury. If, instead, this pathophysiology goes uninterrupted, it can mean brain herniation and brain stem death. As such, DC can save lives when all else fails. Regardless, it is no panacea and can also "ruin deaths," and leave patients profoundly disabled. DC is not a new procedure; however, this therapy is increasingly noteworthy due to advances in neurocritical care, alongside ethical concerns. We cover the physiological rationale, the surgical basics, the trial data, and focus on secondary decompression (for refractory intracranial pressure (ICP)) rather than primary decompression (i.e. during evacuation of an intracranial mass). Given that DC should not be undertaken indiscriminately, we conclude by introducing ways in which to discuss DC with families and colleagues. Our goal is to provide a primer and common resource for the multidisciplinary team. We aim to increase not only knowledge but wisdom, prudence, collegiality, and family-focused care.

Incidence, risk factors, and clinical outcomes of acute brain swelling associated with traumatic acute subdural hematoma: a retrospective study utilizing novel diagnostic criteria

Background

Post-traumatic acute brain swelling (ABS) is a major cause of elevated intracranial pressure and thus mortality. The current definition of post-traumatic ABS has certain limitations, and there is limited information available regarding ABS associated with traumatic acute subdural hematoma (ASDH).

Objectives

To investigate the incidence, risk factors, and clinical outcomes of ABS associated with traumatic ASDH.

Design

Retrospective study.

Methods

Data for 161 patients diagnosed with traumatic ASDH were retrospectively collected. Novel computed tomography-based criteria were proposed for diagnosing ABS in patients with ASDH and determining its incidence. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of post-traumatic ABS. The Glasgow Outcome Scale (GOS) score, mortality, and functional prognosis of all patients at discharge and the proportion of intraoperative malignant brain bulge in surgical patients were taken as clinical outcome measures.

Results

A total of 45 (28%) patients experienced post-traumatic ABS, exhibiting significantly lower Glasgow Coma Scale scores on admission (p < 0.001). The incidence of hemispheric and whole-brain swelling was 8.1% and 19.9%, respectively. Risk factors independently associated with post-traumatic ABS were: (1) age [odds ratio (OR) = 0.917, p < 0.001]; (2) platelet to white blood cell ratio (PWR) (OR = 0.887, p = 0.012); and (3) traumatic subarachnoid hemorrhage (SAH) (OR = 4.346, p = 0.005). The ABS cohort had a lower GOS score [2 (1-3) versus 4 (3-5); p < 0.001], higher mortality (46.7% versus 6.9%; p < 0.001), and higher proportion of unfavorable functional prognosis (75.6% versus 34.5%; p < 0.001) upon discharge compared to the no ABS cohort, along with higher proportion of intraoperative malignant brain bulge (43.8% versus 0%; p < 0.001).

Conclusion

The incidence of ABS associated with ASDH is significantly high overall. Patients with ASDH who have young age, low PWR, and traumatic SAH are at an increased risk of developing post-traumatic ABS, and therefore of poor clinical outcomes.

Comparison of Retroauricular and Reverse Question Mark Incisions for Decompressive Hemicraniectomy

BACKGROUND

The retroauricular (RA) incision has several theoretical benefits compared with the reverse question mark (RQM) incision for decompressive hemicraniectomy (DHC), but limited data comparing the 2 exist.

METHODS

Consecutive patients who underwent DHC between 2016 and 2022 and survived ≥30 days at a single institution were included. The primary outcome was wound complication within 30 days (30dWC) requiring reoperation. Secondary outcomes included 90-day wound complication (90dWC), craniectomy size in anterior-posterior (AP) and superior-inferior dimensions, distance from the inferior craniectomy margin to the middle cranial fossa (MCF), estimated blood loss (EBL), and operative duration. Multivariate analyses were performed for each outcome.

RESULTS

A total of 110 patients (RA group: 27, RQM group: 83) were included. The incidence of 30dWC was 1.2% and 0 in the RQM and RA groups, respectively. The incidence of 90dWC was 2.4% and 3.7% in the RQM and RA groups, respectively. There was no difference in mean AP size (RQM: 15 cm, RA: 14.4 cm; P = 0.18), superior-inferior size (RQM: 11.8 cm, RA: 11.9 cm; P = 0.92), and distance from MCF (RQM: 15.4 mm, RA: 18 mm; P = 0.18). Mean EBL (RQM: 418 mL, RA: 314 mL; P = 0.36) and operative duration (RQM: 103 min, RA: 89 min; P = 0.14) were similar. There was no difference in cranioplasty wound complications, EBL, or operative duration.

CONCLUSIONS

Wound complications are comparable between the RQM and RA incisions. The RA incision does not compromise craniectomy size or temporal bone removal.

The Adjustable Cranial Plate: A Novel Implant Designed to Eliminate the Need for Cranioplasty Surgery Following a Hemicraniectomy Operation

BACKGROUND

Decompressive hemicraniectomy (DHC) is performed to relieve life-threatening intracranial pressure elevations. After swelling abates, a cranioplasty is performed for mechanical integrity and cosmesis. Cranioplasty is costly with high complication rates. Prior attempts to obviate second-stage cranioplasty have been unsuccessful. The Adjustable Cranial Plate (ACP) is designed for implantation during DHC to afford maximal volumetric expansion with later repositioning without requiring a second major operation.

METHODS

The ACP has a mobile section held by a tripod fixation mechanism. Centrally located gears adjust the implant between the up and down positions. Cadaveric ACP implantation was performed. Virtual DHC and ACP placement were done using imaging data from 94 patients who had previously undergone DHC to corroborate our cadaveric results. Imaging analysis methods were used to calculate volumes of cranial expansion.

RESULTS

The ACP implantation and adjustment procedures are feasible in cadaveric testing without wound closure difficulties. Results of the cadaveric study showed total volumetric expansion achieved was 222 cm3. Results of the virtual DHC procedure showed the volume of cranial expansion achieved by removing a standardized bone flap was 132 cm3 (range, 89-171 cm3). Applied to virtual craniectomy patients, the total volume of expansion achieved with the ACP implantation operation was 222 cm3 (range, 181-263 cm3).

CONCLUSIONS

ACP implantation during DHC is technically feasible. It achieves a volume of cranial expansion that will accommodate that observed following survivable hemicraniectomy operations. Moving the implant from the up to the down position can easily be performed as a simple outpatient or inpatient bedside procedure, thus potentially eliminating second-stage cranioplasty procedures.

Size of Craniectomy Predicts Approach-Related Shear Bleeding in Poor-Grade Subarachnoid Hemorrhage

Decompressive craniectomy is an option to decrease elevated intracranial pressure in poor-grade aneurysmal subarachnoid hemorrhage (SAH) patients. The aim of the present study was to analyze the size of the bone flap according to approach-related complications in patients with poor-grade SAH. We retrospectively analyzed poor-grade SAH patients (WFNS 4 and 5) who underwent aneurysm clipping and craniectomy (DC or ommitance of bone flap reinsertion). Postoperative CT scans were analyzed for approach-related tissue injury at the margin of the craniectomy (shear bleeding). The size of the bone flap was calculated using the De Bonis equation. Between 01/2012 and 01/2020, 67 poor-grade SAH patients underwent clipping and craniectomy at our institution. We found 14 patients with new shear bleeding lesion in postoperative CT scan. In patients with shear bleeding, the size of the bone flap was significantly smaller compared to patients without shear bleeding (102.1 ± 45.2 cm2 vs. 150.8 ± 37.43 cm2, p > 0.0001). However, we found no difference in mortality rates (10/14 vs. 23/53, p = 0.07) or number of implanted VP shunts (2/14 vs. 18/53, p = 0.2). We found no difference regarding modified Rankin Scale (mRS) 6 months postoperatively. In poor-grade aneurysmal SAH, the initial planning of DC—if deemed necessary —and enlargement of the flap size seems to decrease the rate of postoperatively developed shear bleeding lesions.

Complications of Decompressive Craniectomy: A Case-Based Review

Background Decompressive craniectomy (DC) is a frequently performed procedure to treat intracranial hypertension following traumatic brain injury (TBI) and stroke. DC is a salvage procedure that reduces mortality at the expense of severe disability and compromises the quality of life. The procedure is not without serious complications.

Methods We describe the complications following DC and its management in a case-based review in this article.

Results Complications after DC are classified as early or late complications based on the time of occurrence. Early complication includes hemorrhage, external cerebral herniation, wound complications, CSF leak/fistula, and seizures/epilepsy. Contusion expansion, new contralateral epidural, and subdural hematoma in the immediate postoperative period mandate surgical intervention. It is necessary to repeat non-contrast CT head at 24 hours and 48 hours following DC. Late complication includes subdural hygroma, hydrocephalus, syndrome of the trephined, bone resorption, and falls on the unprotected cranium. An early cranioplasty is an effective strategy to mitigate most of the late complications.

Conclusions DC can be associated with a number of complications. One should be aware of the possible complications, and timely intervention is required.

Decompressive Craniectomy in Severe Traumatic Brain Injury: The Intensivist's Point of View

INTRODUCTION

Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical-surgical consultation.

The compensatory mechanism and clinical significance of hydrocephalus after cranioplasty

Objective

Cranioplasty (CP) and ventriculoperitoneal shunt (VPS) are procedures required after decompression of the flap (DC) to protect the cranial frame and prevent hydrocephalus. This study evaluated the safety and efficacy of different surgical sequences of CP and VPS after DC and identified risk factors for necessary permanent VPS.

Methods

From January 2017 to December 2021, valid follow-up data were collected in 192 cases. The observation group preferred CP, and then evaluated whether to receive VPS according to the progress of hydrocephalus. the control group was prioritized for VPS and continued with CP after 1 week. The improvement of hydrocephalus symptoms, follow-up outcomes, and post-operative complications before and after surgery were compared between the two groups, and univariate analysis was used to determine the risk factors for necessary permanent risk factors for VPS.

Results

There were 86 cases (44.8%) in the observation group, who received CP first, while 106 cases (55.2%) in the control group received VPS and CP, respectively. There was no significant difference between the two groups according to Barthel index, FMAS, Mrs, GCS, and Evans index, and there was no statistical difference in complications between the two groups. However, in the observation group, hydrocephalus disappeared after CP operation in 29 cases (33.7%), and finally avoided VPS. Univariate analysis showed that the main etiology was related to the size of the skull defect, the distance of the talus margin relative to the flap to the midline, and lumbar puncture pressure was a predictor of the need for permanent VPS.

Conclusion

This study provides detailed information on the efficacy and complications of different sequences of preferential CP or VPS after DC surgery. We found that priority CP reduced the incidence of VPS surgery without affecting surgical outcomes and complications.

Preventing Poor Outcomes for Neurosurgical Patients

Ensuring that patients with neurosurgical conditions have the best possible outcome requires early diagnosis, monitoring, and interventions to prevent complications and optimize care. Here, we review several neurosurgical conditions and the measures taken to prevent complications and optimize outcomes. We hope that the practical tips provided herein prove helpful in caring for neurosurgical patients.

Postoperative Hematoma Expansion in Patients Undergoing Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage

Introduction: The aim of the study was to analyze risk factors for hematoma expansion (HE) in patients undergoing decompressive hemicraniectomy (DC) in patients with elevated intracranial pressure due to spontaneous intracerebral hematoma (ICH). Methods: We retrospectively evaluated 72 patients with spontaneous ICH who underwent DC at our institution. We compared the pre- and postoperative volumes of ICH and divided the patients into two groups: first, patients with postoperative HE > 6 cm3 (group 1), and second, patients without HE (group 2). Additionally, we screened the medical history for anticoagulant and antiplatelet medication (AC/AP), bleeding-related comorbidities, age, admission Glasgow coma scale and laboratory parameters. Results: The rate of AC/AP medication was higher in group 1 versus group 2 (15/16 vs. 5/38, p < 0.00001), and patients were significantly older in group 1 versus group 2 (65.1 ± 16.2 years vs. 54.4 ± 14.3 years, p = 0.02). Furthermore, preoperative laboratory tests showed lower rates of hematocrit (34.1 ± 5.4% vs. 38.1 ± 5.1%, p = 0.01) and hemoglobin (11.5 ± 1.6 g/dL vs. 13.13 ± 1.8 g/dL, p = 0.0028) in group 1 versus group 2. In multivariate analysis, the history of AC/AP medication was the only independent predictor of HE (p < 0.0001, OR 0.015, CI 95% 0.001−0.153). Conclusion: We presented a comprehensive evaluation of risk factors for hematoma epansion by patients undergoing DC due to ICH.

A systematic review and meta-analysis of factors involved in bone flap resorption after decompressive craniectomy

Decompressive craniectomy (DC) is effective in controlling increasing intracranial pressure determined by a wide range of conditions, mainly traumatic brain injury (TBI) and stroke, and the subsequent cranioplasty (CP) displays potential therapeutic benefit in terms of overall neurological function. While autologous bone flap (ABF) harvested at the time of DC is the ideal material for skull defect reconstruction, it carries several risks. Aseptic bone flap resorption (BFR) is one of the most common complications, often leading to surgical failure. The aim of our study was to systematically review the literature and carry out a meta-analysis of possible factors involved in BFR in patients undergoing ABF cranioplasty after DC. A systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. Different medical databases (PubMed, Embase, and Scopus) were screened for eligible scientific reports until April 30th 2021. The following data were collected for meta-analysis to assess their role in BFR: sex, age, the interval time between DC and CP, the presence of systemic factors, the etiology determining the DC, CP surgical time, CP features, VP shunt placement, CP infection. Studies including pediatric patients or with less than 50 patients were excluded. Fifteen studies were included. There was a statistically significant increased incidence of BFR in patients with CPF > 2 compared to patients with CPF ≤ 2 (54.50% and 22.76% respectively, p = 0.010). TBI was a significantly more frequent etiology in the BFR group compared to patients without BFR (61.95% and 47.58% respectively, p < 0.001). Finally, patients with BFR were significantly younger than patients without BFR (39.12 ± 15.36 years and 47.31 ± 14.78 years, respectively, p < 0.001). The funnel plots were largely symmetrical for all the studied factors. Bone flap fragmentation, TBI etiology, and young age significantly increase the risk of bone resorption. Further studies are needed to strengthen our results and to clarify if, in those cases, a synthetic implant for primary CP should be recommended.

Intracranial pressure management: moving beyond guidelines

PURPOSE OF REVIEW

The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for care, moving from traditional to more recent concepts.

RECENT FINDINGS

Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skull, an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull.

SUMMARY

ICP management is a complex task, moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.

Pre-hospital mild therapeutic hypothermia for patients with severe traumatic brain injury

BACKGROUND

We aimed to assess the effects of pre-hospital mild therapeutic hypothermia (MTH) on patients with severe traumatic brain injury (sTBI).

METHODS

Eighty-six patients with sTBI were prospectively enrolled into the pre-hospital MTH group and the late MTH group (initiated in hospital). Patients in the pre-hospital MTH group were maintained at a tympanic temperature of 33°C-35°C before admission and continued to be treated with a therapeutic hypothermia device for 4 days. Patients in the late MTH group were treated with the same MTH parameters. Intracranial pressure (ICP), complications and Glasgow Outcome Scale (GOS) scores were monitored.

RESULTS

ICP was significantly lower for patients in the pre-hospital MTH group 24, 48, and 72 h after treatment (17.38 ± 4.88 mmHg, 18.40 ± 4.50 mmHg, and 16.40 ± 4.13 mmHg, respectively) than that in the late MTH group (20.63 ± 3.00 mmHg, 21.80 ± 6.00 mmHg, and 18.81 ± 4.50 mmHg) (P < .05). The favorable prognosis (GOS scores 4-5) rate in the pre-hospital MTH group was higher tha n the late MTH group (65.1% vs. 37.2%, respectively; P < .05) without complications .

CONCLUSION

Pre-hospital MTH for patients with STBI can reduce ICP and improve neurological outcomes.

Decompressive craniectomy in traumatic brain injury: The intensivist's point of view

OBJETIVE

To perform a score with early clinical and radiological findings after a TBI that identifies the patients who in their subsequent evolution are going to undergo DC.

METHOD

Observational study of a retrospective cohort of patients who, after a TBI, enter the Neurocritical Section of the Intensive Care Unit of our hospital for a period of 5 years (2014-2018). Detection of clinical and radiological criteria and generation of all possible models with significant, clinically relevant and easy to detect early variables. Selection of the one with the lowest Bayesian Information Criterion and Akaike Information Criterion values for the creation of the score. Calibration and internal validation of the score using the Hosmer-Lemeshow and a bootstrapping analysis with 1000 re-samples respectively.

RESULTS

37 DC were performed in 153 patients who were admitted after a TBI. The resulting final model included Cerebral Midline Deviation, GCS and Ventricular Collapse with an Area under ROC Curve: 0.84 (95% IC 0.78-0.91) and Hosmer-Lemeshow p=0.71. The developed score detected well those patients who were going to need an early DC (first 24h) after a TBI (2.5±0.5) but not those who would need it in a later stage of their disease (1.7±0.8). However, it seems to advice us about the patients who, although not requiring an early DC are likely to need it later in their evolution (DC after 24h vs. do not require DC, 1.7±0.8 vs. 1±0.7; p=0.002).

CONCLUSION

We have developed a prognostic score using early clinical-radiological criteria that, in our environment, detects with good sensitivity and specificity those patients who, after a TBI, will require a DC.

Effects of Yunanan Baiyao adjunct therapy on postoperative recovery and clinical prognosis of patients with traumatic brain injury: A randomized controlled trial

BACKGROUND

Effective therapies are needed to prevent the secondary injury and poor prognosis associated with emergency craniotomy of traumatic brain injury (TBI).

HYPOTHESIS/PURPOSE

The wound-healing medicine Yunnan Baiyao (YB) and Xingnaojing (XNJ) adjunct-therapy may improve the outcome of orthodox mono-therapy (OT).

STUDY DESIGN

Randomized controlled trial.

METHODS

Eighty patients with moderate-to-severe TBI received emergency craniotomy (within 12 h after TBI) at the Chinese PLA General Hospital before being randomly assigned to 4 different treatments (n = 20) for 7 days: 1) OT; 2) OT+XNJ (i.v. 20 ml/daily); 3) OT+low dose-YB (oral, 1,000 mg/day); 4) OT+high dose-YB, 2,000 mg/day).

RESULTS

GCS score was improved more quickly and became significantly higher in XNJ, l-YB, h-YB groups than in OT group (p<0.01). Serum S100B peaked higher but declined more slowly in OT group than in other groups (p<0.01). On postoperative Day 7, S100B was 20% below baseline in YB and XNJ groups but remained 19% above baseline in OT group which also lost 38% of superoxide dismutase (SOD) activity on Day 3 and recovered 69% of SOD on Day 7 whereas the YB and XNJ groups lost 16%∼23% of SOD activity on Day 3 and recovered 92%∼99% of SOD on Day 7 (p<0.01). Clinical prognosis (Glasgow Outcome Scale and Karnofsky Performance Scale) were significantly better (25%∼30%) in the XNJ, l-YB and h-YB groups than in OT group 3 months post-surgery and were correlated with serum S100B and SOD.

CONCLUSIONS

YB and XNJ adjunct therapies improved postoperative recovery and clinical prognosis in patients with moderate-to-severe TBI partly through divergent regulation of S100B and SOD pathways. (The trial was registered at Chinese Clinical Trial Registry (ChiCTR) trial registration number: ChiCTR2000030280).

How do we identify the crashing traumatic brain injury patient - the neurosurgeon's view

PURPOSE OF REVIEW

To provide an overview on recent advances in the field of assessment and monitoring of patients with severe traumatic brain injury (sTBI) in neurocritical care from a neurosurgical point of view.

RECENT FINDINGS

In high-income countries, monitoring of patients with sTBI heavily relies on multimodal neurocritical parameters, nonetheless clinical assessment still has a solid role in decision-making. There are guidelines and consensus-based treatment algorithms that can be employed in both absence and presence of multimodal monitoring in the management of patients with sTBI. Additionally, novel dynamic monitoring options and machine learning-based prognostic models are introduced. Currently, the acute management and treatment of secondary injury/insults is focused on dealing with the objective evident pathology. An ongoing paradigm shift is emerging towards more proactive treatment of neuroworsening as soon as premonitory signs of deterioration are detected.

SUMMARY

Based on the current evidence, serial clinical assessment, neuroimaging, intracranial and cerebral perfusion pressure and brain tissue oxygen monitoring are key components of sTBI care. Clinical assessment has a crucial role in identifying the crashing patient with sTBI, especially from a neurosurgical standpoint. Multimodal monitoring and clinical assessment should be seen as complementary evaluation methods that support one another.

Does the Size of Unilateral Decompressive Craniectomy Impact Clinical Outcomes in Patients with Intracranial Mass Effect after Severe Traumatic Brain Injury?

Objective

Decompressive craniectomy (DC) is one of the treatment modalities in severe traumatic brain injury (TBI), however, there was a lack of evidence for optimal craniectomy size. The authors aimed to investigate optimal DC size and analyze clinical outcome according to craniectomy size.

Methods

We retrospectively reviewed the medical data of 87 patients with a space occupying lesion following TBI who underwent unilateral DC. Craniectomy size was measured by anterior-posterior (AP) diameter and surface estimate (SE). Mortality, clinical outcome, and complications were collected and analyzed according to craniectomy size.

Results

Nineteen patients (21.8%) died and 35 patients (40.2%) had a favorable outcome at last follow-up (a mean duration, 30.3±39.4 months; range, 0.2-132.6 months). Receiver operating curve analyses identified AP diameter more than 12.5 cm (area under the curve [AUC]=0.740; p=0.002) and SE more than 98.0 cm² (AUC=0.752; p=0.001) as cut-off values for survival, and AP diameter more than 13.4 cm (AUC=0.650; p=0.018) and SE more than 107.3 cm² (AUC=0.685; p=0.003) for favorable outcome. Large craniectomy resulted in a significantly lower mortality rate and a higher rate of favorable outcome than small craniectomy (p=0.005 and p=0.014, respectively). However, procedure related bleeding occurred more frequently in the large craniectomy group (p=0.044).

Conclusion

Unilateral DC size is associated with clinical outcome of patients with a space occupying lesion following severe TBI. Large craniectomy is needed for survival and favorable outcome.

Scenario for the use of effusion-peritoneal shunt necessary against subdural effusion secondary to decompressive craniectomy

OBJECTIVES

This study aimed to summarize the surgical strategies for subdural effusion secondary to decompressive craniectomy (SESDC) and discuss the applicable scenarios of effusion-peritoneal shunt (EP shunt).

METHODS

A total of 53 consecutive patients with SESDC were screened out of 7569 cases. The SESDC was divided into five types, and the treatment methods of each type were analyzed and compared. According to the implementation strategy of cranioplasty (CP), patients were divided into CP-first and delayed-CP groups. The differences in surgical methods were compared between the two groups.

RESULTS

All patients with SESDC in this cohort had undergone cranioplasty. Subcutaneous puncture and aspiration (SPAA) proved ineffective. Only 2/30 patients in the CP-first group used EP shunt, while 6/19 patients in the delayed-CP group used EP shunt; the difference was statistically significant (P = 0.03). A significant difference was found in the use of EP shunt among type 1, type 2, and type 5 SESDC (χ² = 6.778, P = 0.034).

CONCLUSIONS

CP combined with other treatments could cure most SESDC. EP shunt should be used preferentially in some specific scenarios in which CP cannot be performed first, rather than as a backup measure that can only be used when other preceding treatments fail.

An economic evaluation for the use of decompressive craniectomy in the treatment of refractory traumatic intracranial hypertension

Objectives: The management of intracranial hypertension is a primary concern following traumatic brain injury. Data from recent randomized controlled trials have indicated that decompressive craniectomy results in some improved clinical outcomes compared to medical treatment for patients with refractory intracranial hypertension post-traumatic brain injury (TBI). This economic evaluation aims to assess the cost-effectiveness of decompressive craniectomy as a last-tier intervention for refractory intracranial hypertension from the perspective of the National Health Service (NHS).Methods: A Markov model was used to present the results from an international, multicentre, parallel-group, superiority, randomized trial. A cost-utility analysis was then carried out over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling.Results: The cost-utility analysis produced an incremental cost-effectiveness ratio (ICER) of £96,155.67 per QALY. This means that for every additional QALY gained by treating patients with decompressive craniectomy, a cost of £96,155.67 is incurred to the NHS.Conclusions: The ICER calculated is above the National Institute for Health and Care Excellence (NICE) threshold of £30,000 per QALY. This indicates that decompressive craniectomy is not a cost-effective first treatment option for refractory intracranial hypertension and maximum medical management is preferable initially.

Decompressive craniectomy in traumatic brain injury: the intensivist's point of view

OBJETIVE

To perform a score with early clinical and radiological findings after a TBI that identifies the patients who in their subsequent evolution are going to undergo DC.

METHOD

Observational study of a retrospective cohort of patients who, after a TBI, enter the Neurocritical Section of the Intensive Care Unit of our hospital for a period of 5 years (2014-2018). Detection of clinical and radiological criteria and generation of all possible models with significant, clinically relevant and easy to detect early variables. Selection of the one with the lowest Bayesian Information Criterion and Akaike Information Criterion values for the creation of the score. Calibration and internal validation of the score using the Hosmer-Lemeshow and a bootstrapping analysis with 1,000 re-samples respectively.

RESULTS

37 DC were performed in 153 patients who were admitted after a TBI. The resulting final model included Cerebral Midline Deviation, GCS and Ventricular Collapse with an Area under ROC Curve: 0.84 (95% IC 0.78-0.91) and Hosmer-Lemeshow p=0.71. The developed score detected well those patients who were going to need an early DC (first 24hours) after a TBI (2.5±0.5) but not those who would need it in a later stage of their disease (1.7±0.8). However, it seems to advice us about the patients who, although not requiring an early DC are likely to need it later in their evolution (DC after 24hours vs do not require DC, 1.7±0.8 vs 1±0.7; p=0.002).

CONCLUSION

We have developed a prognostic score using early clinical-radiological criteria that, in our environment, detects with good sensitivity and specificity those patients who, after a TBI, will require a DC.

Escalate and De-Escalate Therapies for Intracranial Pressure Control in Traumatic Brain Injury

Severe traumatic brain injury (TBI) is frequently associated with an elevation of intracranial pressure (ICP), followed by cerebral perfusion pressure (CPP) reduction. Invasive monitoring of ICP is recommended to guide a step-by-step “staircase approach” which aims to normalize ICP values and reduce the risks of secondary damage. However, if such monitoring is not available clinical examination and radiological criteria should be used. A major concern is how to taper the therapies employed for ICP control. The aim of this manuscript is to review the criteria for escalating and withdrawing therapies in TBI patients. Each step of the staircase approach carries a risk of adverse effects related to the duration of treatment. Tapering of barbiturates should start once ICP control has been achieved for at least 24 h, although a period of 2–12 days is often required. Administration of hyperosmolar fluids should be avoided if ICP is normal. Sedation should be reduced after at least 24 h of controlled ICP to allow neurological examination. Removal of invasive ICP monitoring is suggested after 72 h of normal ICP. For patients who have undergone surgical decompression, cranioplasty represents the final step, and an earlier cranioplasty (15–90 days after decompression) seems to reduce the rate of infection, seizures, and hydrocephalus.

Decompressive Craniectomy for Traumatic Brain Injury: In-hospital Mortality-Associated Factors

Objective  Determine predictors of in-hospital mortality in patients with severe traumatic brain injury (TBI) who underwent decompressive craniectomy. Materials and Methods  This retrospective study reviewed consecutive patients who underwent a decompressive craniectomy between March 2017 and March 2020 at our institution, and analyzed clinical characteristics, brain tomographic images, surgical details and morbimortality associated with this procedure. Results  Thirty-three (30 unilateral and 3 bifrontal) decompressive craniectomies were performed, of which 27 patients were male (81.8%). The mean age was 52.18 years, the mean Glasgow coma scale (GCS) score at admission was 9, and 24 patients had anisocoria (72.7%). Falls were the principal cause of the trauma (51.5%), the mean anterior-posterior diameter (APD) of the bone flap in unilateral cases was 106.81 mm (standard deviation [SD] 20.42) and 16 patients (53.3%) underwent a right-sided hemicraniectomy. The temporal bone enlargement was done in 20 cases (66.7%), the mean time of surgery was 2 hours and 27 minutes, the skull flap was preserved in the subcutaneous layer in 29 cases (87.8%), the mean of blood loss was 636.36 mL,and in-hospital mortality was 12%. Univariate analysis found differences between the APD diameter (120.3 mm vs. 85.3 mm; p = 0.003) and the presence of midline shift > 5 mm ( p = 0.033). Conclusion  The size of the skull flap and the presence of midline shift > 5 mm were predictors of mortality. In the absence of intercranial pressure (ICP) monitoring, clinical and radiological criteria are mandatory to perform a decompressive craniectomy.

A Systematic Review and Meta-Analysis of Hypothermia in Experimental Traumatic Brain Injury: Why Have Promising Animal Studies Not Been Replicated in Pragmatic Clinical Trials?

Therapeutic hypothermia was a mainstay of severe traumatic brain injury (TBI) management for half a century. Recent trials have suggested that its effect on long-term functional outcome is neutral or negative, despite apparently promising pre-clinical data. Systematic review and meta-analysis is a useful tool to collate experimental data and investigate the basis of its conclusions. We searched three online databases to identify studies testing systemic hypothermia as monotherapy for treatment of animals subjected to a TBI. Data pertaining to TBI paradigm, animal subjects, and hypothermia management were extracted as well as those relating to risk of bias. We pooled outcome data where sufficient numbers allowed and investigated heterogeneity in neurobehavioral outcomes using multi-variate meta-regression. We identified 90 publications reporting 272 experiments testing hypothermia in animals subject to TBI. The subjects were mostly small animals, with well-established models predominating. Target temperature was comparable to clinical trial data but treatment was initiated very early. Study quality was low and there was some evidence of publication bias. Delay to treatment, comorbidity, and blinded outcome assessment appeared to predict neurobehavioral outcome on multi-variate meta-regression. Therapeutic hypothermia appears to be an efficacious treatment in experimental TBI, which differs from the clinical evidence. The pre-clinical literature showed limitations in quality and design and these both appeared to affect neurobehavioral experiment outcome. These should be acknowledged when designing and interpreting pre-clinical TBI studies in the future.

Traumatic subdural haematoma: integrating case-based clinical judgement with guidelines

Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity with a significant loss of functional capacity and a huge socioeconomic burden. Road traffic accidents are the most common (60%) cause followed by falls and violence in India and worldwide. This case discusses the story of a 23-year-old man with severe TBI-subdural haematoma, who presented in a comatose state. The patient was a purported candidate for emergency decompressive surgery as per Brain Trauma Foundation (BTF) guidelines but was managed conservatively. This case questions the plausibility of the BTF guidelines for severe TBI, particularly in rural hospitals in India and how such cases are often managed with clinical judgement based on the review of literature. The patient recovered well with a perfect 8/8 on Glasgow Outcome Scale Extended Score.

Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations

When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of "living guidelines," whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at: https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/.

Protocol-Based Early Decompressive Craniectomy in a Resource-Constrained Environment: A Tertiary Care Hospital Experience

OBJECTIVES

Decompressive craniectomy (DC) is an emergency life-saving procedure used to treat refractory intracranial hypertension (RICH). The authors aim to analyze their experience with protocol-based early DC (<24 h) in RICH cases diagnosed based on clinical and radiological evidence, without preoperative intracranial pressure monitoring done over 10 years.

MATERIALS AND METHODS

This is a retrospective, observational study which includes 58 consecutive patients who underwent protocol-based early DC by the senior author at a single institution between 2007 and 2017. Background variables and outcome in the form of Glasgow Outcome Score-Extended (GOS-E) at 6 months and 1 year were analyzed.

RESULTS

Fourteen patients had traumatic brain injury (TBI), 17 had intracranial hemorrhage (ICH), 14 had malignant cerebral infarcts (MCI), and the reminder 13 patients had other causes. At 6 months, the mortality rate was 22.4%. Good recovery, moderate disability, and severe disability were seen in 13.8%, 17.2%, and 43.1% of patients, respectively. Two patients were in vegetative state. The cutoff for favorable/unfavorable outcome was defined as GOS-E 4-8/1-3. By this application, 63.8% of patients had favorable outcome at 6 months. The favorable outcome in patients of TBI, ICH, and MCI was 57.1%, 58.8%, and 85.7%, respectively.

CONCLUSIONS

DC helps in obtaining a favorable outcome in selected patients with a defined pathology. The diagnosis of RICH based on clinical and radiological parameters, and protocol-based early DC, is reasonably justified as the way forward for resource-constrained environments. The risk of vegetative state is small.

Optimal Bone Flap Size for Decompressive Craniectomy for Refractory Increased Intracranial Pressure in Traumatic Brain Injury: Taking the Patient's Head Size into Account

BACKGROUND

Decompressive craniectomy (DC) is a widely used treatment for refractory high intracranial pressure (ICP). While the Brain Trauma Foundation guidelines favor large DC, there remains a lack of consensus regarding the optimal size of DC in relationship to the patient's head size. The aim of this study is to determine the optimal size of DC to effectively control refractory ICP in traumatic brain injury and to measure that size with a method that takes into consideration the patient's head size.

METHODS

All cases of unilateral DC performed to control refractory increased ICP due to cerebral edema during a 7½-year period were included. Demographic and injury-related data were collected by retrospective chart review. The patients were categorized in 2 groups: 21 patients with a "small flaps" and 9 patients with a "large flap."

RESULTS

Two groups had similar preoperative characteristics. The amount of cerebrospinal fluid drained and the doses of hyperosmolar therapy given were not different between the 2 groups. The postoperative ICP was significantly lower for the large craniectomy flap group: 13.3 mm Hg confidence interval 99% [12.7, 13.8] versus 16.9 mm Hg confidence interval 99% [16.5, 17.2] (P = 0.01), and this difference was maintained for 96 hours postoperatively.

CONCLUSIONS

Better ICP control was achieved in patients who underwent a large decompressive craniectomy (ratio >65%) when compared with smaller craniectomy sizes. The proposed method of measuring the craniectomy size, to our knowledge, is the first to take into account the patient's head size and can be easily measured intraoperatively.

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.

Inadequate Decompressive Craniectomy Following a Wartime Traumatic Brain Injury - An Illustrative Case of Why Size Matters

Traumatic brain injury has been called the "signature injury" of the wars in Iraq and Afghanistan, and the management of severe and penetrating brain injury has evolved considerably based on the experiences of military neurosurgeons. Current guidelines recommend that decompressive hemicraniectomy be performed with large, frontotemporoparietal bone flaps, but practice patterns vary markedly. The following case is illustrative of potential clinical courses, complications, and efforts to salvage inadequately-sized decompressive craniectomies performed for combat-related severe and penetrating brain injury. The authors follow this with a review of the current literature pertaining to decompressive craniectomy, and finally provide their recommendations for some of the technical nuances of performing decompressive hemicraniectomy after severe or penetrating brain injury.

The Role of Decompressive Craniectomy in the Context of Severe Traumatic Brain Injury: Summary of Results and Analysis of the Confidence Level of Conclusions From Systematic Reviews and Meta-Analyses

Introduction: Traumatic brain injury (TBI) is a global epidemic. The incidence of TBI in low and middle-income countries (LMICs) is three times greater than in high-income countries (HICs). Decompressive craniectomy (DC) is a surgical procedure to reduce intracranial pressure (ICP) and prevent secondary injury. Multiple comparative studies, and several randomized controlled trials (RCTs) have been conducted to investigate the influence of DC for patients with severe TBI on outcomes such as mortality, ICP, neurological outcomes, and intensive care unit (ICU) and hospital length of stay. The results of these studies are inconsistent. Systematic reviews and meta-analyses have been conducted in an effort to aggregate the data from the individual studies, and perhaps derive reliable conclusions. The purpose of this project was to conduct a review of the reviews about the effectiveness of DC to improve outcomes.

Methods: We conducted a systematic search of the literature to identify reviews and meta-analyses that met our pre-determined criteria. We used the AMSTAR 2 instrument to assess the quality of each of the included reviews, and determine the level of confidence.

Results: Of 973 citations from the original search, five publications were included in our review. Four of them included meta-analyses. For mortality, three reviews found a positive effect of DC compared to medical management and two found no significant difference between groups. The four reviews that measured neurological outcome found no benefit of DC. The two reviews that assessed ICP both found DC to be beneficial in reducing ICP. DC demonstrated a significant reduction in ICU length of stay in the one study that measured it, and a significant reduction in hospital length of stay in the two studies that measured it. According to the AMSTAR 2 criteria, the five reviews ranged in levels of confidence from low to critically low.

Conclusion: Systematic reviews and meta-analyses are important approaches for aggregating information from multiple studies. Clinicians rely of these methods for concise interpretation of scientific literature. Standards for quality of systematic reviews and meta-analyses have been established to support the quality of the reviews being produced. In the case of DC, more attention must be paid to quality standards, in the generation of both individual studies and reviews.

Early autologous cranioplasty: complications and identification of risk factors using virtual reality visualisation technique

Background: Cranioplasty (CP) of autologous bone flap after decompressive craniectomy (DC) is known to be associated with a high complication rate, particularly bone flap resorption (BFR). In a retrospective study, we used a novel virtual reality (VR) visualisation technique to identify and evaluate risk factors associated with CP.Method: Twenty-five patients underwent early autologous CP. All complications were recorded. Cranial computed tomography scans were visualised via the VR software to access the fitting accuracy of the bone flap (bone flap size, gap width at trepanation cutting edge, extent of osteoclastic extension).Results: An overall complication rate of 44% was seen, and BFR was the most common (36%). Only 'osteoclastic extension of trepanation' (p = .04) was a significant risk factor for BFR. The factors 'indication for DC' (p = .09) and 'size of bone flap' (p = .09) had a tendency towards influencing the rate of BFR, while 'age' (p = .68), 'time interval between DC and CP' (p = 1.00), and 'gap width' (p = .50) were not considered to influence the BFR rate.Conclusions: DC and subsequent CP is a complication-prone procedure. Therefore, it is relevant to identify and quantify probable risk factors for the most common complications, such as BFR. Here, we found that the extent of osteoclastic extension may impair the patient's healing process. Our investigation was made considerably easier by using the novel VR visualisation technique, which allows parallax free measurements of distances in 3D space.

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement

BACKGROUND

Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach.

METHODS

The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries.

RESULTS

The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval.

CONCLUSIONS

In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.