Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis

Noninvasive and reliable automated detection of spreading depolarization in severe traumatic brain injury using scalp EEG

BACKGROUND

Spreading depolarizations (SDs) are a biomarker and a potentially treatable mechanism of worsening brain injury after traumatic brain injury (TBI). Noninvasive detection of SDs could transform critical care for brain injury patients but has remained elusive. Current methods to detect SDs are based on invasive intracranial recordings with limited spatial coverage. In this study, we establish the feasibility of automated SD detection through noninvasive scalp electroencephalography (EEG) for patients with severe TBI.

METHODS

Building on our recent WAVEFRONT algorithm, we designed an automated SD detection method. This algorithm, with learnable parameters and improved velocity estimation, extracts and tracks propagating power depressions using low-density EEG. The dataset for testing our algorithm contains 700 total SDs in 12 severe TBI patients who underwent decompressive hemicraniectomy (DHC), labeled using ground-truth intracranial EEG recordings. We utilize simultaneously recorded, continuous, low-density (19 electrodes) scalp EEG signals, to quantify the detection accuracy of WAVEFRONT in terms of true positive rate (TPR), false positive rate (FPR), as well as the accuracy of estimating SD frequency.

RESULTS

WAVEFRONT achieves the best average validation accuracy using Delta band EEG: 74% TPR with less than 1.5% FPR. Further, preliminary evidence suggests WAVEFRONT can estimate how frequently SDs may occur.

CONCLUSIONS

We establish the feasibility, and quantify the performance, of noninvasive SD detection after severe TBI using an automated algorithm. The algorithm, WAVEFRONT, can also potentially be used for diagnosis, monitoring, and tailoring treatments for worsening brain injury. Extension of these results to patients with intact skulls requires further study.

A prospective, randomized, controlled study comparing two surgical procedures of decompressive craniectomy in patients with traumatic brain injury: Dural closure without dural closure

Decompressive craniectomy (DC) is used to treat severe traumatic brain injury [TBI]. The present study compared dural open and closed surgical procedures for DC and their relationship with Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (E) (GOS-E) scores and survival in prospective randomized controlled TBI patients. Patients aged 10-65 (36.97 ± 13.23) with DC were hospitalized in the neurotrauma unit of King George's Medical University, Lucknow, India. The patients were randomized into test; with dural closure (n = 60) and control without dural closure (OD) (n = 60) groups. After decompressive craniectomy, patients were monitored daily until hospital discharge or death and for three months. GSC/E leakage, infection, and functional status were also assessed. Age (p = 0.795), sex (p = 0.104), mode of injury (p = 0.195), GCS score (p = 0.40, p = 0.469), Rotterdam score (p = 0.731), and preoperative midline shift (MLS) (p = 0.378) did not vary between the OD and CD groups. Neither technique affected the mortality, motor score, or pupil response (p > 0.05). After one and three months, GOS extension was associated with open and closed dural procedures (p = 0.089). Intracranial pressure, brain bulge, GCS score, and MLS were not associated with theoperative method(p > 0.05). The open dural group had a significantly shorter procedure time than the closed dural group (P = 0.026). Both groups showed no significant difference (p > 0.05) between CSF leak and post-traumatic hydrocephalus. Dural opensurgery for a compressed craniectomy is shorter and not associated with significant surgical consequences compared to close dural close surgery.

Decompressive Craniectomy in the Management of Low Glasgow Coma Score Patients With Extradural Hematoma: A Review of Literature and Guidelines

An extradural hematoma (EDH), also known as an epidural hematoma, is a collection of blood between the inner skull table and the dura mater. It is restricted by the coronal, lambdoid, and sagittal sutures, as these are dural insertions. EDH most frequently occurs in 10- to 40-year-old patients. EDH is uncommon after age 60, as dura matter adheres firmly to the inner skull table. EDH is more common among men as compared to women. EDH most commonly occurs in the temporo-frontal regions and can also be seen in the parieto-occipital, parasagittal regions, and middle and posterior fossae. An EDH contributes approximately 2% of total head injuries and 15% of total fatal head injuries. In EDH, patients typically have a persistent, severe headache, and also, following a few hours of injury, they gradually lose consciousness. The primary bleeding vessels for EDH are the middle meningeal artery, middle meningeal vein, and torn dural venous sinuses. EDH is one of the many consequences of severe traumatic brain injuries that might lead to death. EDH is potentially a lethal condition that requires immediate intervention as, if left untreated, it can lead to growing transtentorial herniation, diminished consciousness, dilated pupils, and other neurological problems. Non-contrast computed tomography (NCCT) imaging is the gold standard of investigation for diagnosing EDH. For patients with surgical indications, early craniotomy and evacuation of acute extradural hematoma (AEDH) is the gold standard procedure and is predicted to have significant clinical results. Nevertheless, there is an ongoing debate regarding the best surgical operations for AEDH. Neurosurgeons must choose between a decompressive craniectomy (DC) or a craniotomy to manage EDH, especially in patients with low Glasgow coma scores, to have a better prognosis and clinical results. This is a consultant-based review article in which we have tried to contemplate various pieces of available literature. Here, the objective is to hypothesize DC as the primary surgical management for massive hematoma, which usually presents as a low Glasgow coma score. This is because DC was found to be beneficial in clinical practice.

Tissue Healing in Hemicraniectomy

Introduction

Decompressive hemicraniectomy (DHC) is a last-resort treatment for refractory intracranial hypertension. Perioperative morbidity is associated with high risks of wound healing disturbances (WHD). Recently, a retromastoidal frontoparietooccipital (RMF) incision type was performed to avoid healing disturbance due to enhanced tissue flap perfusion compared to the classical reverse “question mark” (“Dandy flap”) incision. The goal of this study was to analyze the details of tissue healing problems in DHC. 

Materials and methods

A total of 60 patients who underwent DHC were retrospectively analyzed. In 30 patients the “Dandy flap” incision (group A) and in 30 patients the RMF incision (group B) was made. Since no evidence-based data for the incision type that favors better wound healing exists, the form of incision was left at the surgeon´s discretion. Documentation of the patients was screened for the incidence of WHD: wound necrosis, dehiscence, and cerebrospinal fluid (CSF) leakage. Patient age, the time interval from surgery until the appearance of WHD, the length of surgeries in minutes, and the indications of the DHC were analyzed. A Chi-square test of independence was performed to examine the relationship between the incision type and the appearance of WHD with the statistical significance level set at p<0.05. The mean age of the patients, the mean time interval from surgery until the occurrence of WHD, and the mean length of the surgery between the two groups were compared using an independent sample t-test with the statistical significance level set at p<0.05.

Results

The most common indication for DHC in both groups was malignant MCA infarction (n=20, 66.6% for group A and n=16, 53.3% for group B). CSF leakage was 20% of the most frequent WHD in each group. Wound necrosis was observed only in group A. Although group B showed 13.3% fewer WHD than group A, this difference was not statistically significant. There was no statistically significant difference in the time range between surgery and the occurrence of WHD between the two groups. The length of surgery in group B was significantly shorter than in group A (120.2 mins vs. 103.7 mins).

Conclusion

A noticeable trend for reduced WHD was observed in the patient group using the RMF incision type although the difference was not statistically significant. We praise that the RMF incision allows an optimized skin-flap vascularization and, thereby, facilitates better wound healing. We were able to show a statistically shorter length of surgery with the RMF incision in contrast to the classic “Dandy flap” incision. Larger multicenter studies should be implemented to analyze and address the major advantages and pitfalls of the routinely applied incision techniques.

Surgical Management of Neurotrauma: When to Intervene

Neurotrauma, often defined as abrupt damage to the brain or spinal cord, is a substantial cause of mortality and morbidity that is widely recognized. As such, establishing an effective course of action is crucial to the enhancement of neurotrauma guidelines and patient outcomes in healthcare worldwide. Following the onset of neurotraumatic injuries, time is perhaps the most critical facet in diminishing mortality and morbidity rates. Thus, procuring the airway should be of utmost priority in a patient to allow for optimal ventilation, with a shift in focus resorting to surgical interventions after the patient reaches a suitable care facility. In particular, ventriculoperitoneal shunt (VPS) procedures have long been utilized to treat traumatic brain and spinal cord injuries to direct additional cerebrospinal fluid (CSF) from the lateral ventricles through a ventricular catheter attached to a valve that is further connected to a distal catheter. Decompressive cranio omie (DCs), cranioplasties, and intracranial pressure measurements (ICP) are also frequently performed in combination with VPS to manage intracranial hypertension and cerebral edema. Although the current surgical methods utilized in the treatment of neurotrauma prove to be highly efficacious in the prevention of adverse outcomes, emergent therapies are growing in popularity. Of interest, the Three Pillars Expansive Craniotomy, cisternostomy, and external lumbar drainages are cutting-edge procedures with promising results that can potentially usher change in the neurosurgical industry but require additional examination.

Basal Cisternostomy - A Microsurgical Cerebro Spinal Fluid Let Out Procedure and Treatment Option in the Management of Traumatic Brain Injury. Analysis of 40 Consecutive Head Injury Patients Operated with and without Bone Flap Replacement Following Cisternostomy in a Tertiary Care Centre in India

Background

Decompressive craniectomy (DC) is considered the gold standard blanket surgical procedure for all medically intractable cerebral oedema in Traumatic Brain Injury (TBI). It's only proven fact is that it reduces Intra Cerebral Pressure (ICP) by providing space for the oedematous brain. Attempts are being made to find additional or alternative procedures to improve outcomes in TBI. Basal Cisternostomy is one such technique proposed to bring such a change in world literature.

Aim

To analyse the validity of Basal Cisternostomy in TBI patients.

Materials and Methods

A total of 40 patients who underwent Basal Cisternostomy (BC) in TBI admitted in the senior author's unit between January 2016 and April 2019 were analysed retrospectively. All surgeries were performed by single surgeon with microsurgical expertise. Outcome was assessed according to Glasgow outcome scale (GOS). Results were analysed using SPSS software.

Results

In severe TBI, Basal Cisternostomy group showed 77.8% favourable outcome while Decompressive Craniectomy in addition to Basal Cisternostomy group showed 72.7% only. While favourable GOS was seen in 82% (33/40), the unfavourable outcome was noticed in 12.5% (5/40) and death in 5% (2/40) in this series. Hydrocephalus was seen in 12.5% (5/40). Patients operated earlier from the time of injury showed better results than those who got operated later irrespective of severity of neurological status. ICU stay and hospital stay duration and its validity could not be assessed.

Conclusion

Basal Cisternostomy is an effective procedure in Traumatic Brain Injury patients that not only improves outcome but also reduces the need for Decompressive Craniectomy as a blanket procedure and thus avoiding its associated complications.

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

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

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.

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.

Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary?

Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.

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.

Bone resorption in autologous cryopreserved cranioplasty: quantitative evaluation, semiquantitative score and clinical significance

BACKGROUND

Changes after reimplantation of the autologous bone have been largely described. However, the rate and the extent of resorption in cranial grafts have not been clearly defined. Aim of our study is to evaluate the bone flap resorption (BFR) after cryopreservation.

METHODS

We retrospectively reviewed 27 patients, aged 18 years or older, subjected to cranioplasty (CP) adopting autologous cryopreserved flap. The BFR was derived from the percentage of decrease in flap volume (BFR%), comparing the first post-operative computed tomography (CT) and the last one available (performed at least 1 year after surgery). We also proposed a semiquantitative scoring system, based on CT, to define a clinically workable BFR classification.

RESULTS

After a mean ± SE follow-up of 32.5 ± 2.4 months, the bone flap volume decreased significantly (p < 0.0001). The mean BFR% was 31.7 ± 3.8% and correlated with CT-score (p < 0.001). Three BFR classes were described: mild (14.8% of cases) consisting in minimal bone remodelling, CT-score ≤ 6, mean BFR% = 3.5 ± 0.7%; moderate (51.9% of cases) corresponding to satisfactory cerebral protection, CT-score < 13, mean BFR% = 25.6 ± 2.2%; severe (33.3% of cases) consisting in loss of cerebral protection, CT-score ≥ 13, mean BFR% = 54.2 ± 3.9%. Females had higher BFR% than males (p = 0.022). BFR classes and new reconstructive surgery were not related (p = 0.58).

CONCLUSIONS

BFR was moderate or severe in 85.2% of re-implanted cryopreserved flaps. The proposed CT-score is an easy and reproducible tool to define resorption extent.

Bone Flap Conservation in the Scalp After Decompressive Craniectomy

BACKGROUND

Decompressive craniectomy may be used as a primary or secondary treatment for intracranial hypertension and is clearly associated with reduced mortality. The removed bone flap is usually preserved in the abdominal subcutaneous tissue or in the bone bank. The aim of this study was to describe an option for preserving the bone flap after decompressive craniectomy using bone flap preservation in the skull subcutaneous tissue in subgaleal space over the pericranium contralateral to the craniectomy site.

METHODS

This was a multicenter retrospective study including patients with severe traumatic brain injury from 2014 to 2016. There were 23 patients who had their bone fragments preserved below the scalp in the subcutaneous tissue for analysis. The following results were analyzed: surgical site infection, bone flap resorption during the period of preservation, and patient discomfort.

RESULTS

Five patients died of systemic infectious complications, and the remaining patients underwent cranioplasty a mean 118 days after craniectomy. There were no surgical wound infections, macroscopically evident bone absorption, or site discomfort in any of the patients during a period of 18 months.

CONCLUSIONS

This variant of the bone flap preservation technique has been shown to be satisfactory as an option for routine use.

Preoperative elevated FDP may predict severe intraoperative hypotension after dural opening during decompressive craniectomy of traumatic brain injury

Purpose

Coagulation disorder and intraoperative hypotension are representative complications of traumatic brain injury which cause worse perioperative outcome. The aim of this study was to survey the relation of coagulation disorder and intraoperative hypotension (IH) during decompressive craniectomy.

Method

Patients who underwent emergency decompressive craniectomy due to traumatic brain injury were retrospectively surveyed. The relation between preoperative coagulation date and intraoperative hypotension (systolic blood pressure < 60 mmHg after dural opening) was analyzed.

Results

Of 41 patients screened, 12 patients (27.9%) developed IH. Fibrinogen degradation products (314 vs 64.4 μg/mL; p = 0.01) were significantly higher in the IH group. In contrast, fibrinogen (181 vs 239 mg/dL; p = 0.01) was significantly lower in the IH group. Reduction rate of sBRP before and after dural opening (%) was higher in IH group than in non-IH group (49.1 vs 27.6%: p = 0.001).

Conclusions

Preoperative elevated FDP may predict IH after dural opening during traumatic decompressive craniectomy.

Outcome of Decompressive Craniectomy in Traumatic Closed Head Injury

Objective:

The aim of the current study was to observe functional outcomes of patients undergoing decompressive craniectomy (DC) for raised intracranial pressure (ICP) after blunt head injury and to assess possible predictive factors.

Methodology:

This study was a prospective cohort study which was conducted at Aga Khan University Hospital, Karachi over a period of 2 years (January 2015–December 2016). Adult patients, aged between 15 and 65 years of both genders undergoing DC during the study period were selected. Outcomes of DC were assessed at an interval of 3 months following injury using the Glasgow outcome score. The data were analyzed on IBM statistics SPSS version 21.

Results:

Seventy-two patients underwent DC for raised and refractory ICP. Glasgow Outcome Scale (GOS) at discharge, 1-month and 3-month follow-up were reported. GOS at 3-month follow-up showed 21 patients (29.2%) patients had a good recovery, moderate disability was reported in 16 patients (22.2%), and severe disability in 12 patients (16.7%), persistent vegetative state was seen in five patients (6.9%). Eighteen patients had in hospital mortality (25.0%). Tracheostomy and sphenoid fractures were found to be negative predictors of good functional outcome.

Conclusions:

DC is associated with an in hospital mortality of 25.0%. Favorable outcomes were seen in 51.4% patients. Tracheostomy and sphenoid fractures were negative predictors of good functional outcome. The results are comparable to international literature.

Decompressive craniectomy in the management of intracranial hypertension after traumatic brain injury: a systematic review and meta-analysis

We aim to perform a systematic review and meta-analysis to examine the prognostic value of decompressive craniectomy (DC) in patients with traumatic intracranial hypertension. PubMed, EMBASE, Cochrane Controlled Trials Register, Web of Science, http://clinicaltrials.gov/ were searched for eligible studies. Ten studies were included in the systematic review, with four randomized controlled trials involved in the meta-analysis, where compared with medical therapies, DC could significantly reduce mortality rate [risk ratio (RR), 0.59; 95% confidence interval (CI), 0.47–0.74, P < 0.001], lower intracranial pressure (ICP) [mean difference (MD), −2.12 mmHg; 95% CI, −2.81 to −1.43, P < 0.001], decrease the length of ICU stay (MD, −4.63 days; 95% CI, −6.62 to −2.65, P < 0.001) and hospital stay (MD, −14.39 days; 95% CI, −26.00 to −2.78, P = 0.02), but increase complications rate (RR, 1.94; 95% CI, 1.31–2.87, P < 0.001). No significant difference was detected for Glasgow Outcome Scale at six months (RR, 0.85; 95% CI, 0.61–1.18, P = 0.33), while in subgroup analysis, early DC would possibly result in improved prognosis (P = 0.04). Results from observational studies supported pooled results except prolonged length of ICU and hospital stay. Conclusively, DC seemed to effectively lower ICP, reduce mortality rate but increase complications rate, while its benefit on functional outcomes was not statistically significant.

The Role of Neurogenic Inflammation in Blood-Brain Barrier Disruption and Development of Cerebral Oedema Following Acute Central Nervous System (CNS) Injury

Acute central nervous system (CNS) injury, encompassing traumatic brain injury (TBI) and stroke, accounts for a significant burden of morbidity and mortality worldwide, largely attributable to the development of cerebral oedema and elevated intracranial pressure (ICP). Despite this, clinical treatments are limited and new therapies are urgently required to improve patient outcomes and survival. Originally characterised in peripheral tissues, such as the skin and lungs as a neurally-elicited inflammatory process that contributes to increased microvascular permeability and tissue swelling, neurogenic inflammation has now been described in acute injury to the brain where it may play a key role in the secondary injury cascades that evolve following both TBI and stroke. In particular, release of the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) appear to be critically involved. In particular, increased SP expression is observed in perivascular tissue following acute CNS injury, with the magnitude of SP release being related to both the frequency and degree of the insult. SP release is associated with profound blood-brain barrier disruption and the subsequent development of vasogenic oedema, as well as neuronal injury and poor functional outcomes. Inhibition of SP through use of a neurokinin 1 (NK1) antagonist is highly beneficial following both TBI and ischaemic stroke in pre-clinical models. The role of CGRP is more unclear, especially with respect to TBI, with both elevations and reductions in CGRP levels reported following trauma. However, a beneficial role has been delineated in stroke, given its potent vasodilatory effects. Thus, modulating neuropeptides represents a novel therapeutic target in the treatment of cerebral oedema following acute CNS injury.

APOE ε4 positive patients suffering severe traumatic head injury are more prone to undergo decompressive hemicraniectomy

OBJECT

In this paper we tested the hypothesis if patients with severe traumatic brain injury and presence of the apolipoprotein E (APOE) ε4 allele are more prone to undergo the surgical procedure decompressive hemicraniectomy (DC) in order to bring the intracranial pressure (ICP) under control.

METHODS

In this prospective consecutive study patients with sTBI were enrolled (n=48). Inclusion criteria were arrival to our level one trauma university hospital within 24h after trauma, patient age between 15 and 70years, Glasgow Coma Scale (GCS) score ≤8 at the time of intubation and sedation, an initial cerebral perfusion pressure >10mmHg. Venous blood was sampled for APOE genotype determination. Clinical outcome at 6months after injury was assessed with the Extended Glasgow Outcome Scale (GOSE). All surgical procedures needed for each patient were registered.

RESULTS

Patients with the APOE ε4 allele were significantly overrepresented in the DC group. In the APOE ε4+DC group, ICP_max and ICP_mean during the first 36h were significantly higher and GOSE was significantly worse at 6months.

CONCLUSION

Our data suggest that patients with the APOE ε4 allele are predisposed for the need of DC more often than patients without the APOE ε4 allele. Thus, it seems to be of importance to consider the APOE genotype in patients suffering severe traumatic brain injury in order to forecast the need for a more exquisite intensive care.