Evaluation of prognostic factors of decompressive craniectomy in the treatment of severe traumatic brain injury

Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study

Decompressive craniectomy (DC) is a well-established neurosurgical intervention in patients with high intracranial pressure who fail to respond to medical treatment. Data on predictive factors for functional outcomes in patients with DC who have malignant middle cerebral artery (MCA) infarction as opposed to intracranial hemorrhage (ICH) are scarce. Eighty-four patients who underwent DC treatment for ICH and malignant MCA infarction were examined. All patients underwent surgery in the Bahrain Salmaniya Medical Complex Neurosurgery Unit between January 2017 and June 2021. To determine whether any of these demonstrated a link to the functional outcome, radiographic factors were compared with clinical data. The postsurgical midline shift (MLS) (ICH group) showed the strongest correlation (ρ = 0.434; P = .006), as in the MCA infarction group as well (ρ = 0.46; P = .005). Further analyses using binary logistic regression with postsurgical basal cistern status and ∆ MLS, and it was observed to be statistically significant (odds ratios: 0.067, 95% CI: 0.007, 0.67; P = .021). The initial Glasgow coma scale, postsurgical MLS, basal cistern status, and ∆ are Measurable variables that can be used to predict outcomes in the groups with ICH and MCA infarction.

Decompressive Craniectomy in Traumatic Brain Injury: An Institutional Experience of 131 Cases in Two Years

Decompressive craniectomy (DC) effectively reduces intracranial pressure (ICP), but is not considered to be a first-line procedure. We retrospectively analyzed sociodemographic, clinical, and surgical characteristics associated with the prognosis of patients who underwent DC to treat traumatic intracranial hypertension (ICH) at the Restauração Hospital (HR) in Recife, Brazil between 2015 and 2016, and compared the clinical features with surgical timing and functional outcome at discharge. The data were collected from 131 medical records in the hospital database. A significant majority of the patients were young adults (age 18-39 years old; 75/131; 57.3%) and male (118/131; 90.1%). Road traffic accidents, particularly those involving motorcycles (57/131; 44.5%), were the main cause of the traumatic event. At initial evaluation, 63 patients (48.8%) were classified with severe traumatic brain injury (TBI). Pupil examination showed no abnormalities for 91 patients (71.1%), and acute subdural hematoma was the most frequently observed lesion (83/212; 40%). Glasgow Outcome Scale (GOS) score was used to categorize surgical results and 51 patients (38.9%) had an unfavorable outcome. Only the Glasgow Coma Scale (GCS) score on admission (score of 3-8) was more likely to be associated with unfavorable outcome (p-value = 0.009), indicating that this variable may be a determinant of mortality and prognostic of poor outcome. Patients who underwent an operation sooner after injury, despite having a worse condition on admission, presented with clinical results that were similar to those of patients who underwent surgery 12 h after hospital admission. These results emphasize the importance of early DC for management of severe TBI. This study shows that DC is a common procedure used to manage TBI patients at HR.

Unilateral mydriasis after video-assisted thoracic thymectomy: case report and review of literature

The article reviews a clinical case of unilateral mydriasis after uncomplicated video-assisted thoracic thymectomy as well as results of literature data analysis of.

Development of Posttraumatic Hydrocephalus Requiring Ventriculoperitoneal Shunt After Decompressive Craniectomy for Traumatic Brain Injury: a Systematic Review and Meta-analysis of Retrospective Studies

BACKGROUND

Decompressive craniotomy (DC) is a known risk factor for the development of posttraumatic hydrocephalus (PTH) in the patients with traumatic brain injury (TBI). Herein, the present study reported the development of PTH requiring ventriculoperitoneal (VP) shunt after DC for TBI.

METHODS

Four databases (PubMed, Web of Science, Scopus, and Cochrane Library) were searched from 1983 to April 2018. The studies evaluating the prevalence of PTH requiring VP shunt after DC in the patients with TBIwere selected without language restriction. A random-effects meta-analysis using event rate (ER) and 95% confidence intervals(CIs), was runby RevMan5.3 software.

RESULTS

Out of 355 studies obtained from the databases, 25 studies were included and analyzed in the meta-analysis. The studies included 2402 patients undergoing DC for TBI, 354 of whohad PTH. The pooled ER of hydrocephalus in the patients undergoing DC for TBI was 17.7% [95%CI: 13.2 to 23.4%; P<0.001]. In addition, the pooled analysis showed that ER of hydrocephalus was 13% in adults [95%CI: 9 to 18.5%; P<0.001] and 37.6% in children [95%CI: 27.79 to 48.7%; P=0.029; I2=0%].

CONCLUSION

The present study demonstrated that DC after TBI was associated with the development of PTH, especially in children compared to adults.

Efficiency and Limitations of Decompressive Craniectomy in Patients after Traumatic Brain Injury – Preliminary Results

Introduction: Decompressive craniectomy (DC) has been recently proven effective tier II therapeutic procedure in the treatment of refractory posttraumatic intracranial hypertension. However, its full potential and effectivity is yet to be described and this surgery remains controversial. The goals of our study include analysis of efficiency of DC and description of risk factors associated with unfavourable outcome.

Methods: 24 patients who underwent DC at the Clinic of Neurosurgery, JFM CU in Martin, during years 2015–2016 were prospectively observed. Selected demographic, clinical, and radiographic factors were analysed and compared with patient’s GOS (Glasgow Outcome Scale) at the time of their first ambulatory control (after 3.5 months in average).

Results: We observed mortality of 29.17 %. Good outcome (GOS 4–5) was achieved by 29.17 % of the patients as well. Preoperative GCS ≤ 5 (p = 0.049), intraventricular bleeding (p = 0.0268), midline shift ≥ 15 mm (p = 0.0067), and the volume of intracranial lesion (R = −0.41, p = 0.046), especially its extracerebral component (R = −0.46, p = 0.02), were identified as statistically significant negative prognostic factors.

Conclusion: DC is effective in the management of patients with traumatic brain injury. Good outcome is achieved by 29.17 % of the patients. Described negative prognostic factors (preoperative GCS ≤ 5, intraventricular bleeding, midline shift ≥ 15 mm, and increasing the volume of traumatic mass lesion) could help in targeting this surgery only to patients who are expected to benefit from it.

Decompressive Craniectomy in Patients with Traumatic Brain Injury: Are the Usual Indications Congruent with Those Evaluated in Clinical Trials?

BACKGROUND

In patients with traumatic brain injury (TBI), multicenter randomized controlled trials have assessed decompressive craniectomy (DC) exclusively as treatment for refractory elevation of intracranial pressure (ICP). DC reliably lowers ICP but does not necessarily improve outcomes. However, some patients undergo DC as treatment for impending or established transtentorial herniation, irrespective of ICP.

METHODS

We performed a population-based cohort study assessing consecutive patients with moderate-severe TBI. Indications for DC were compared with enrollment criteria for the DECRA and RESCUE-ICP trials.

RESULTS

Of 644 consecutive patients, 51 (8 %) were treated with DC. All patients undergoing DC had compressed basal cisterns, 82 % had at least temporary preoperative loss of ≥1 pupillary light reflex (PLR), and 80 % had >5 mm of midline shift. Most DC procedures (67 %) were "primary," having been performed concomitantly with evacuation of a space-occupying lesion. ICP measurements influenced the decision to perform DC in 18 % of patients. Only 10 and 16 % of patients, respectively, would have been eligible for the DECRA and RESCUE-ICP trials. DC improved basal cistern compression in 76 %, and midline shift in 94 % of patients. Among patients with ≥1 absent PLR at admission, DC was associated with lower mortality (46 vs. 68 %, p = 0.03), especially when the admission Marshall CT score was 3-4 (p = 0.0005). No patients treated with DC progressed to brain death. Variables predictive of poor outcome following DC included loss of PLR(s), poor motor score, midline shift ≥11 mm, and development of perioperative cerebral infarcts.

CONCLUSIONS

DC is most often performed for clinical and radiographic evidence of herniation, rather than for refractory ICP elevation. Results of previously completed randomized trials do not directly apply to a large proportion of patients undergoing DC in practice.

New Radiologic Parameters Predict Clinical Outcome after Decompressive Craniectomy

OBJECTIVE

Decompressive craniectomy (DC) is an established part of the management of patients with increased intracranial pressure due to malignant middle cerebral artery (MCA) infarction or traumatic brain injury (TBI). The aim of this study was to determine prognostic radiologic parameters regarding the functional outcome of patients with increased intracranial pressure (ICP) undergoing DC. Special focus was put on the potential differences between malignant MCA infarction and TBI.

METHODS

A total of 113 patients were analyzed for their clinical course where preoperative and postoperative radiologic features in computed tomography (CT) scans were correlated to the clinical outcome assessed by the Glasgow Outcome Scale. The difference between presurgical and postsurgical midline shift (ΔMLS) and the ratio between the diameter of the affected and contralateral hemisphere (HDratio) in presurgical and postsurgical CT scans were calculated.

RESULTS

ΔMLS (MCA infarction group) and postsurgical HDratio (TBI group) were found to be highly correlating with the clinical outcome on Spearman-correlation testing and underwent further analysis using a binary logistic regression model to evaluate their prognostic value on the outcome, which showed the predictive power of ΔMLS in malignant MCA infarction patients (odds ratio [OR] 0.715; confidence interval [CI] 0.551-0.865). Postsurgical HDratio correlated significantly (OR 0.620; CI 0.384-0.901) with the outcome in the TBI group.

CONCLUSION

ΔMLS is an objectifiable parameter, predicting outcome in malignant MCA infarction. In contrast, ΔMLS was of no predictive value in TBI patients. Here postsurgical HDratio serves as a strong predictor of clinical outcome. We recommend applying postsurgical HDratio to TBI patients in order to estimate their clinical outcome and adjust treatment.

Analysis of the Risk Factors Affecting the Surgical Site Infection after Cranioplasty Following Decompressive Craniectomy

OBJECTIVE

The risk factors for surgical site infections (SSIs) after cranioplasty following decompressive craniectomy remain unclear. The goal of this study was to analyze the risk factors related to developing SSIs after cranioplasty and to suggest valuable predictors.

METHODS

A retrospective review was conducted of patients who underwent cranioplasty following decompressive craniectomy at our institution from January 2011 to December 2014, a total of 78 patients who underwent 78 cranioplasties. Univariate and multivariate logistic regression analyses were carried out to determine possible risk factors related to developing SSIs. We analyzed both patient-specific and surgery-specific factors.

RESULTS

The overall rate of SSIs was 9.0% (7/78). SSIs after cranioplasty were significantly related to being female, having the primary etiology of traumatic brain injury (TBI) and having had a bilateral cranioplasty in the univariate analysis. Multivariate logistic regression analysis showed that being female [odds ratio (OR) 5.98, p=0.000] and having had a bilateral cranioplasty (OR 4.00, p=0.001) significantly increased the risk of SSIs.

CONCLUSION

Based on our data, cranioplasty following decompressive craniectomy is associated with a high incidence of SSI. Being female, having a primary etiology of TBI and having had a bilateral cranioplasty may be risk factors for surgical site infections after cranioplasty.

Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications

OBJECTIVE

To analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy.

METHODS

Retrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed.

RESULTS

A total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome.

CONCLUSION

This study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population.