Decompressive craniotomy: prognostic factors and complications in 89 patients

Shunt-Dependent Post-Traumatic Hydrocephalus: Predictors and Long-Term Functional Outcomes

INTRODUCTION

As a disorder of the brain in adults and children, traumatic brain injury (TBI) is considered the major cause of mortality and morbidity. As a serious complication of TBI, post-traumatic hydrocephalus (PTH) is commonly identified and significantly associated with neurocognitive impairment, motor dysfunction, and growth impairment. The long-term functional outcomes after shunt dependence are totally not clear.

METHODS

This study included 6279 patients between 2012 and 2022. To identify the unfavorable functional outcomes and the PTH-related factors, we carried out univariable logistic regression analyses. To identify the occurrence time of PTH, we conducted the log-rank test and Kaplan-Meier analysis.

RESULTS

Mean patient age was 51.03 ± 22.09 years. Of the 6279 patients with TBI, 327 developed PTH (5.2%). Several PTH development-associated factors, such as intracerebral hematoma, diabetes, longer initial hospital stay, craniotomy, low GCS (Glasgow Coma Scale), EVD (external ventricular drain), and DC (decompressive craniectomy) (p < 0.01), were identified. We also analyzed the factors of unfavorable outcomes after TBI including > 80 years, repeated operations, hypertension, EVD, tracheotomy, and epilepsy (p < 0.01). Ventriculoperitoneal shunt (VPS) itself is not an independent factor of the unfavorable outcome but shunt complication is a strong independent factor of unfavorable outcome (p < 0.05).

CONCLUSION

We should emphasize the practices that can minimize the risks of shunt complications. Additionally, the rigorous radiographic and clinical surveillance will benefit those patients at high risk of developing PTH.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, ChiCTR2300070016.

Prediction of Shunt-Dependent Hydrocephalus after Primary Supratentorial Intracerebral Hemorrhage with a Focus on the Influence of Craniectomies

Objective

Hydrocephalus after intracerebral hemorrhage (ICH) is known to be related to poor prognosis and mortality. We analyzed predictors of permanent hydrocephalus in the patients with surgically treated supratentorial ICH.

Methods

From 2004 to 2019, a total of 414 patients with surgically treated primary supratentorial ICH were included. We retrospectively analyzed age, sex, preexisting hypertension and diabetes, location and volume of ICH, presence and severity of intraventricular hemorrhage (IVH), and type of surgery.

Results

Forty patients (9.7%) required shunt surgery. Concomitant IVH was higher in the 'shunt required' group (92.5%) than in the 'shunt not required' group (67.9%) (p=0.001). IVH severity was worse in the 'shunt required' group (13.5 vs. 7.5, p=0.008). Craniectomy (47.5%) was significantly high in the 'shunt required' group. According to multivariable analysis, the presence of an IVH was 8.1 times more frequent and craniectomy was 8.6 times more frequent in the 'shunt required' group. In the comparison between craniotomy and craniectomy group, the presence of an IVH was related with a 3.9 times higher (p=0.033) possibility and craniectomies rather than craniotomies with a 7-times higher possibility of shunt surgery (p<0.001). Within the craniectomy group, an increase in the craniectomy area by 1 cm2 was correlated with a 3.2% increase in the possibility of shunt surgery (odds ratio, 1.032; 95% confidence interval, 1.005-1.061; p=0.022).

Conclusion

Presence of IVH, the severity of IVH and decompressive craniectomy were related to the development of shunt dependent hydrocephalus in the patients with ICH. The increasing size of craniectomy was related with increasing rate of shunt requirement.

Post Traumatic Hydrocephalus: Incidence, Pathophysiology and Outcomes

Background

Post-traumatic hydrocephalus (PTH) is a sequel of traumatic brain injury (TBI) that is seen more often in patients undergoing decompressive craniectomy (DC). It is associated with prolonged hospital stay and unfavorable outcomes.

Objective

To study the incidence and risk factors for development of PTH in patients undergoing DC in our institution and to review the literature on PTH with respect to incidence, risk factors, pathophysiology, and outcomes of management.

Methods

Data from 95 patients (among 220 patients who underwent DC for TBI and fulfilled the inclusion criteria) over a 5-year period at Christian Medical College, Vellore were collected and analyzed to study the incidence and possible risk factors for development of PTH. A review of the literature on PTH was performed by searching PUBMED resources.

Results

Thirty (31.6%) out of 95 patients developed post-traumatic ventriculomegaly, of whom seven (7.3%) developed symptomatic PTH, necessitating placement of ventriculoperitoneal shunt (VPS). No risk factor for development of PTH could be identified. The reported incidence of PTH in the literature is from 0.07% to 29%, with patients undergoing DC having a higher incidence. Younger age, subarachnoid hemorrhage, severity of TBI, presence of subdural hygroma, and delayed cranioplasty after DC are the main risk factors reported in the literature.

Conclusions

PTH occurs in a significant proportion of patients with TBI and can lead to unfavorable outcomes. PTH has to be distinguished from asymptomatic ventriculomegaly as early as possible so that a CSF diversion procedure can be planned early during development of PTH.

Decompressive craniectomy: indications and results of 24 cases at the neurosurgery clinic of Fann university hospital of Dakar

Decompressive craniectomy is a surgical technique considered to be the last step in the management of intracranial hypertension. The objective of our study was to evaluate our results in the management of intracranial hypertension by decompressive craniectomy. This was a retrospective study of 24 cases of decompressive craniectomy performed over a 9-year period (from January 2010 to December 2019) at the Fann Neurosurgery Clinic. The mean age of the patients was 33.82 years, there was a male predominance with a sex ratio of 2.42. The most frequent indication was severe cranioencephalic trauma with 50%. The cerebral computed tomography (CT) scan was the key examination and was performed in all our patients. Complications were entirely infectious and were the cause of 73.33% of deaths. Thirty-five percent of the patients had received prior treatment before the decompressive craniectomy. The functional prognosis was good in 44.44% of cases, moderate in 33.33% of cases, 1 (11.11%) patient had a severe disability and 1 (11.11%) patient was in a vegetative state. Mortality rate was 62.5% of patients in our study series. Despite the lack of sophisticated techniques for diagnosis and monitoring of intracranial hypertension, our results remain acceptable with 37.5% survival. The early completion of this surgery allows us to be more efficient with a significant reduction in morbidity and mortality.

Simultaneous decompressive craniectomy and caesarean section

A 24-year-old primigravid woman at 29-weeks gestation presented with headache, hypertension and proteinuria. A diagnosis of pre-eclampsia was made. Later that day she developed a left hemiparesis and neuroimaging demonstrated an intracerebral haemorrhage in the right frontal lobe as well as thrombosis of the superior sagittal sinus. She was commenced on an IV heparin infusion to manage the sinus thrombosis, and nifedipine and labetalol to treat the hypertension. GCS remained 15/15. However, 12 hours later, she became progressively agitated. Her GCS decreased to 10/15 (E3V2M5). Repeat imaging demonstrated enlargement of the haematoma, causing significant mass effect and midline shift. A decision was made to perform decompressive hemicraniectomy to save the life of the mother, and caesarean section to protect the foetus as well as providing definitive treatment of pre-eclampsia. Due to further neurological deterioration of the mother it became necessary to perform the two procedures simultaneously. We present the first reported case of decompressive craniectomy and caesarean section performed simultaneously. After discussing the case, we consider why this clinical scenario is rare and why it became necessary in this patient to perform the two procedures simultaneously.

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.

The Role of Decompressive Craniectomy in Traumatic Brain Injury: A Systematic Review and Meta-analysis

The objective is to evaluate the efficacy of early decompressive craniectomy (DC) versus standard medical management ± late DC in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies, and prospective cohort studies on DC in moderate and severe TBI. Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and extended GCOS, and mortality. Data were extracted to Review Manager software. A total of 45 articles and abstracts that met the inclusion criteria were retrieved and analyzed. Ultimately, seven studies were included in our meta-analysis, which revealed that patients who had early DC had no statistically significant likelihood of having a favorable outcome at 6 months than those who had a standard medical care alone or with late DC (OR of favorable clinical outcome at 6 months: 1.00; 95% confidence interval (CI): 0.75–1.34; P = 0.99). The relative risk (RR) of mortality in early DC versus the standard medical care ± late DC at discharge or 6 months is 0.62; 95% CI: 0.40–0.94; P = 0.03. Subgroup analysis based on RR of mortality shows that the rate of mortality is reduced significantly in the early DC group as compared to the late DC. RR of Mortality is 0.43; 95% CI: 0.26–0.71; P = 0.0009. However, good clinical outcome is the same. Early DC saves lives in patients with TBI. However, further clinical trials are required to prove if early DC improve clinical outcome and to define the best early time frame in performing early DC in TBI population.

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.

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

OBJECTIVE

to determine predictive factors for prognosis of decompressive craniectomy in patients with severe traumatic brain injury (TBI), describing epidemiological findings and the major complications of this procedure.

METHODS

we conducted a retrospective study based on analysis of clinical and neurological outcome, using the extended Glasgow outcome in 56 consecutive patients diagnosed with severe TBI scale treated in the emergency department from February 2004 to July 2012. The variables assessed were age, mechanism of injury, presence of pupillary changes, Glasgow coma scale (GCS) score on admission, CT scan findings (volume, type and association of intracranial lesions, deviation from the midline structures and classification in the scale of Marshall and Rotterdam).

RESULTS

we observed that 96.4% of patients underwent unilateral decompressive craniectomy (DC) with expansion duraplasty, and the remainder to bilateral DC, 53.6% of cases being on the right 42.9% on the left, and 3.6% bilaterally, with predominance of the fourth decade of life and males (83.9%). Complications were described as transcalvarial herniation (17.9%), increased volume of brain contusions (16.1%) higroma (16.1%), hydrocephalus (10.7%), swelling of the contralateral lesions (5.3%) and CSF leak (3.6%).

CONCLUSION

among the factors studied, only the presence of mydriasis with absence of pupillary reflex, scoring 4 and 5 in the Glasgow Coma Scale, association of intracranial lesions and diversion of midline structures (DML) exceeding 15 mm correlated statistically as predictors of poor prognosis.

Emergency neurosurgery in Darwin: still the generalist surgeons' responsibility

BACKGROUND

Royal Darwin Hospital (RDH) is the only major hospital for the 'Top End' of Northern Territory and Western Australia. As retrieval distances exceed 2600 km, resident generalist surgeons undertake all emergency neurosurgery.

METHODS

Retrospective clinical study from RDH records and review of prospectively collected datasets from RDH Intensive Care Unit and National Critical Care Trauma Response Centre for all emergency neurosurgery patients between 2008 and 2013.

RESULTS

Data were obtained from 161 patients with 167 admissions (73% male, 39% indigenous) who underwent 195 procedures (33 per year), including burr hole, craniotomy, cerebral and posterior fossa craniectomy, elevation fracture and ventricular drain. Trauma accounted for 68%, with alcohol as a known factor in 57%. Subdural haematoma (SDH) accounted for 53%. Severity of head injury at presentation correlated with outcome (R(2) = 0.12, P < 0.001). Factors associated with death included injury at remote location (P = 0.022), time injury to operation >24 h (P = 0.023) and specific diagnoses of acute SDH (P = 0.006), acute-on-chronic SDH (P = 0.053) and infection (P = 0.052). Indigenous patients were younger (40 versus 55 years, P < 0.001) and more likely to have alcohol as a factor in trauma cases (71% versus 49%, P = 0.027). Time from injury to hospital was high for accidents at a remote location (12.9 versus 1.3 h, P < 0.001); however, Glasgow Outcome Scales (P = 0.13) were no different to accident at metropolitan Darwin.

CONCLUSION

General surgeons at RDH perform a wide range of emergency neurosurgical procedures primarily for trauma. Factors contributing to poor outcomes included remote location of trauma and delay in reaching the hospital. Outcomes at 3 months appear acceptable.

Primary or Secondary Decompressive Craniectomy: Different Indication and Outcome

Background:

Intracranial hypertension can cause secondary damage after a traumatic brain injury. Aggressive medical management might not be sufficient to alleviate the increasing intracranial pressure (ICP), and decompressive craniectomy (DC) can be considered. Decompressive craniectomy can be divided into categories, according to the timing and rationale for performing the procedure: primary (done at the time of mass lesion evacuation) and secondary craniectomy (done to treat refractory ICP). Most studies analyze primary and secondary DC together. Our hypothesis is that these two groups are distinct and the aim of this retrospective study is to evaluate the differences in order to better predict outcome after DC.

Methods:

Seventy patients had DC over a period of four years at our center. They were divided into two groups based on the timing of the DC. Primary DC (44 patients) was done within 24 hours of the injury for mass lesion evacuation. Secondary DC (26 patients) was done after 24 hours and purely for the treatment of refractory ICP. Pre-op characteristics and post-op outcomes were compared between the two groups.

Results:

There was a significant difference in the mechanism of injury, the pupil abnormalities and Marshall grade between primary and secondary DC. There was also a significant difference in outcome with primary DC showing 45.5% good outcome and 40.9% mortality and secondary DC showing 73.1% good outcome and 15.4% mortality.

Conclusions:

Primary and secondary DC have different indications and patients characteristics. Outcome prediction following DC should be adjusted according to the surgical indication.

The influence of decompressive craniectomy on the development of hydrocephalus: a review

Decompressive craniectomy (DC) is widely used to treat intracranial hypertension following traumatic brain injury (TBI) or cerebral vascular disease. Many studies have discussed complications of this procedure, and hydrocephalus is a common complication of DC. To further evaluate the relationship between DC and hydrocephalus, a review of the literature was performed. Numerous complications may arise after DC, including contusion or hematoma expansion, epilepsy, herniation of the cortex through a bone defect, CSF leakage through the scalp incision, infection, subdural effusion, hydrocephalus and “syndrome of the trephined”. Several hydrocephalus predictors were identified; these included DC, distance from the midline, hygroma, age, injury severity, subarachnoid or intraventricular hemorrhage, delayed time to craniotomy, repeated operation, and duraplasity. However, results differed among studies. The impact of DC on hydrocephalus remains controversial.

Study of the long-term results of decompressive craniectomy after severe traumatic brain injury based on a series of 60 consecutive cases

Background. Decompressive craniectomy can be proposed in the management of severe traumatic brain injury. Current studies report mixed results, preventing any clear conclusions on the place of decompressive craniectomy in traumatology. Methods. The objective of this retrospective study was to evaluate the results of all decompressive craniectomies performed between 2005 and 2011 for refractory intracranial hypertension after severe traumatic brain injury. Sixty patients were included. Clinical parameters (Glasgow scale, pupillary examination) and radiological findings (Marshall CT scale) were analysed. Complications, clinical outcome, and early and long-term Glasgow Outcome Scale (GOS) were evaluated after surgery. Finally, the predictive value of preoperative parameters to guide the clinician's decision to perform craniectomy was studied. Results. Craniectomy was unilateral in 58 cases and the mean bone flap area was 100 cm². Surgical complications were observed in 6.7% of cases. Mean followup was 30 months and a favourable outcome was obtained in 50% of cases. The initial Glasgow Scale was the only statistically significant predictive factor for long-term outcome. Conclusion. Despite the discordant results in the literature, this study demonstrates that decompressive craniectomy is useful for the management of refractory intracranial hypertension after severe traumatic brain injury.

Decompressive craniectomy with multi-dural stabs - A combined (SKIMS) technique to evacuate acute subdural hematoma with underlying severe traumatic brain edema

Context:

The decompressive craniotomy alone or with dural flap opening to evacuate acute subdural hematoma with underlying brain edema in severe traumatic brain injury has proved either insufficient in the first place or has fatal complications secondly.

Aims:

To reduce the fatality of conventional procedures and to evacuate acute subdural hematoma with severe brain edema by a combination of decompressive craniotomy and multi-dural stabs (SKIMS-Technique) without brain pouting and lacerations in low Glasgow coma scale (GCS) score patients.

Settings and Design:

The prospective study was conducted in the Department of Neurosurgery, from June, 2006 to June 2011, under a uniform protocol.

Materials and Methods:

A total of 225 patients of severe brain trauma were admitted to the accident and emergency unit of Neurosurgery and after initial resuscitation a CT brain was performed. All patients had a GCS score of 8 and below. All patients were ventilated postoperatively and ICP was monitored.

Statistical Analysis Used:

The data was analyzed and evaluated by the statistical methods like student's T-test. The analysis of Variance was used where-ever applicable.

Results:

The survival of multi-dural stab group was 77.31% (92/119) with good recovery in 42.02% (50/119) and a mortality of 22.69% (27/119) as compared with 46.23% (49/106) survival in open dural flap (control) group with 15.09% (16/106) good recovery and mortality of 53.77% (57/106).

Conclusions:

This new approach, known as SKIMS-Technique or Combined Technique i.e., “decompressive craniectomy with multi-dural stabs”, proved much effective in increasing survival of low GCS and severe traumatic brain edema patients with acute subdural hematoma.

Marked reduction in wound complication rates following decompressive hemicraniectomy with an improved operative closure technique

Although decompressive hemicraniectomy with dural expansion and bone flap removal is a potentially life-saving procedure, concerns remain regarding the morbidity associated with this approach. We and others have noted the high rate of wound complications resulting from this technique, often associated with cerebrospinal fluid (CSF) absorption problems. Here, we present our experience with an improved technique for wound closure after unilateral decompressive hemicraniectomy with a wide cruciate durotomy. Data for all patients who underwent a decompressive hemicraniectomy at our institution from October 2005 to October 2009 were gathered prospectively. Starting in mid 2008, we adopted an alternate approach to operative wound closure, which involved skin closure with a running Monocryl absorbable stitch, and prolonged subgaleal drainage. We compared the rates of wound complication using this approach with those obtained with earlier conventional closure techniques. Over a 1year period, we dramatically reduced the rate of wound complications in patients undergoing hemicraniectomy at our hospital using this new (Monocryl technique, 0% (n=29) compared to other techniques, 35% (n=98), chi-squared [χ(2)] p<0.001). Patients closed using our new technique experienced markedly reduced rates of wound infection (p<0.01), and CSF leak (p<0.05), compared to other, more standard, techniques. Thus, attention to closure of hemicraniectomy wounds can markedly reduce the rate of wound complications, thus improving the risk-to-benefit ratio of this procedure.

Initial predictive factors of outcome in severe non-accidental head trauma in children

OBJECT

The aim of this study is to evaluate the outcome of young children hospitalized for non-accidental head trauma in our PICU, to evaluate PRISM II score in this sub-population of pediatric trauma and to identify factors that might influence the short-term outcome.

MATERIALS AND METHODS

Files of all children less than 2 years old with the diagnosis of non-accidental head trauma over a 10-years period were systematically reviewed. We collected data on demographic information, medical history, clinical status, and management in the PICU. Three severity scores were then calculated: PRISM II, Glasgow Coma Scale (GCS), and Pediatric Trauma Score (PTS). Prognosis value of qualitative variables was tested with a univariate procedure analysis (anemia, diabetes insipidus...). Then, quantitative variables were tested with univariate procedure too (age, weight, PRISM II, GCS, Platelet count, fibrin, prothrombin time (PT)...). Potential association between variables and death was tested using univariate procedure. Variables identified by univariate analysis were then analyzed with multivariate analysis through a forward-stepping logistic regression.

RESULTS

Thirty-six children were included. Mean age was 5.5 months (8 days-21.5 months). Mortality rate was 27.8%. At admission, PTS, PRISM II, GCS, PT, PTT, and diabetes insipidus were significantly altered or more frequent in non survivors. Cutoff value for PRISM II at which risk of mortality increased was 17.5 (sensitivity = 0.8; specificity = 0.88).

CONCLUSION

PRISM II is a reliable and easy performing tool for assessing the prognosis of non-accidental cranial traumatism in young children. GCS and PTS, scores even simpler than PRISM II, showed good accuracy regarding survival prediction.

Decompressive craniectomy following brain injury: factors important to patient outcome

BACKGROUND

Decompressive craniectomy (DC) is often performed as an empirical lifesaving measure to protect the injured brain from the damaging effects of propagating oedema and intracranial hypertension. However, there are no clearly defined indications or specified guidelines for patient selection for the procedure.

AIMS

To evaluate outcome determinants and factors important in patient selection for the procedure.

METHODS

We reviewed the literature on DC, including single case reports and reported case series, to identify factors affecting outcome following the procedure, as well as its pitfalls and associated complications.

RESULTS

Glasgow coma score of 8 and above, age less than 50 years and early intervention were found to be among the most significant determinants of prognosis.

CONCLUSION

Improving patient selection for DC may be expected to further improve the outcome following the procedure in severely brain-injured patients.

Decompressive craniectomy following brain injury: factors important to patient outcome

BACKGROUND

Decompressive craniectomy (DC) is often performed as an empirical lifesaving measure to protect the injured brain from the damaging effects of propagating oedema and intracranial hypertension. However, there are no clearly defined indications or specified guidelines for patient selection for the procedure.

AIMS

To evaluate outcome determinants and factors important in patient selection for the procedure.

METHODS

We reviewed the literature on DC, including single case reports and reported case series, to identify factors affecting outcome following the procedure, as well as its pitfalls and associated complications.

RESULTS

Glasgow coma score of 8 and above, age less than 50 years and early intervention were found to be among the most significant determinants of prognosis.

CONCLUSION

Improving patient selection for DC may be expected to further improve the outcome following the procedure in severely brain-injured patients.

Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury

BACKGROUND

High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). High ICP is treated by general maneuvers (normothermia, sedation etc) and a set of first line therapeutic measures (moderate hypocapnia, mannitol etc). When these measures fail to control high ICP, second line therapies are started. Among these, second line therapies such as barbiturates, hyperventilation, moderate hypothermia or removal of a variable amount of skull bone (known as decompressive craniectomy) are used.

OBJECTIVES

To assess the effects of secondary decompressive craniectomy (DC) on outcome and quality of life in patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP.

SEARCH STRATEGY

We searched the Cochrane Injuries Group's Trial Register, CENTRAL, MEDLINE, EMBASE, Best Evidence, Clinical Practice Guidelines, PubMed, CINAHL, the National Research Register and Google Scholar. We also handsearched relevant conference proceedings and contacted experts in the field and the authors of included studies.

SELECTION CRITERIA

Randomized or quasi-randomized studies assessing patients over the age of 12 months with a severe TBI who underwent DC to control ICP refractory to conventional medical treatments.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the electronic search results for reports of possibly relevant trials and for retrieval in full. One author applied the selection criteria, performed the data extraction and assessed methodological quality. Study authors were contacted for additional information.

MAIN RESULTS

We found one trial with 27 participants conducted in the pediatric population (>18 years). DC was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72), and RR of 0.54 for death, vegetative status or severe disability 6 to 12 months after injury (95% CI 0.29 to 1.07).

AUTHORS' CONCLUSIONS

There is no evidence to support the routine use of secondary DC to reduce unfavourable outcome in adults with severe TBI and refractory high ICP. In the pediatric population DC reduces the risk of death and unfavourable outcome. Despite the wide confidence intervals for death and the small sample size of the only study identified, this treatment maybe justified in patients below the age of 18 when maximal medical treatment has failed to control ICP. To date, there are no results from randomised trials to confirm or refute the effectiveness of DC in adults. However, the results of non-randomized trials and controlled trials with historical controls involving adults, suggest that DC may be a useful option when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of DC (Rescue ICP and DECRAN) that may allow further conclusions on the efficacy of this procedure in adults.