Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury: a clinical study

Ultrasound-based radiomics and clinical factors-based nomogram for early intracranial hypertension detection in patients with decompressive craniotomy

Objective

This study aims to develop and validate a nomogram that combines traditional ultrasound radiomics features with clinical parameters to assess early intracranial hypertension (IH) following primary decompressive craniectomy (DC) in patients with severe traumatic brain injury (TBI). The study incorporates the Shapley Additive Explanations (SHAP) method to interpret the radiomics model.

Methods

This study included 199 patients with severe TBI (training cohort: n = 159; testing cohort: n = 40). Postoperative ultrasound images of the optic nerve sheath (ONS) were obtained at 6 and 18 h after DC. Based on invasive intracranial pressure (ICPi) measurements, patients were grouped according to threshold values of 15 mmHg and 20 mmHg. Radiomics features were extracted from ONS images, and feature selection methods were applied to construct predictive models using logistic regression (LR), support vector machine (SVM), random forest (RF), and K-Nearest Neighbors (KNN). Clinical-ultrasound variables were incorporated into the model through univariate and multivariate logistic regression. A combined nomogram was developed by integrating radiomics features with clinical-ultrasound variables, and its diagnostic performance was evaluated using Receiver Operating Characteristic (ROC) curve analysis and decision curve analysis (DCA). The SHAP method was adopted to explain the prediction models.

Results

Among the machine learning models, the LR model demonstrated superior predictive efficiency and robustness at threshold values of 15 mmHg and 20 mmHg. At a threshold of 20 mmHg, the AUC values for the training and testing cohorts were 0.803 and 0.735 for the clinical model, 0.908 and 0.891 for the radiomics model, and 0.918 and 0.902 for the nomogram model, respectively. Similarly, at a threshold of 15 mmHg, the AUC values were consistent across models: 0.803 and 0.735 for the clinical model, 0.908 and 0.891 for the radiomics model, and 0.918 and 0.902 for the nomogram model. Notably, the nomogram model outperformed the clinical model. Decision curve analysis (DCA) further confirmed a higher net benefit for predicting intracranial hypertension across all models.

Conclusion

The nomogram model, which integrates both clinical-semantic and radiomics features, demonstrated strong performance in predicting intracranial hypertension across different threshold values. It shows promise for enhancing non-invasive ICP monitoring and supporting individualized therapeutic strategies.

Is Intracranial Pressure Monitoring After Open Cranial Procedures Associated With Outcome?

INTRODUCTION

It is unclear if intracranial pressure monitoring (ICPM) after open cranial procedures (craniotomy or craniectomy) (OC) for traumatic brain injury is associated with mortality. We hypothesized that ICPM placed early after OC was associated with lower mortality compared to no ICPM or delayed ICPM placement.

METHODS

Using 2020-2021 data from the American College of Surgeons Trauma Quality Improvement Program, patients ≥16 y from level 1 and 2 trauma centers who underwent OC were divided into two groups: ICPM placed within 72 h of OC (early) and no ICPM or ICPM placed after 72 h (none/delayed). Outcome was in-hospital mortality. Logistic regression was used to elucidate predictors of mortality.

RESULTS

A total of 19,830 patients (early ICPM, 29%) were included. Early patients were more likely to be from level 1 centers (63% versus 60%, P = 0.004), younger (median age 47 versus 60, P < 0.0001), to have a lower Glasgow Coma Score (median, 6 versus 14, P < 0.0001), higher injury severity score (median, 26 versus 26, P < 0.0001), an unreactive pupil (33% versus 18%, P < 0.0001), midline shift >5 mm (69% versus 60%, P < 0.0001), received ≥2 units of blood/first 4 h (14% versus 6%, P < 0.0001) and higher mortality (31% versus 19%, P < 0.0001) compared to none/delayed patients. Controlled for significant variables, early ICPM was associated with increased mortality (odds ratio 1.35, 95% confidence interval 1.24-1.47). Analysis of subjects with isolated brain injury found a similar association (odds ratio 1.32, 95% C1 1.15-1.52).

CONCLUSIONS

ICPM placed within 72 h of OC was associated with increased mortality. Indications for ICPM after OC should be investigated further in multicenter prospective studies.

Post-craniotomy intracranial pressure monitoring: a novel approach combining optic nerve sheath diameter ultrasonography and cervical-cerebral arterial ultrasound

Objective

Elevated intracranial pressure (ICP), a common complication in traumatic brain injuries (TBI), can lead to optic nerve sheath diameter (ONSD) enlargement and flow spectrum changes from the internal carotid artery (ICA) to middle cerebral artery (MCA). This study will investigate the use of Cervical-Cerebral Arterial Ultrasound (CCAU) for non-invasive ICP assessment and evaluating the related indices' clinical utility in TBI patients with decompressive craniotomy (DC).

Methods

ONSD and flow spectrum changes were measured within 24 h after DC in 106 patients via ultrasonic ONSD measurement and CCAU, simultaneously. Intracranial pressures were invasively monitored, using a microsensor or ventricular catheter as the gold standard. Patients were classified into two groups, namely the normal group and the elevated group, based on distinct intracranial pressure thresholds of 15 mmHg, 20 mmHg and 22 mmHg. Subsequently, Bland Altman plot used for evaluating agreement between estimate for ICP (ICPe) and invasive ICP (ICPi). Then, the correlation between ONSD, MCAPI (pulsatility index of MCA), PI-ratio (MCAPI/ICAPI), and ICPe was examined through linear regression analysis. Finally, receiver operator characteristic curves (ROC) were also analyzed for different indexes and their combinations (using logistic model).

Results

Significant differences were observed between the normal and elevated ICP groups with respect to ONSD, PI-ratio, MCAPI and MCAFVd (diastolic flow velocity of MCA) (p < 0.05). The correlation coefficients for the relationships between ONSD, PI ratio, FVdMCA, and PI with ICPi were 0.62, 0.33, 0.32 and 0.21, respectively, each demonstrating statistical significance (p < 0.05). Analysis of the ROC curves demonstrated that the area under the curve (AUC) for predicting elevated ICPi at thresholds of 15 mmHg, 20 mmHg, and 22 mmHg via combined ultrasonographic measurements of the PI ratio and ONSD was the largest, specifically 0.74 (95% CI: 0.65-0.82), 0.77 (95% CI: 0.69-0.85), and 0.79 (95% CI: 0.70-0.86), respectively.

Conclusion

Ultrasonographic measurements of ONSD, PI-ratio, MCAPI and MCAFVd demonstrate a moderate to low weak correlation with ICPi measurements. ICPe is not considered sufficiently precise for noninvasive accurate ICP assessment. The concurrent utilization of CCAU and ONSD measurements may offer superior accuracy for elevated ICP in TBI patients with DC, especially in specificity. Further research is imperative to validate these findings within a more extensive patient population.

Resuscitation and Initial Management After Moderate-to-Severe Traumatic Brain Injury: Questions for the On-Call Shift

Traumatic brain injury (TBI) is a leading cause of disability and mortality globally, stemming from both primary mechanical injuries and subsequent secondary responses. Effective early management of moderate-to-severe TBI is essential to prevent secondary damage and improve patient outcomes. This review provides a comprehensive guide for the resuscitation and stabilization of TBI patients, combining clinical experience with current evidence-based guidelines. Key areas addressed in this study include the identification and classification of severe TBI, intubation strategies, and optimized resuscitation targets to maintain cerebral perfusion. The management of coagulopathy and special considerations for patients with concomitant hemorrhagic shock are discussed in depth, along with recommendations for neurosurgical interventions. This article further explores the role of multimodal neuromonitoring and targeted temperature management to mitigate secondary brain injury. Finally, it discusses end-of-life care in cases of devastating brain injury (DBI). This practical review integrates foundational and recent advances in TBI management to aid in reducing secondary injuries and enhancing long-term recovery, presenting a multidisciplinary approach to support acute care decisions in TBI patients.

Intraoperative Intracranial Pressure Monitoring as an Intraoperative Guide During Operations for Relieving Elevated Intracranial Pressure

BACKGROUND

Intracranial pressure (ICP) is a well-established measure in managing not only traumatic brain injury but also nontraumatic intracranial bleeding or edema. When ICP increases despite nursing or medical management, ICP may be reduced via surgical measures. Deciding whether to perform a craniotomy vs. craniectomy (whether the bone flap is replaced or not, respectively) is commonly made intraoperatively following preoperative planning. While ICP monitoring (ICPm) is standard pre- and postoperatively, its intraoperative utility remains understudied.

METHODS

We conducted a study utilizing prospectively gathered and retrospectively analyzed data from 25 traumatic brain injury surgical decompression cases at a single center. All cases had intraoperative ICPm throughout surgery.

RESULTS

Our findings indicate that ICPm significantly influenced real-time intraoperative decision-making, diverging from preoperative.

CONCLUSIONS

These results bring forward the potential pivotal role of intraoperative ICPm in guiding surgical strategies for elevated ICP, suggesting a novel data-driven approach to intraoperative management of decompression surgery.

Invasive and Noninvasive Techniques for Intracranial Pressure Monitoring After Decompressive Craniectomy: A Systematic Review and Meta-Analysis

The use of invasive or noninvasive intracranial pressure (ICP) monitoring post-decompressive craniectomy (DC) has been a continuous matter of debate. Accordingly, this meta-analysis aims to examine the existing evidence of both approaches and compare their impact among patients undergoing DC, guiding clinical decision-making in the management of elevated ICP. The databases used were Pubmed, Cochrane, Web of Science, and Embase. Inclusion criteria included: (1) English studies; (2) randomized and nonrandomized studies; (3) reporting on invasive OR noninvasive ICP monitoring after DC; (4) with at least one of the outcomes of interest: incidence of mortality, new cerebral hemorrhages, and the Glasgow Outcome Scale. The study followed the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Thirty-six studies were included in this meta-analysis, resulting in a sample of 1624 patients. One thousand two hundred eighty-six underwent invasive monitoring, and 338 underwent noninvasive methods. In the invasive group, a mortality rate of 17% (95% confidence interval [CI]: 12%-22%), a good outcome rate of 58% (95% CI: 38%-49%), a poor outcome rate of 42% (95% CI: 21%-62%), and an overall incidence of new hemorrhages of 4% (95% CI: 0%-8%) were found. Whereas in the noninvasive sample, a mortality rate of 20% (95% CI: 15%-26%) and a good outcome rate of 38% (95% CI: 25%-52%) were obtained. It seems that the effectiveness of invasive and noninvasive ICP monitoring methods are comparable in post-DC patients. While invasive monitoring remains gold standard, noninvasive methods offer a safer and cost-effective alternative, potentially improving post-DC patient care, and can mostly be used simultaneously with invasive methods.

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.

Correlating Intracranial Pressure Following Decompressive Craniectomy With Neurological Outcomes in Severe Traumatic Brain Injury Patients: A Prospective Observational Study

Introduction Decompressive craniectomies have been performed in settings with raised intracranial pressure (ICP) after severe traumatic brain injury (TBI). A decompressive craniectomy (DC) is an important salvage procedure for intracranial hypertension. The changes in the intracranial microenvironment after a primary DC are significant in terms of the neurological outcome in the postoperative period. Materials and methods The study comprised 68 patients with severe TBIs who were undergoing primary DC; of these, 59% were male. Recorded data include demographic profiles, clinical features, and cranial computed tomography (CT) scans. All patients underwent a primary unilateral DC with augmentation duraplasty. Intracranial pressure was recorded in the first 24 hours at regular intervals, and the outcome was recorded using the Extended Glasgow Outcome Scale (GOS-E) at two-week and two-month intervals. Results Road traffic accidents (RTAs) are the most common cause of severe TBIs. Imaging studies and intraoperative findings suggest that acute subdural hematomas (SDHs) are the most common pathology leading to high ICP in the postoperative period. Mortality was strongly statistically associated with high ICP values postoperatively at all intervals. The average ICP for the patients who died was 11.871 mmHg higher than the patients who survived (p=0.0009). The Glasgow Coma Scale (GCS) at the time of admission is positively correlated with the neurological outcome at two weeks and two months, with a Pearson correlation coefficient of 0.4190 and 0.4235, respectively. There is a strong negative correlation between ICP in the postoperative period and the neurological outcome at two weeks and two months (Pearson correlation coefficients are -0.828 and -0.841, respectively). Conclusion The results indicate that RTAs are the most common cause of severe TBIs, and acute SDHs are the most common pathology leading to high ICP after the surgery. ICP values in the postoperative period have a strong negative correlation with survival and neurological outcome. Preoperative GCS and postoperative ICP monitoring are important methods of prognostication and planning further management.

Influence of TRPM4 rs8104571 genotype on intracranial pressure and outcomes in African Americans with traumatic brain injury

The TRPM4 gene codes for a membrane ion channel subunit related to inflammation in the central nervous system. Recent investigation has identified an association between TRPM4 single nucleotide polymorphisms (SNPs) rs8104571 and rs150391806 and increased intracranial (ICP) pressure following traumatic brain injury (TBI). We assessed the influence of these genotypes on clinical outcomes and ICP in TBI patients. We included 292 trauma patients with TBI. DNA extraction and real-time PCR were used for TRPM4 rs8104571 and rs150391806 allele discrimination. Five participants were determined to have the rs8104571 homozygous variant genotype, and 20 participants were identified as heterozygotes; 24 of these 25 participants were African American. No participants had rs150391806 variant alleles, preventing further analysis of this SNP. Genotypes containing the rs8104571 variant allele were associated with decreased Glasgow outcome scale-extended (GOSE) score (P = 0.0231), which was also consistent within our African-American subpopulation (P = 0.0324). Regression analysis identified an association between rs8104571 variant homozygotes and mortality within our overall population (P = 0.0230) and among African Americans (P = 0.0244). Participants with rs8104571 variant genotypes exhibited an overall increase in ICP (P = 0.0077), although a greater frequency of ICP measurements > 25 mmHg was observed in wild-type participants (P =  < 0.0001). We report an association between the TRPM4 rs8104571 variant allele and poor outcomes following TBI. These findings can potentially be translated into a precision medicine approach for African Americans following TBI utilizing TRPM4-specific pharmaceutical interventions. Validation through larger cohorts is warranted.

Decompressive Hemicraniectomy in the Stroke Patient

Decompressive hemicraniectomy (DHC) is a life-saving procedure involving removal of large portions of the skull to relieve intracranial pressure in patients with space occupying cerebral edema such as traumatic brain injury (TBI) and stroke. Although the procedure has been shown to decrease mortality in patients, the risk of severe disability is significant. Quality of life, not just survival, following DHC has emerged as an important consideration when the decision is made to perform a DHC.

Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis

BACKGROUND

Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial.

METHODS

We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models.

RESULTS

The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC).

CONCLUSIONS

According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.

The Evaluation of Skin Turgor in Relation to Changes in Intracranial Pressure in Patients After Decompressive Hemicraniectomy

Introduction

Decompressive hemicraniectomies have been the mainstay of treating medically refractory elevated intracranial pressures (ICPs). Afterward, ICP continues to be monitored. However, the reliability of monitoring the ICP in a patient after craniectomy has been shown to be variable, at best. We propose the use of a durometer to investigate a temporal relationship between skin turgor and elevated ICP.

Methods

Patients were included via the following criteria: age >18 and unilateral decompressive craniectomy, with an external ventricular drain (EVD) in place. Patients were excluded if they were younger than 18, underwent bilateral decompressive craniectomy, or did not have an ICP monitor. Skin turgor over the skin flap was measured with a durometer over the center of the defect. ICPs were monitored using an EVD. The optic nerve sheath diameter (ONSD) was measured with ultrasound with the eye closed and Tegaderm (3M, Saint Paul, MN) covering the eyelid. The optic nerve was measured 3 mm behind the globe, and the diameter of the optic nerve at the widest point was recorded. The Neurological Pupil index (NPi) was recorded with a pupillometer.

Results

Fourteen patients were included, with over 100 data points for ICP, skin turgor, ONSD, and NPi. Five patients went on to have elevated ICP after decompressive hemicraniectomy. The correlation coefficient (R) for ONSD to ICP correlation was 0.62. The R for ICP to skin turgor was 0.31. The data shows that a skin turgor of >9 is related to increasing ICP within 24 hours, a skin turgor of 6-9 is a warning, and a skin turgor of <6 is normal.

Conclusion

A temporal relationship between skin turgor and ICP exists, which could be used to predict impending elevations in ICP sooner than an ICP monitor can determine. By using this in conjunction with traditional methods of evaluating these patients, we could sooner act on elevations in ICP and potentially improve outcomes.

Primary Decompressive Craniectomy After Traumatic Brain Injury: A Literature Review

Traumatic brain injuries (TBIs) still put a high burden on public health worldwide. Medical and surgical treatment strategies are continuously being studied, but the role and indications of primary decompressive craniectomy (DC) remain controversial. In medically refractory intracranial hypertension after severe traumatic brain injury, secondary decompressive craniectomy is a last resort treatment option to control intracranial pressure (ICP). Randomized controlled studies have been extensively performed on secondary decompressive craniectomy and its role in the management of severe traumatic brain injuries. Indications, prognostic factors, and long-term outcomes in primary decompressive craniectomy during the evacuation of an epidural, subdural, or intracerebral hematoma in the acute phase are still a matter of ongoing research and controversy to this day. Prospective trials have been designed, but the results are yet to be published. In isolated epidural hematoma without underlying brain injury, osteoplastic craniotomy is likely to be sufficient. In acute subdural hematoma (ASDH) with relevant brain swelling and preoperative CT signs such as effaced cisterns, overly proportional midline-shift compared to a relatively small acute subdural hematoma, and accompanying brain contusions as well as pupillary abnormalities, intraventricular hemorrhage, and coagulation disorder, primary decompressive craniectomy is more likely to be of benefit for patients with traumatic brain injury. The role of intracranial pressure monitoring after primary decompressive craniectomy is recommended, but prospective trials are pending. More refined guidelines and hopefully class I evidence will be established with the ongoing trials: randomized evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural hematoma (RESCUE-ASDH), prospective randomized evaluation of decompressive ipsilateral craniectomy for traumatic acute epidural hematoma (PREDICT-AEDH), and pragmatic explanatory continuum indicator summary (PRECIS).

Intracranial Hypertension After Primary Decompressive Craniectomy for Head Trauma

BACKGROUND

Primary decompressive craniectomy (DC) is commonly performed for patients with traumatic brain injury (TBI). Some, but not all patients, will benefit from invasive monitoring of intracranial pressure (ICP) after surgery. We intended to identify risk factors for elevated ICP after primary DC to treat TBI.

METHODS

A retrospective chart review study identified all patients at our institution who underwent primary DC for TBI during the study period and who had ICP monitors placed at the time of surgery. Various preoperative and intraoperative variables were assessed for correlation with the presence of postoperative elevated ICP.

RESULTS

Postoperative elevated ICP occurred in 36% of patients after DC. In univariate analysis, Glasgow Coma Scale <8, abnormal pupillary examination, and intraoperative brain swelling were all associated with elevated postoperative ICP. However, in multivariate analysis only intraoperative brain swelling was associated with elevated postoperative ICP (incidence 56% vs. 5%, P = 0.0043).

CONCLUSIONS

Placement of an ICP monitor at the time of primary DC for patients with TBI should be considered if there is intraoperative brain swelling.

Perioperative management of severe brain injured patients

Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.

Spectrum of remote site extradural hematomas following decompressive craniectomy: Does fracture always co-exist?

Background

Remote-site extradural hematomas (EDHs) after decompressive-surgeries for traumatic brain injury (TBI) are rarely encountered. Typically, they form contralateral to the injured side, with an overlying fracture. We present a subset which developed EDH immediately after decompressive-hemi-craniectomy for TBI, most without an evidence of fracture, and not limited to contralateral location.

Methods

Nine such patients were retrospectively identified. Plausible mechanisms, management issues and outcomes have been discussed.

Results

All nine patients were victims of severe-TBI. Six did not have any skull-fractures. Eight showed hemispheric-injuries while one had bifrontal-contusions. In hemispheric-injuries, midline-shift was at least 8 mm except one with midline-shift of 6 mm. The EDH was straddling the midline in 2 (bifrontal-1, bi-occipital-1), and juxtaposed to the previous craniectomy in 1, apart from a contralateral-bleed in 6; all, except one, needed evacuation. In most patients, venous-source of bleed was identified. All had improved from their preoperative Glasgow coma scale (GCS) at follow-up.

Conclusion

A fracture need not always co-exist in EDH following decompressive craniectomy. However, an extra-caution is suggested in its presence. Given the need for surgical-evacuation in most patients and an inability to assess immediate postoperative-GCS in severely head-injured, a routine postoperative-computed tomography is recommended to avoid overlooking such potentially treatable condition.

Management of intracranial hypertension following traumatic brain injury: a best clinical practice adoption proposal for intracranial pressure monitoring and decompressive craniectomy. Joint statements by the Traumatic Brain Injury Section of the Italian Society of Neurosurgery (SINch) and the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.

A Retrospective Analysis of Intracranial Pressure Monitoring and Outcomes in Adults after Severe Traumatic Brain Injury at Kaiser Permanente Trauma Centers

BACKGROUND

The role of intracranial pressure (ICP) monitoring in improving outcomes after severe traumatic brain injury especially at level II trauma centers remains controversial. A retrospective analysis was undertaken to assess the impact of ICP monitoring on mortality and long-term functional outcome in adults after severe traumatic brain injury at level II trauma centers.

METHODS

The data were extracted from the Kaiser Permanente trauma database. Inclusion criteria were adults (≥ 18 years) with severe traumatic brain injury (Glasgow Coma Scale score, < 9) admitted to 2 level II trauma centers in Northern California from 2014 to 2019.

RESULTS

Of 199 patients, 58 (29.1%) underwent ICP monitoring. The monitored subgroup was significantly younger (< 65 years), had lower Glasgow Coma Scale scores (3-5), underwent cranial procedures (craniotomy or decompressive craniectomy) more often, and had greater injury severity scores (≥ 15). Despite monitored patients being more severely injured, there was no significant difference in mortality or 6-month favorable outcomes between monitored and nonmonitored patients, including patients who underwent cranial procedures. Increased monitoring frequency and reduction in overall mortality was seen throughout the study period yet with a parallel reduction in both groups.

CONCLUSION

ICP monitoring may not impact in-patient mortality or long-term outcomes at level II trauma centers. Improved outcomes may be more related to identifying patients who may benefit from ICP-guided therapy rather than simply increasing the overall use of it. Last, our pattern of care and outcomes are comparable to level I trauma centers and our findings may serve as a benchmark for future studies.

Complications Following Decompressive Craniectomy

BACKGROUND

 Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications.

METHODS

 We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed.

RESULTS

 DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome.

CONCLUSIONS

 The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.

Assessment of Dynamic Intracranial Compliance in Children with Severe Traumatic Brain Injury: Proof-of-Concept

Background and Aims

Intracranial compliance refers to the relationship between a change in intracranial volume and the resultant change in intracranial pressure (ICP). Measurement of compliance is useful in managing cardiovascular and respiratory failure; however, there are no contemporary means to assess intracranial compliance. Knowledge of intracranial compliance could complement ICP and cerebral perfusion pressure (CPP) monitoring in patients with severe traumatic brain injury (TBI) and may enable a proactive approach to ICP management. In this proof-of-concept study, we aimed to capitalize on the physiologic principles of intracranial compliance and vascular reactivity to CO₂, and standard-of-care neurocritical care monitoring, to develop a method to assess dynamic intracranial compliance.

Methods

Continuous ICP and end-tidal CO₂ (ETCO₂) data from children with severe TBI were collected after obtaining informed consent in this Institutional Review Board-approved study. An intracranial pressure-PCO₂ Compliance Index (PCI) was derived by calculating the moment-to-moment correlation between change in ICP and change in ETCO₂. As such, “good” compliance may be reflected by a lack of correlation between time-synched changes in ICP in response to changes in ETCO₂, and “poor” compliance may be reflected by a positive correlation between changes in ICP in response to changes in ETCO₂.

Results

A total of 978 h of ICP and ETCO₂ data were collected and analyzed from eight patients with severe TBI. Demographic and clinical characteristics included patient age 7.1 ± 5.8 years (mean ± SD); 6/8 male; initial Glasgow Coma Scale score 3 [3–7] (median [IQR]); 6/8 had decompressive surgery; 7.1 ± 1.4 ICP monitor days; ICU length of stay (LOS) 16.1 ± 6.8 days; hospital LOS 25.9 ± 8.4 days; and survival 100%. The mean PCI for all patients throughout the monitoring period was 0.18 ± 0.04, where mean ICP was 13.7 ± 2.1 mmHg. In this cohort, PCI was observed to be consistently above 0.18 by 12 h after monitor placement. Percent time spent with PCI thresholds > 0.1, 0.2, and 0.3 were 62% [24], 38% [14], and 23% [15], respectively. The percentage of time spent with an ICP threshold > 20 mmHg was 5.1% [14.6].

Conclusions

Indirect assessment of dynamic intracranial compliance in TBI patients using standard-of-care monitoring appears feasible and suggests a prolonged period of derangement out to 5 days post-injury. Further study is ongoing to determine if the PCI—a new physiologic index, complements utility of ICP and/or CPP in guiding management of patients with severe TBI.

Electronic supplementary material

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Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

OBJECTIVE

To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI).

METHODS

A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, "primary procedure" and "secondary procedure", was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO₂) values as well as the need for additional osmotherapy and CSF drainage.

RESULTS

Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average post-surgical ICP values, higher PbO₂ values and required less osmotic treatments as compared with those treated with DC alone.

CONCLUSION

Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.

First Intracranial Pressure Monitoring or First Operation: Which One Is Better?

BACKGROUND

For patients with TBI, traditional methods such as clinical examination and imaging data are the primary references used for deciding whether to operate or not. Intracranial pressure (ICP) monitoring based on lateral ventricles or parenchymal pressure is a more direct reflection of ICP. However, the research on whether the outcome results of ICP monitoring are better than results based on clinical signs and imaging is sparse. Therefore, we compared treatment results for patients with TBI based on ICP monitoring and traditional methods.

METHODS

This retrospective study included patients with TBI admitted to our collaborative hospitals between January 1, 2012, and December 31, 2013. All patients enrolled were divided into a traditional methods group and ICP monitoring group. Follow-up treatment was determined by ICP monitoring value or traditional methods in the 2 groups. Propensity matching scores were used to ensure that baseline characteristics of patients in the 2 groups were consistent.

RESULTS

A significant association was found between the initial ICP value and neurologic deterioration (odds ratio 1.24; P < 0.001), and nonlinear correlation achieved the best fit (R² = 0.547). Both 6-month good recovery rate and favorable outcome rate were higher in the ICP monitoring group than the traditional methods group by propensity score analysis (P < 0.05).

CONCLUSIONS

For patients with TBI with cerebral contusion volume >20 mL, both 6-month good recovery rate and favorable outcome rate were significantly higher in the ICP monitoring group than the traditional methods group.

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.

The current status of decompressive craniectomy in traumatic brain injury

PURPOSE

This review describes the evidence base that has helped define the role of decompressive craniectomy (DC) in the management of patients with traumatic brain injury (TBI).

RECENT FINDINGS

The publication of two randomized trials (DECRA and RESCUEicp) has strengthened the evidence base. The DECRA trial showed that neuroprotective bifrontal DC for moderate intracranial hypertension is not helpful, whereas the RESCUEicp trial found that last-tier DC for severe and refractory intracranial hypertension can significantly reduce the mortality rate but is associated with a higher rate of disability. These findings have reopened the debate about 1) the indications for DC in various TBI subtypes, 2) alternative techniques (e.g. hinge craniotomy), 3) optimal time and material for cranial reconstruction, and 4) the role of shared decision-making in TBI care. Additionally, the role of primary DC when evacuating an acute subdural hematoma is currently undergoing evaluation in the context of the RESCUE-ASDH randomized trial.

SUMMARY

This review provides an overview of the current evidence base, discusses its limitations and presents a global perspective on the role of DC, as there is growing recognition that attention should also focus on low- and middle-income countries due to their much greater TBI burden.

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.