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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sedation Intensity in Patients with Moderate to Severe Traumatic Brain Injury in the Intensive Care Unit: A TRACK-TBI Cohort Study

BACKGROUND

Interventions to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI) are multimodal but variable, including sedation-dosing strategies. This article quantifies the different sedation intensities administered in patients with moderate to severe TBI (msTBI) using the therapy intensity level (TIL) across different intensive care units (ICUs), including the use of additional ICP-lowering therapies.

METHODS

Within the prospective Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, we performed a retrospective analysis of adult patients with msTBI admitted to an ICU for a least 5 days from seven US level 1 trauma centers who received invasive ICP monitoring and intravenous sedation. Sedation intensity was classified prospectively as one of three ordinal levels as part of the validated TIL score, which were collected at least once a day.

RESULTS

A total of 127 patients met inclusion criteria (mean age 41.6 ± 17.7 years; 20% female). The median Injury Severity Score was 27 (interquartile range 17-33), with a median admission Glasgow Coma Score of 3 (interquartile range 3-7); 104 patients had severe TBI (82%), and 23 patients had moderate TBI (18%). The sedation intensity score was highest on the first ICU day (2.69 ± 1.78), independent of patient severity. Time to reaching each sedation intensity level varied by site. Sedation level I was reached within 24 h for all sites, but sedation levels II and III were reached variably between days 1 and 3. Sedation level III was never reached by two of seven sites. The total TIL score was highest on the first ICU day, with a modest decrease for each subsequent ICU day, but there was high site-specific practice-pattern variation.

CONCLUSIONS

Intensity of sedation and other therapies for elevated ICP for patients with msTBI demonstrate large practice-pattern variation across level 1 trauma centers within the TRACK-TBI cohort study, independent of patient severity. Optimizing sedation strategies using patient-specific physiologic and pathoanatomic information may optimize patient outcomes.

Comparative Effectiveness of Midazolam-Based Sedation on the Need for Intracranial Pressure Lowering Therapies in Traumatic Brain Injury

Sedatives play an important role in the management of patients with severe traumatic brain injury (sTBI) in the intensive care unit (ICU). Benzodiazepines are common for sedation (midazolam-based) but have been discouraged for non-brain-injured patients in the ICU. This study aimed to investigate the effect of midazolam-based sedation versus non-midazolam-based sedation on the need for intracranial pressure (ICP) lowering therapies in patients with sTBI in the ICU. We studied patients with sTBI (Glasgow Coma Sale ≤8) from 14 ICUs in Europe and Australia, who received ICP monitoring and continuous instrumental variable (IV) sedation for at least 24 h. We analyzed the association between sedation strategy and the need for ICP lowering therapies during the first 7 ICU days using a multivariable logistic regression model, adjusted for clinical markers of injury severity. We also analyzed the center as an IV in a random effects model to address potentially unmeasured confounding. Among 227 patients with sTBI, 152 (67%) received midazolam-based sedation. These patients had a lower age and higher median Glasgow Coma Scale on admission compared with 75 patients in the non-midazolam-sedated group. In logistic regression analyses, patients with midazolam-based sedation had higher odds of receiving hyperosmolar therapy (odds ratio [OR]: 3.4, 95% confidence intervals [CI]: 1.6-7.7). This effect could not be confirmed in the instrumental variable analysis (hyperosmolar therapy: OR: 1.3, 95% CI: 0.1-13.1). The mean ICU length of stay was significantly longer in the midazolam-based sedation group compared with the non-midazolam-based sedation group (19 vs. 13 days, hazards ratio 0.6, 95% CI: 0.4-0.8). Midazolam-based sedation was common for patients with sTBI without a significantly increased need for ICP therapies but an association with longer ICU stay. Larger prospective comparative effectiveness studies are needed regarding sedation strategies in critically ill patients with TBI.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Time-to-surgery for traumatic brain injury in the hyperacute period: a systemic review and meta-analysis

OBJECTIVE

To study the functional outcomes of traumatic brain injury (TBI) patients who have undergone surgical intervention in the hyperacute phase (<24 h).

DATA SOURCES

Cochrane Library, PubMed, Embase, Medline and Web of Science databases.

REVIEW METHODS

A meta-analysis of 7 trials involving 237 patients was performed. Patients were categorized into two groups based on time to surgery: within 6 h and within 24 h. Patients were also categorized into developed and developing regions. Effect estimates were calculated using a fixed-effects model and heterogeneity was assessed with Cochrane I² statistic.

RESULTS

Our findings revealed that those who underwent neurosurgery in the hyperacute phase of TBI were at risk of adverse outcomes. The odds ratio (OR) was 1.50 (95% CI 1.03-2.19). Subgroup analysis demonstrated that TBI patients who underwent surgery within 6 h were at a greater risk of adverse effects (OR, 1.72; 95% CI, 1.08-2.74). Moreover, a greater risk was observed in developing regions (OR, 2.33; 95% CI, 0.97-5.58).

CONCLUSION

Earlier neurosurgical intervention in the acute phase of TBI might result in higher incidence of adverse events. Surgery would be postponed for TBI patients whose initial GCS score is greater than 8 during the hyperacute period.

Baseline Characteristics Associated with Improved Outcomes in Patients Undergoing Primary Decompressive Craniectomy for Acute Subdural Hematoma Evacuation-A Retrospective Observational Study

Background and Objective: The study's aim is to identify a subgroup of patients who would benefit from primary decompressive craniectomy (pDC) after acute subdural hematoma (aSDH) evacuation. Materials and Methods: A retrospective analysis of 290 patients undergoing aSDH evacuation between 2016 and 2021 was conducted. Osteoplastic craniotomy (OC) was performed in 213 cases (73.4%), whereas 77 individuals underwent pDC. Preoperative characteristics, such as age, initial GCS score, hematoma thickness, midline shift, and cisternal effacement score (CES), were used to predict outcome at discharge by the Glasgow Outcome Scale (GOS). Results: Older age, lower initial GCS, and higher CES preoperatively were independently associated with lower GOS scores at discharge. Age and degree of cisternal compression remained significant predictors of GOS score in the pDC subgroup. Survivors who underwent pDC were younger in comparison to deceased individuals receiving OC (mean age 55.43 ± 14.58 vs. 72.28 ± 14.63, p < 0.001). Patients who achieved favorable outcomes after pDC were significantly younger compared to those who had poor outcomes after OC (mean age 49.20 ± 12.05 vs. 72.28 ± 14.32, p < 0.001). Conclusions: Younger patients (<55 years old) with initial GCS scores of 4-6, midline shifts of 1 to 2 cm, subdural hematoma thickness of 1 to 2.5 cm, and CES in a range of 7-12 may benefit from pDC as it could potentially improve survival and functional outcomes after aSDH evacuation.

Adherence in Evidence-Based Neurotrauma Guidelines: A Worldwide Survey

BACKGROUND

Traumatic brain injury management guidelines vary across regions and there is limited research on real-world adherence to these guidelines. We conducted a global survey to assess the adherence of neurosurgeons to traumatic brain injury guidelines and evidence-based medicine (EBM).

METHODS

A 24-item survey was created using Google Forms, covering demographic information, neurotrauma training, basic knowledge of EBM, and surgical and in-hospital management.

RESULTS

Responses were collected from 233 neurosurgeons across 53 different countries. Approximately 45% of respondents reported not staying up to date with Brain Trauma Foundation guidelines, and 48% indicated a preference for relying on their own experience over EBM guidelines. Neurosurgeons from Asia and Africa were more likely to rely on personal experience, while those from Europe and North/Central and South America leaned toward EBM (P = 0.021). Additionally, 56% of respondents reported that their neurotrauma management at least sometimes diverged from recommended guidelines. Specifically, 58% never or rarely managed epidural hematoma of 30 cm³ conservatively, and 45% sometimes, often, or always treated subdural hematomas conservatively, even when EBM recommended surgery. Moreover, 24% at least sometimes managed patients conservatively despite a Glasgow Coma Scale score of less than 9 or a decrease of 2 or more points. In cerebellar hematomas, 46% sometimes opted for external ventricular drainage alone.

CONCLUSIONS

Neurosurgeons from Europe and North/Central and South America tend to follow EBM guidelines more closely, while those from Asia and Africa often favor individual decision-making approaches.

Post-craniectomy hydrocephalus in adult traumatic brain injury patients: a systematic review and meta-analysis of risk factors and outcome

Traumatic Brain Injury (TBI) is a major cause of death, disability, and healthcare expenses worldwide. Decompressive craniectomy (DC) is a critical surgery used when there is uncontrollable swelling in the brain following a TBI. Research has shown that 27.4% of patients who underwent DC for severe TBI developed hydrocephalus, leading to a significant impact on their quality of life and long-term outlook. We conducted a review of hydrocephalus risk factors in adult TBI patients who underwent DC to better understand the factors contributing to this condition. The comprehensive search strategy covered PubMed, Scopus, Embase, and Web of Science databases from inception to June 2024. The search terms "Craniectomy AND Hydrocephalus AND Trauma* and Decompress*" were applied to titles, abstracts, and keywords. Out of 887 publications found, 591 remained after removing duplicates. After reviewing titles and abstracts, 480 articles were excluded. Of the remaining 111 articles, 87 were excluded for various reasons, leaving 22 for the meta-analysis. The cumulative sample size was 2888, and the incidence of hydrocephalus was 20.5%. We analyzed 28 variables and of them, 13 were associated with hydrocephalus, Subrachnoid hemorrhage (OR:1.75), Intraventricular hemorrhage (OR: 2.49), At least one pupil dilation (OR: 2.01), Preoperative GCS < 6, Craniectomy Margin Distance from Midlineless than 21 mm, size of craniectomy greater than 106.75 cm2, TCHBV greater than 69, bilateral craniectomy (OR: 3.75), Postoperative intracranial infection (OR: 2.7), Postoperative Cerebral infarction (OR: 2.74), interhemispheric Hygroma (OR: 5.53), contralateral Hygroma (OR: 4.18), and bilateral Hygroma (OR: 2.55). Hydrocephalus following DC is notably linked to an adverse outcome (Glasgow Outcome Scale 1, 2, 3 OR: 4.06). After decompressive craniectomy, hydrocephalus significantly affects traumatic brain injury recovery. Our analysis found that the craniectomy margin distance from the midline less than 21 mm is a modifiable risk factor for hydrocephalus development. Other significant risk factors will help diagnose at-risk patients, address hydrocephalus promptly, and ultimately improve patient outcomes.

RADAR - Radiomics on aSDH: predicting outcome with surface area

BACKGROUND

Acute subdural hematoma is a critical condition, leading to significant morbidity and mortality. Despite advancements in surgical techniques, a portion of patients only show limited clinical improvement post-evacuation. Surgical intervention decisions are critically important, as they can either improve or worsen a patient's condition. Radiomics offers significant potential by extracting complex patterns from digital medical images and transforming them into high-dimensional data that reflect the underlying pathophysiology. By integrating Radiomics with individual patient characteristics, we can develop decision support models. This study aims to analyze radiomic parameters of aSDH to determine whether they support the decision to proceed with urgent surgery or opt for a conservative approach. We hypothesized that surface area could be a significant predictor of neurological outcome such as maintaining independent mobility (mRS ≥ 3) and survival rates.

METHODS

This retrospective study involved radiomic analysis according to neurological outcome and survival. Radiomic parameters were measured using 3D Slicer software. Statistical analyses explored correlations, employing AUC-analysis and Kaplan-Meier survival.

RESULTS

Our findings revealed significant correlations between hematoma and surface area with poorer neurological prognosis. Further subgroup analysis showed surface area as a significant predictor for poorer outcomes in patients undergoing craniotomy (p = 0.006 in univariant- and p = 0.020 in multivariant analysis). In the total cohort, among conservatively managed and craniotomy subgroups, survival analysis highlighted an advantageous survival for patients exhibiting smaller surface areas (< 339.50 cm2).

CONCLUSIONS

Especially in craniotomy patients, surface area emerged as a possible predictor for neurological outcome and survival.

Complications Following Decompressive Craniectomy

Decompressive craniectomy (DC) is performed to treat refractory intracranial hypertension following traumatic brain injury and stroke. Though technically not demanding, DC is still associated with several early and delayed complications. Early complications can be fatal, whereas delayed complications may result in regression of recovery. Adequately sized DC along with aggressive medical management mitigates most of the acute complications whereas early cranioplasty prevents delayed complications.

Intraoperative variations in intra-axial brain tumor size after craniotomy: a prospective study with histopathological and tumor tissue composition correlation, introducing concepts of tumor expansion and tumor surfacing

Intraoperative assessment of tumor margins can be challenging; as neoplastic cells may extend beyond the margins seen on preoperative imaging. Real-time intraoperative ultrasonography (IOUS) has emerged as a valuable tool for delineating tumor boundaries during surgery. However, concerns remain regarding its ability to accurately distinguish between tumor margins, peritumoral edema, and normal brain tissue. Preoperative contrast-enhanced MRI (CEMRI) and contrast-enhanced CT (CECT) were performed to assess tumor dimensions, and IOUS was used intraoperatively to further evaluate tumor characteristics. Tumor volume was estimated using the prolate ellipsoid formula. Statistical analysis was conducted to compare tumor dimensions between imaging modalities and assess tumor expansion post-craniotomy. Our study included 51 patients with intracranial tumors. IOUS revealed larger tumor dimensions compared to preoperative CEMRI and CECT, with significant differences observed in surface area and volume. Tumors exhibited varied echogenicity on IOUS, with most showing mixed echogenicity. Histopathological analysis revealed a range of tumor grades, with gliomas being the most common. Statistical analysis indicated significant differences in tumor dimensions between imaging modalities, with tumor expansion observed post-craniotomy. Tumor type and grade were predictive factors for tumor volume expansion. Tumors exhibit expansion after craniotomy, with both tumor volume and surface area increasing. This expansion phenomenon, not solely attributed to tumor edema, underscores the importance of considering tumor mass expansion during surgical planning and intraoperative decision-making. These findings highlight the utility of IOUS in accurately delineating tumor boundaries and optimizing surgical outcomes in the management of intracranial tumors.

Neuroprotective and neuroregenerative drugs after severe traumatic brain injury : A narrative review from a clinical perspective

Traumatic brain injuries cause enormous individual and socioeconomic burdens. Survivors frequently struggle with motor handicaps as well as impaired cognition and emotion. In addition to the primary mechanical brain damage, complex secondary mechanisms are the main drivers of functional impairment. Many of these pathophysiological mechanisms are now well known: excitotoxic amino acids, breakdown of the blood-brain barrier, neuroinflammation with subsequent damage to cell organelles and membranes, cerebral edema, and apoptotic processes triggering neuronal death; however, paracrine resilience factors may counteract these processes. Specific neuroprotective and neuroregenerative intensive care therapies are few. This review highlights medical approaches aimed at mitigating secondary damage and promoting neurotrophic processes in severe traumatic brain injury. Some pharmacologic attempts that appeared very promising in experimental settings have had disappointing clinical results (progesterone, cyclosporine A, ronopterin, erythropoietin, dexanabinol). Thus, the search for drugs that can effectively limit ongoing posttraumatic neurological damage is ongoing. Some medications appear to be beneficial: N‑methyl-D-aspartate receptor (NMDA) antagonists (esketamine, amantadine, Mg++) reduce excitotoxicity and statins and cerebrolysin are known to counteract neuroinflammation. By supporting the impaired mitochondrial energy supply, oxidative processes are inhibited and neuroregenerative processes, such as neurogenesis, angiogenesis and synaptogenesis are promoted by citicoline and cerebrolysin. First clinical evidence shows an improvement in cognitive and thymopsychic outcomes, underlined by own clinical experience combining different therapeutic approaches. Accordingly, adjuvant treatment with neuroprotective substances appears to be a promising option, although more randomized prospective studies are still needed.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Risk score for early prognostication of aseptic bone flap necrosis

PURPOSE

Aseptic bone flap necrosis (ABFN) is a common complication of autologous cranioplasty that often requires reoperation. This study aimed to create a risk score for ABFN using relevant demographic, clinical, and laboratory markers.

METHODS

We included all patients who underwent autologous cranioplasty after decompressive surgery between 2007 and 2019. We collected laboratory data, initial clinical diagnoses, and demographic parameters before autologous bone flap reimplantation. The significant predictors of ABFN identified in the final multivariate analysis were used to develop a risk score.

RESULTS

Of the 412 patients who underwent craniectomy, 58 (14%, 32 females: 55.2%) developed ABFN. The following independent predictors of ABFN were included in the risk score (0-7 points): craniectomy due to trauma or hemorrhagic stroke (2 points), younger age (< 40 years, 2 points), cranioplasty timing (> 95 days post-craniectomy, 1 point), glutamate-pyruvate transferase < 18 U/L (1 point), and serum creatinine level < 0.815 mg/dL (1 point). The ABFN rates in patients with scores of 0-2, 3-4, and 5-7 points were 4.2%, 16.1%, and 34.6%, respectively. The risk score demonstrated moderate diagnostic accuracy for predicting ABFN, with an area under the curve of 0.739.

CONCLUSION

The proposed risk score may help in early identification of individuals prone to ABFN. These data suggest that future studies should investigate the significance of metabolic syndromes related to ABFN occurrence. Understanding the potential impact of metabolic factors on ABFN can enhance risk assessment and targeted preventive measures for patients undergoing cranioplasty procedures.

Efficacy of decompressive craniectomy: A retrospective case series study with 321 patients and an update on controversies

Decompressive craniectomy (DC) is considered a cornerstone in the management of refractory intracranial hypertension. For decades, DC was known as an occasionally lifesaving procedure; however, it was associated with numerous severe complications. The present study is a single-center retrospective case series study on with 321 patients who underwent DC between January, 2010 and December, 2020. All patients were divided into four groups as follows: Group A included patients who suffered from a space-occupying middle cerebral artery (MCA) ischemic event; group B included individuals who developed intracerebral hemorrhage; group C included patients admitted for traumatic brain injury; and group D included patients with other neurosurgical entities that underwent DC, such as subarachnoid hemorrhage, tumors, brain abscess and cerebral ventricular sinus thrombosis events. The present study enrolled a total of 321 patients who underwent DC. Group A included 52 out of the 321 (16.1%) patients, group B included 51 (15.8%) patients, group C included 164 (51.0%) patients, and group D included 54 (16.8%) patients. Of the 321 patients, 235 (73.2%) were males, and the median age was 53.7 years. Multivariate analysis revealed that only the group A parameter was an independent factor associated with a Glasgow outcome scale score >2 during follow-up (P<0.05). On the whole, the results of the present study suggest that among patients who underwent DC with different neurological entities, those who had experienced MCA events had more favorable outcomes.

Guidelines in Neurosurgery: a critical appraisal

BACKGROUND

The process of grading and stratifying evidence in the extensive literature on neurosurgical guidelines has evolved significantly, ranging from high-quality standards to suggested options. However, the methodology for guideline development has become increasingly complex, leading to challenges in their application across various neurosurgical specialties and settings. This mini review aims to explore the practical implications of published suggestions for managing neurosurgical patients.

METHODS

A critical and focused collection of published literature concerning guidelines in different neurosurgical topics, from Pubmed and other sources formed the basis of this non-systematic narrative review. Only guidelines produced by neurosurgeons in the era of evidence based medicine (after 1996) were included.

RESULTS

Neurosurgical guidelines often rely on a limited number of Randomized Controlled Trials (RCTs) and Class I evidence, particularly in surgical and emergency contexts where randomization of patient treatments may conflict with established clinical practices. Challenges also include the timely update of guidelines, which sometimes lags behind rapid shifts in evidence, and varying methodologies in guideline production that can result in divergent recommendations. Geographical disparities in disease burden and literature production further influence guideline applicability, suggesting a need for greater inclusion of authors from Low- and Middle-Income Countries (LMICs) to enhance realism and global relevance. Consensus conferences and expert reviews may serve as viable alternatives to address these challenges.

CONCLUSION

While Evidence-Based Medicine remains pivotal, critical appraisal and practical application of guidelines must consider these complexities to optimize patient care and outcomes.

Basal cisternostomy as an adjunct to decompressive hemicraniectomy in moderate to severe traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Basal cisternostomy (BC) is a surgical technique to reduce intracranial hypertension following moderate to severe traumatic brain injury (TBI). As the efficacy and safety of BC in patients with TBI has not been well-studied, we aim to summarize the published evidence on the effect of BC as an adjunct to decompressive hemicraniectomy (DHC) on clinical outcome following moderate to severe TBI.

METHODS

A systematic literature review was carried out in PubMed/MEDLINE and EMBASE to identify studies evaluating BC as an adjunct to decompressive hemicraniectomy (DHC) in moderate to severe TBI. Random effects meta-analysis was performed to calculate summary effect estimates.

RESULTS

Eight studies reporting on 1345 patients were included in the qualitative analysis, of which five (1206 patients) were considered for meta-analysis. Overall, study quality was low and clinical heterogeneity was high. Adjuvant BC (BC + DHC) compared to standalone DHC was associated with a reduction in the length of stay in the ICU (Mean difference [MD]: -3.25 days, 95% CI: -5.41 to -1.09 days, p = 0.003), significantly lower mean brain outward herniation (MD: -0.68 cm, 95% CI: -0.90 to -0.46 cm, p < 0.001), reduced odds of requiring osmotherapy (OR: 0.09, 95% CI: 0.02 to 0.41, p = 0.002) as well as decreased odds of mortality at discharge (OR 0.68, 95% CI: 0.4 to 0.96, p = 0.03). Adjuvant BC compared to DHC did not result in higher odds of a favourable neurological outcome (OR = 2.50, 95% CI: 0.95-6.55, p = 0.06) and did not affect mortality at final follow-up (OR: 0.80, 95% CI: 0.17 to 3.74, p = 0.77).

CONCLUSION

There is insufficient data to demonstrate a potential beneficial effect of adjuvant BC. Despite some evidence for reduced mortality and length of stay, there is no effect on neurological outcome. However, these results need to be interpreted with caution as they carry a high risk of bias due to overall scarcity of published clinical data, technical variations, methodological differences, limited cohort sizes, and a considerable heterogeneity in study design and reported outcomes.

Decompressive craniectomy in trauma: What you need to know

ABSTRACT

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

Navigating the Role of Surgery in Optimizing Patient Outcomes in Traumatic Brain Injuries (TBIs): A Comprehensive Review

Traumatic brain injuries (TBIs) present with symptoms ranging from a mildly altered level of consciousness to irreversible coma and death. The most severe stage of TBIs is diffuse axonal injury and swelling affecting the whole brain. Management strategies are based on the classification of TBIs by severity and type and range from cognitive therapy sessions to complex surgeries. Neuroimaging modalities, predominantly magnetic resonance imaging, and the clinical Glasgow Coma Scale are principal indicators to diagnose and assess a patient's condition and neurological status and decide optimal treatment modality. In this review, we have summarized the indications and patient outcomes based on neurological and functional status, post-surgical complications, and mortality rates for various life-saving interventional procedures including surgery for brain contusions, intracranial hematomas and penetrating injuries, and craniectomy and ventriculostomy for elevated intracranial pressure and hydrocephalus. Cranioplasty performed for aesthetic purposes has also been explored. Overall quality evidence presented advocates surgery as needed for improved patient outcomes resulting in early recovery and decreased mortality, especially with the emergence of minimally invasive techniques. However, there is still an increased risk of certain complications like infections and bleeding and severe disabilities leading to a vegetative state with surgery. Some guidelines have been formed to provide indications for optimal management of TBI patients including surgeries, although their effectiveness in each individual case is debatable. It is imperative to explore certain key areas like the timing of the surgery and the role of intensive patient monitoring pre- and post-procedure in future studies and lay down guidelines also applicable to resource-limited areas. Also, a deeper understanding of physiological and pathological mechanisms of functional outcomes post-surgery will help clinicians predict the patient's course of recovery.

A Rose by Any Other Name: The Long Intricate History of Localized Aggressive Periodontitis

This review addresses the recent World Workshop Consensus Conference (WWCC) decision to eliminate Localized Aggressive Periodontitis (LAgP) in young adults as a distinct form of periodontitis. A "Consensus" implies widespread, if not unanimous, agreement among participants. However, a significant number of attendees were opposed to the elimination of the LAgP classification. The substantial evidence supporting a unique diagnosis for LAgP includes the (1) incisor/molar pattern of disease, (2) young age of onset, (3) rapid progression of attachment and bone loss, (4) familial aggregation across multiple generations, and (5) defined consortium of microbiological risk factors including Aggregatibacter actinomycetemcomitans. Distinctive clinical signs and symptoms of LAgP are presented, and the microbial subgingival consortia that precede the onset of signs and symptoms are described. Using Bradford-Hill guidelines to assess causation, well-defined longitudinal studies support the unique microbial consortia, including A. actinomycetemcomitans as causative for LAgP. To determine the effects of the WWCC elimination of LAgP on research, we searched three publication databases and discovered a clear decrease in the number of new publications addressing LAgP since the new WWCC classification. The negative effects of the WWCC guidelines on both diagnosis and treatment success are presented. For example, due to the localized nature of LAgP, the practice of averaging mean pocket depth reduction or attachment gain across all teeth masks major changes in disease recovery at high-risk tooth sites. Reinstating LAgP as a distinct disease entity is proposed, and an alternative or additional way of measuring treatment success is recommended based on an assessment of the extension of the time to relapse of subgingival re-infection. The consequences of the translocation of oral microbes to distant anatomical sites due to ignoring relapse frequency are also discussed. Additional questions and future directions are also presented.

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

CONTEXT

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Three-dimensional personalized porous polyethylen cranioplasty in patients at increased risk of surgical site infection

BACKGROUND

Surgical site infection (SSI) is the most consistently reported complication of cranioplasty. No material showed a categorical superiority in the incidence of infection. Porous polyethylene (PE) is considered a low risk material regarding SSI. However, the literature data are very limited. Thus, our objective was to verify the assumed low incidence of SSI after PE cranioplasty in patients at high risk of SSI. The primary objective was the infection rate, while secondary objectives were implant exposure, revision and cosmetic results.

METHOD

Patients who underwent three-dimensional (3D) personalized PE cranioplasty in the period 2014-2023 were evaluated prospectively. Only patients with an increased risk of SSI, and a satisfactory clinical conditions were included in the study.

RESULTS

Thirty procedures were performed in 30 patients. Cranioplasty was performed 23 times after hemispheric decompressive craniectomy, five times after limited size craniotomy and two times after bifrontal decompressive craniectomy. Risk factors for the development of infection were 18 previous SSIs, 16 previous repeated revision surgeries, four intraoperatively opened frontal sinuses and two times radiotherapy. Neither infection nor implant exposure was detected in any patient. All patients were satisfied with the aesthetic result. In two cases, a revision was performed due to postoperative epidural hematoma.

CONCLUSIONS

Three-dimensional personalized PE cranioplasty is associated with an extremely low incidence of SSI even in high-risk patients. However, our conclusions can only be confirmed in larger studies.

Contusion expansion, low platelet count and bifrontal contusions are associated with worse patient outcome following traumatic brain injury-a retrospective single-center study

BACKGROUND

Cortical contusions are common in moderate-severe traumatic brain injury (TBI). Cortical contusions often expand, potentially causing neuro-worsening several hours to days post-trauma. While contusion expansion (CE) may affect outcome, potential clinical and radiological markers that can predict CE have been insufficiently explored. In the present single-center retrospective observational cohort study, we evaluated clinical outcome by the Glasgow Outcome Scale extended (GOSE) scale and evaluated risk factor for CE.

METHOD

Adult TBI patients > 18 years of age, and of all injury severities, were included. Main variables of interest were low platelet count, defined as < 150 × 109/L, presence of bifrontal contusions and CE, defined as absolute contusion volume increase in cm3. Factors associated with CE and clinical outcome according to GOSE were analyzed.

RESULTS

Between 2012-2022, 272 patients were included. Contusion size on admission correlated positively with CE, as did the Marshall and Rotterdam radiological classification scores. Bifrontal contusions were significantly larger at admission, experienced larger CE, and had a worse outcome than contusions in other locations. Patients with a platelet count < 150 × 109/L experienced a greater volume CE and had a worse outcome when compared to patients with a normal platelet count. In a multivariate analysis, CE remained significantly associated with a poor outcome six months post- injury.

CONCLUSION

Contusion volume at admission, Marshall CT classification and Rotterdam CT score, positively correlated to CE. Bifrontal contusions and a platelet count < 150 × 109/L were associated with CE, and a poor clinical outcome. Large CE volumes were associated with a worse clinical outcome, and CE was per se associated with outcome in a multivariate analysis. Management of these risk factors for CE in the acute post-injury setting may be needed to attenuate contusion expansion and to improve clinical outcome in TBI patients suffering from cortical contusion injuries.

Controlled lumbar cerebrospinal fluid drainage effectively decreases the need for second and third tier interventions for intracranial hypertension in severe traumatic brain injury patients

INTRODUCTION

Early treatment of elevated intracranial pressure (ICP) is a cornerstone of the therapy in severe traumatic brain injury (TBI) patients. Treatment of refractory high ICP however, remain challenging as only limited and risky third-tier therapeutic interventions are available. Controlled lumbar cerebrospinal fluid (CSF) drainage has been known as an efficient method of ICP reduction after TBI for decades, but it is not recommended in international guidelines because of low evidence background and safety issues. Our centre has a long-standing experience using this intervention for more than 15 years. Here we present our data about the safety and efficacy of controlled lumbar drainage to avoid further second- and third tier ICP lowering therapies and beneficially influence functional outcome.

METHODS

Observational (retrospective and prospective) analysis was performed using demographic, clinical and outcome data of severe TBI patients admitted to our centre. Analysis was retrospective between 2008 and 2013 and prospective from 2014 to 2019. Only severe TBI patients (GCS<9) with ICP monitoring were enrolled. Lumbar drainage (LD) was used as a second-tier therapy to control intracranial hypertension in salvageable patients with normal haemostasis and discernible basal cisterns on pre-interventional CT scan.

RESULTS

Data of 45 patients were analysed. Patients were young, comatose and with severe injuries (median age: 29, GMS: 4, ISS: 25). Lumbar drain was inserted mainly on the first week and maintained for further 5 days. Episodes of intracranial hypertension (ICP>20 Hgmm) within one day (10 vs 2) were reduced. The need of additional second- and third-line therapies (deep sedation, hyperventilation, barbiturate administration, decompressive craniectomy) also significantly decreased (60 vs 25 interventions, p<0.001). The in-hospital mortality and 6-month functional outcome were more favourable than the whole TBI population and as predicted by prognostic calculations (mortality: 16% vs. 48 %; GOSE 1-4: 49% vs. 65% vs CRASH: 87% vs. IMPACT: 51 %) in this period.

CONCLUSIONS

Our results support the view that controlled lumbar drainage is a highly efficient method to manage intracranial hypertension and significantly decreases the need of further harmful ICP lowering therapies without altering functional outcome of severe TBI patients.

Intracranial pressure monitoring in adult patients with traumatic brain injury: challenges and innovations

Intracranial pressure monitoring enables the detection and treatment of intracranial hypertension, a potentially lethal insult after traumatic brain injury. Despite its widespread use, robust evidence supporting intracranial pressure monitoring and treatment remains sparse. International studies have shown large variations between centres regarding the indications for intracranial pressure monitoring and treatment of intracranial hypertension. Experts have reviewed these two aspects and, by consensus, provided practical approaches for monitoring and treatment. Advances have occurred in methods for non-invasive estimation of intracranial pressure although, for now, a reliable way to non-invasively and continuously measure intracranial pressure remains aspirational. Analysis of the intracranial pressure signal can provide information on brain compliance (ie, the ability of the cranium to tolerate volume changes) and on cerebral autoregulation (ie, the ability of cerebral blood vessels to react to changes in blood pressure). The information derived from the intracranial pressure signal might allow for more individualised patient management. Machine learning and artificial intelligence approaches are being increasingly applied to intracranial pressure monitoring, but many obstacles need to be overcome before their use in clinical practice could be attempted. Robust clinical trials are needed to support indications for intracranial pressure monitoring and treatment. Progress in non-invasive assessment of intracranial pressure and in signal analysis (for targeted treatment) will also be crucial.

Telemedicine for Potential Application in Austere Military Environments: Neurosurgical Support for a Decompressive Craniectomy

INTRODUCTION

The main goal of this study was to assess the feasibility of a head-mounted display (HMD) providing telemedicine neurosurgical support during a decompressive craniectomy by a military surgeon who is isolated from readily available neurosurgical care. The secondary aim was to assess the usability perceived by the military surgeon and to evaluate technical aspects of the head-mounted display.

MATERIALS AND METHODS

After a standard concise lecture, 10 military surgeons performed a decompressive craniectomy on a AnubiFiX-embalmed post-mortem human head. Seven military surgeons used a HMD to receive telemedicine neurosurgical support. In the control group, three military surgeons performed a decompressive craniectomy without guidance. The performance of the decompressive craniectomy was evaluated qualitatively by the supervising neurosurgeon and quantified with the surgeons' operative performance tool. The military surgeons rated the usability of the HMD with the telehealth usability questionnaire.

RESULTS

All military surgeons performed a decompressive craniectomy adequately directly after a standard concise lecture. The HMD was used to discuss potential errors and reconfirmed essential steps. The military surgeons were very satisfied with the HMD providing telemedicine neurosurgical support. Military surgeons in the control group were faster. The HMD showed no hard technical errors.

CONCLUSIONS

It is feasible to provide telemedicine neurosurgical support with a HMD during a decompressive craniectomy performed by a non-neurosurgically trained military surgeon. All military surgeons showed competence in performing a decompressive craniectomy after receiving a standardized concise lecture. The use of a HMD clearly demonstrated the potential to improve the quality of these neurosurgical procedures performed by military surgeons.

Analysis of Causes of Complications and Prognostic Factors After Titanium Mesh Ultra-Early Cranioplasty Following Decompressive Craniectomy for Craniocerebral Trauma

OBJECTIVE

Craniocerebral trauma is one of the main causes of death and disability worldwide. Decompressive craniectomy is a common emergency measure in the treatment of craniocerebral trauma, aimed at relieving intracranial pressure. However, cranial bone reconstruction (CP) following this surgery is crucial for the patient's long-term recovery. Despite this, research on complications and prognostic factors after ultra-early cranioplasty remains limited. Therefore, this study aims to explore the complications of ultra-early cranioplasty with titanium mesh and its impact on prognosis.

METHODS

From January 2020 to November 2022, 44 patients with craniocerebral trauma who needed ultra-early CP after decompressive craniectomy were collected. The basic data of the National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale, modified Rankin Scale, and Montreal Cognitive Assessment scores of patients were collected, and the complications and prognosis of patients 3 months after operation were collected. Multivariate logistic regression was used to analyze the prognostic factors.

RESULTS

Compared with preoperative, the postoperative NIHSS score of patients with ultra-early CP decreased, the postoperative Glasgow Coma Scale score increased, the postoperative modified Rankin Scale score decreased (P < 0.05), and the postoperative Montreal Cognitive Assessment score was higher. Postoperative complications occurred in 42 patients with ultra-early CP. There were 37 complications, including 7 cases of hydroaccumulation, 18 cases of hematocele, 11 cases of pneumatosis, 3 cases of scalp swelling, 2 cases of epilepsy, 10 cases of hydrocephalus, and 1 case of intracranial infection, and no incision infection occurred. Age and postoperative NIHSS score were related factors affecting the poor prognosis of ultra-early CP patients (P < 0.05).

CONCLUSIONS

Ultra-early CP can promote the recovery of neurological function, reduce the disturbance of consciousness, improve daily living ability, and improve cognitive function in patients with craniocerebral trauma, but there is a high risk of postoperative complications. In addition, age and postoperative NIHSS score are related factors affecting the poor prognosis of ultra-early CP patients.

Outcome after decompressive craniectomy in older adults after traumatic brain injury

Objective

Globally, many societies are experiencing an increase in the number of older adults (>65 years). However, there has been a widening gap between the chronological and biological age of older adults which trend to a more active and social participating part of the society. Concurrently, the incidence of traumatic brain injury (TBI) is increasing globally. The aim of this study was to investigate the outcome after TBI and decompressive craniectomy (DC) in older adults compared with younger patients.

Methods

A retrospective, multi-centre, descriptive, observational study was conducted, including severe TBI patients who were treated with DC between 2005 and 2022. Outcome after discharge and 12 months was evaluated according to the Glasgow Outcome Scale (Sliding dichotomy based on three prognostic bands). Significance was established as p ≤ 0.05.

Results

A total of 223 patients were included. The majority (N = 158, 70.9%) survived TBI and DC at discharge. However, unfavourable outcome was predominant at discharge (88%) and after 12 months (67%). There was a difference in favour of younger patients (≤65 years) between the age groups at discharge (p = 0.006) and at 12 months (p < 0.001). A subgroup analysis of the older patients (66 to ≤74 vs. ≥75 years) did not reveal any significant differences. After 12 months, 64% of the older patients had a fatal outcome. Only 10% of those >65 years old had a good or very good outcome. 25% were depending on support in everyday activities. After 12 months, the age (OR 0.937, p = 0.007, CI 95%: 0.894-0.981; univariate) and performed cranioplasty (univariate and multivariate results) were influential factors for the dichotomized GOS. For unfavourable outcome after 12 months, the thresholds were calculated for age = 55.5 years (p < 0.001), time between trauma and surgery = 8.25 h (p = 0.671) and Glasgow Coma Scale (GCS) = 4 (p = 0.429).

Conclusion

Even under the current modern conditions of neuro-critical care, with significant advances in intensive care and rehabilitation medicine, the majority of patients >65 years of age following severe TBI and DC died or were dependent and usually required extensive support. This aspect should also be taken into account during decision making and counselling (inter-, intradisciplinary or with relatives) for a very mobile and active older section of society, together with the patient's will.

Traumatic Brain Injury and Traumatic Spinal Cord Injury

OBJECTIVE

This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury.

LATEST DEVELOPMENTS

Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated.

ESSENTIAL POINTS

Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.

Partial Cranial Reconstruction Using Titanium Mesh after Craniectomy: An Antiadhesive and Protective Barrier with Improved Aesthetic Outcomes

OBJECTIVE

Describe a new, safe, technique that uses titanium mesh to partially cover skull defects immediately after decompressive craniectomy (DC).

METHODS

This study is a retrospective review of 8 patients who underwent DC and placement of a titanium mesh. The mesh partially covered the defect and was placed between the temporalis muscle and the dura graft. The muscle was sutured to the mesh. All patients underwent cranioplasty at a later time. The study recorded and analyzed demographic information, time between surgeries, extra-axial fluid collections, postoperative infections, need for reoperation, cortical hemorrhages, and functional and aesthetic outcomes.

RESULTS

After craniectomy, all patients underwent cranioplasty within an average of 112.5 days (30-240 days). One patient reported temporalis muscle atrophy, which was the only complication observed. During the cranioplasties, no adhesions were found between temporalis muscle, titanium mesh, and underlying dura. None of the patients showed complications in the follow-up computerized tomography scans. All patients had favorable aesthetic and functional results.

CONCLUSIONS

Placing a titanium mesh as an extra step during DC could have antiadhesive and protective properties, facilitating subsequent cranioplasty by preventing adhesions and providing a clear surgical plane between the temporalis muscle and intracranial tissues. This technique also helps preserve the temporalis muscle and enhances functional and aesthetic outcomes postcranioplasty. Therefore, it represents a safe alternative to other synthetic anti-adhesive materials. Further studies are necessary to draw definitive conclusions and elucidate long-term outcomes, however, the results obtained hold great promise for the safety and efficacy of this technique.

A comprehensive systematic review and meta-analysis study in comparing decompressive craniectomy versus craniotomy in patients with acute subdural hematoma

There are two controversial surgery methods which are traditionally used: craniotomy and decompressive craniectomy. The aim of this study was to evaluate the efficacy and complications of DC versus craniotomy for surgical management in patients with acute subdural hemorrhage (SDH) following traumatic brain injury (TBI). We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Embase up to July 30, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Relevant articles were reviewed, with a focus on studies comparing decompressive craniectomy to craniotomy techniques in patients with SDH following TBI. Ten studies in 2401 patients were reviewed. A total of 1170 patients had a craniotomy, and 1231 had decompressive craniectomy. The mortality rate was not significantly different between the two groups (OR: 0.46 [95% CI: 0.42-0.5] P-value: 0.07). The rate of revision surgery was insignificantly different between the two groups (OR: 0.59 [95% CI: 0.49-0.69] P-value: 0.08). No significant difference was found between craniotomy and decompressive craniectomy regarding unilateral mydriasis (OR: 0.46 [95% CI: 0.35-0.57] P-value < 0.001). However, the craniotomy group had significantly lower rates of non-pupil reactivity (OR: 0.27 [95% CI: 0.17-0.41] P-value < 0.001) and bilateral mydriasis (OR: 0.59 [95% CI: 0.5-0.66] P-value: 0.04). There was also no significant difference in extracranial injury between the two groups, although the odds ratio of significant extracranial injury was lower in the craniotomy group (OR: 0.58 [95% CI: 0.45-0.7] P-value: 0.22). Our findings showed that non-pupil and bilateral-pupil reactivity were significantly more present in decompressive craniectomy. However, there was no significant difference between the two groups regarding mortality rate, extracranial injury, revision surgery, and one-pupil reactivity.

Consensus-based recommendations for diagnosis and surgical management of cranioplasty and post-traumatic hydrocephalus from a European panel

Introduction

Planning cranioplasty (CPL) in patients with suspected or proven post-traumatic hydrocephalus (PTH) poses a significant management challenge due to a lack of clear guidance.

Research question

This project aims to create a European document to improve adherence and adapt to local protocols based on available resources and national health systems.

Methods

After a thorough non-systematic review, a steering committee (SC) formed a European expert panel (EP) for a two-round questionnaire using the Delphi method. The questionnaire employed a 9-point Likert scale to assess the appropriateness of statements inherent to two sections: "Diagnostic criteria for PTH" and "Surgical strategies for PTH and cranial reconstruction."

Results

The panel reached a consensus on 29 statements. In the "Diagnostic criteria for PTH" section, five statements were deemed "appropriate" (consensus 74.2-90.3 %), two were labeled "inappropriate," and seven were marked as "uncertain."In the "Surgical strategies for PTH and cranial reconstruction" section, four statements were considered "appropriate" (consensus 74.2-90.4 %), six were "inappropriate," and five were "uncertain."

Discussion and conclusion

Planning a cranioplasty alongside hydrocephalus remains a significant challenge in neurosurgery. Our consensus conference suggests that, in patients with cranial decompression and suspected hydrocephalus, the most suitable diagnostic approach involves a combination of evolving clinical conditions and neuroradiological imaging. The recommended management sequence prioritizes cranial reconstruction, with the option of a ventriculoperitoneal shunt when needed, preferably with a programmable valve. We strongly recommend to adopt local protocols based on expert consensus, such as this, to guide patient care.

Results of Surgical Treatment of Aneurysmal Subarachnoid Hemorrhage in a Single Institution Over 12 Years

OBJECTIVE

For patients with aneurysmal subarachnoid hemorrhage (aSAH) in whom endovascular treatment is not the optimal treatment strategy, microsurgical clipping remains a viable option. We examined changes in morbidity and outcome over time in patients treated surgically and in relation to surgeon volume and experience.

METHODS

All patients who underwent microsurgery for aSAH from 2007 to 2019 at our institution were included. We compared technical complication rates and surgical outcomes between experienced (≥50 independent cases) and inexperienced (<50 independent cases) surgeons and between high-volume (≥20 cases/year) and low-volume (<20 cases/year) surgeons.

RESULTS

Most of the 1,003 aneurysms (970 patients, median age 56 years) were in the middle cerebral (41.4%), anterior communicating (27.6%), and posterior communicating (17.5%) arteries; 46.5% were <7 mm. The technical complication rate was 7%, resulting in postoperative infarct in 4.9% of patients. Nineteen patients (2%) died within 30 days of admission. There were no significant changes in rates of technical complication, postoperative infarct, or mortality over the study period. There were no differences in postoperative infarction and technical complication rates between experienced and inexperienced surgeons (P = 0.28 and P = 0.05, respectively), but there were differences when comparing high-volume and low-volume surgeons (P = 0.03 and P < 0.001, respectively). The independent predictors of postoperative infarctions were aneurysm size (P = 0.001), intraoperative large-vessel injury (P < 0.001), and low surgeon volume (P = 0.03).

CONCLUSIONS

We present real-world data on surgical morbidity and outcomes after aSAH. We demonstrated a relationship between surgeon volume and outcome for surgical treatment of aSAH, which supports the benefit of subspecialization in cerebrovascular surgery.

Post-traumatic decompressive craniectomy: Prognostic factors and long-term follow-up

Background

Decompressive craniectomy (DC) is still controversial in neurosurgery. According to the most recent trials, DC seems to increase survival in case of refractory intracranial pressure. On the other hand, the risk of postsurgical poor outcomes remain high. The present study aimed to evaluate a series of preoperative factors potentially impacting on long-term follow-up of traumatic brain injury (TBI) patients treated with DC.

Methods

We analyzed the first follow-up year of a series of 75 TBI patients treated with DC at our department in five years (2015-2019). Demographic, clinical, and radiological parameters were retrospectively collected from clinical records. Blood examinations were analyzed to calculate the preoperative neutrophil-to-lymphocyte ratio (NLR). Disability rating scale (DRS) was used to classify patients' outcomes (good outcome [G.O.] if DRS ≤11 and poor outcome [P.O.] if DRS ≥12) at 6 and 12 months.

Results

At six months follow-up, 25 out of 75 patients had DRS ≤11, while at 12 months, 30 out of 75 patients were included in the G.O. group . Admission Glasgow Coma Scale (GCS) >8 was significantly associated with six months G.O. Increased NLR values and the interval between DC and cranioplasty >3 months were significantly correlated to a P.O. at 6- and 12-month follow-up.

Conclusion

Since DC still represents a controversial therapeutic strategy, selecting parameters to help stratify TBI patients' potential outcomes is paramount. GCS at admission, the interval between DC and cranioplasty, and preoperative NLR values seem to correlate with the long-term outcome.

Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage

PURPOSE

Our review of acute brain insult articles indicated that the patients' individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented.

METHODS

We retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.-45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death ([Formula: see text]; 56%) or 3 years ([Formula: see text]; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors).

RESULTS

The timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome.

CONCLUSIONS

The pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.

Neuro damage control: current concept and civilian applications

Damage control (DC) initially referred to abbreviated (<1 h) surgical procedures to control abdominal hemorrhage in severe trauma patients, to avoid the 'bloody vicious circle' of hypothermia-coagulopathy-acidosis-hypocalcemia. Progressively, the concept was extended to pre-hospital and peri-operative surgical and non-surgical trauma care. The DC strategy can be applied either in a single severe trauma patient at risk of progression toward the bloody vicious circle or in case of limited or overwhelmed health resources (deprived environment, mass casualties, etc.). DC strategies in neurological casualties have improved over the last decade in military neurosurgeons, but remain poorly codified in civilian settings. In this comprehensive review, we summarize the current concept of neuro-DC, which includes surgical and medical care for neurological injuries as part of a DC strategy. Neuro-DC basically consists in: (i) preventing secondary brain injury; (ii) controlling intracranial bleeding; (iii) controlling intracranial pressure; (iv) limiting contamination of compound wounds; and (v) achieving secondary anatomical restoration.

Decompressive craniectomy as a second/third-tier intervention in traumatic brain injury: A multicenter observational study

OBJECTIVES

RESCUEicp studied decompressive craniectomy (DC) applied as third-tier option in severe traumatic brain injury (TBI) patients in a randomized controlled setting and demonstrated a decrease in mortality with similar rates of favorable outcome in the DC group compared to the medical management group. In many centers, DC is being used in combination with other second/third-tier therapies. The aim of the present study is to investigate outcomes from DC in a prospective non-RCT context.

METHODS

This is a prospective observational study of 2 patient cohorts: one from the University Hospitals Leuven (2008-2016) and one from the Brain-IT study, a European multicenter database (2003-2005). In thirty-seven patients with refractory elevated intracranial pressure who underwent DC as a second/third-tier intervention, patient, injury and management variables including physiological monitoring data and administration of thiopental were analysed, as well as Extended Glasgow Outcome score (GOSE) at 6 months.

RESULTS

In the current cohorts, patients were older than in the surgical RESCUEicp cohort (mean 39.6 vs. 32.3; p < 0.001), had higher Glasgow Motor Score on admission (GMS < 3 in 24.3% vs. 53.0%; p = 0.003) and 37.8% received thiopental (vs. 9.4%; p < 0.001). Other variables were not significantly different. GOSE distribution was: death 24.3%; vegetative 2.7%; lower severe disability 10.8%; upper severe disability 13.5%; lower moderate disability 5.4%; upper moderate disability 2.7%, lower good recovery 35.1%; and upper good recovery 5.4%. The outcome was unfavorable in 51.4% and favorable in 48.6%, as opposed to 72.6% and 27.4% respectively in RESCUEicp (p = 0.02).

CONCLUSION

Outcomes in DC patients from two prospective cohorts reflecting everyday practice were better than in RESCUEicp surgical patients. Mortality was similar, but fewer patients remained vegetative or severely disabled and more patients had a good recovery. Although patients were older and injury severity was lower, a potential partial explanation may be in the pragmatic use of DC in combination with other second/third-tier therapies in real-life cohorts. The findings underscore that DC maintains an important role in managing severe TBI.

Hinge craniotomy versus standard decompressive hemicraniectomy: an experimental preclinical comparative study

INTRODUCTION

Decompressive craniectomy (DC) is the most common surgical procedure to manage increased intracranial pressure (ICP). Hinge craniotomy (HC), which consists of fixing the bone operculum with a pivot, is an alternative method conceived to avoid some DC-related complications; nonetheless, it is debated whether it can provide enough volume expansion. In this study, we aimed to analyze the volume and ICP obtained with HC using an experimental cadaver-based preclinical model and compare the results to baseline and DC.

METHODS

Baseline conditions, HC, and DC were compared on both sides of five anatomical specimens. Volume and ICP values were measured with a custom-made system. Local polynomial regression was used to investigate volume differences.

RESULTS

The area of the bone opercula resulting from measurements was 115.55 cm2; the mean supratentorial volume was 955 mL. HC led to intermediate results compared to baseline and DC. At an ICP of 50 mmHg, HC offers 130 mL extra space but 172 mL less than a DC. Based on local polynomial regression, the mean volume difference between HC and the standard craniotomy was 10%; 14% between DC and HC; both are higher than the volume of brain herniation reported in the literature in the clinical setting. The volume leading to an ICP of 50 mmHg at baseline was less than the volume needed to reach an ICP of 20 mmHg after HC (10.05% and 14.95% from baseline, respectively).

CONCLUSIONS

These data confirm the efficacy of HC in providing sufficient volume expansion. HC is a valid intermediate alternative in case of potentially evolutionary lesions and non-massive edema, especially in developing countries.

Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study

Background

Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy.

Methods

We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582).

Findings

Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]).

Interpretation

We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling.

Funding

Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.

Recent changes in practice patterns and outcomes in patients with severe traumatic brain injury

BACKGROUND

Despite recent advances in the management of severe traumatic brain injury, the role of decompressive craniectomy remains unclear. The purpose of this study was to compare practice patterns and patient outcomes between 2 study periods over the past decade.

METHODS

This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Project database. We included patients (age ≥18 years) with isolated severe traumatic brain injury. The patients were divided into the early (2013-2014) and late (2017-2018) groups. The primary outcome was the rate of craniectomy, and secondary outcomes included in-hospital mortality and discharge disposition. A subgroup analysis of patients undergoing intracranial pressure monitoring was also performed. A multivariable logistic regression analysis assessed the association between the early/late period and study outcomes.

RESULTS

A total of 29,942 patients were included. In the logistic regression analysis, the late period was associated with decreased use of craniectomy (odds ratio: 0.58, P < .001). Although the late period was associated with higher in-hospital mortality (odds ratio: 1.10, P = .013), it was also associated with a higher likelihood of discharge to home/rehab (odds ratio: 1.61, P < .001). Similarly, the subgroup analysis of patients with intracranial pressure monitoring showed that the late period was associated with a lower craniectomy rate (odds ratio: 0.26, P < .001) and a higher likelihood of discharge to home/rehab (odds ratio:1.98, P < .001).

CONCLUSION

The use of craniectomy for severe traumatic brain injury has decreased over the study period. Although further studies are warranted, these trends may reflect recent changes in the management of patients with severe traumatic brain injury.

The significance of decompressive craniectomy for older patients with traumatic brain injury: a propensity score matching analysis from large multi-center data

The efficacy of decompressive craniectomy (DC) for traumatic brain injury (TBI) have been investigated in two recent randomized clinical trials (RCTs) and DC is recommended as an optional treatment for improving overall survival compared to medical treatment. However, the two RCTs enrolled extremely young adults, and the efficacy of DC in older adults remains questionable. Therefore, to identify the efficacy of DC in older adults, we compared patients who received medical care with those who underwent DC after propensity score matching (PSM). From the Korea Multi-center Traumatic Brain Injury Database, 443 patients identified as having intracranial hypertension and a necessity of DC were retrospectively enrolled. The patients were classified into the DC (n = 375) and non-DC (n = 68) groups according to operation records. The PSM was conducted to match the patients in the DC group with those receiving medical care (non-DC). After PSM, the newly matched group (DC, n = 126) was compared with patients without DC (non-DC, n = 63). The mean difference in the logit of the propensity scores (LPS) was 0.00391 and the mean age of enrolled patients were 65 years. The results of the comparative analyses after PSM showed that the 6-month mortality rate of the non-DC group was higher than that of the DC group (61.9% vs. 51.6%, p = 0.179). In terms of favorable outcomes (modified Rankin Scale [mRS] score < 4), the DC group showed a lower rate of favorable mRS scores (11.9% vs. 17.5%, p = 0.296) than the non-DC group.

Infection-related failure of autologous versus allogenic cranioplasty after decompressive hemicraniectomy - A systematic review and meta-analysis

Introduction

Cranioplasty is required after decompressive craniectomy (DC) to restore brain protection and cosmetic appearance, as well as to optimize rehabilitation potential from underlying disease. Although the procedure is straightforward, complications either caused by bone flap resorption (BFR) or graft infection (GI), contribute to relevant comorbidity and increasing health care cost. Synthetic calvarial implants (allogenic cranioplasty) are not susceptible to resorption and cumulative failure rates (BFR and GI) tend therefore to be lower in comparison with autologous bone. The aim of this review and meta-analysis is to pool existing evidence of infection-related cranioplasty failure in autologous versus allogenic cranioplasty, when bone resorption is removed from the equation.

Materials and methods

A systematic literature search in PubMed, EMBASE, and ISI Web of Science medical databases was performed on three time points (2018, 2020 and 2022). All clinical studies published between January 2010 and December 2022, in which autologous and allogenic cranioplasty was performed after DC, were considered for inclusion. Studies including non-DC cranioplasty and cranioplasty in children were excluded. The cranioplasty failure rate based on GI in both autologous and allogenic groups was noted. Data were extracted by means of standardized tables and all included studies were subjected to a risk of bias (RoB) assessment using the Newcastle-Ottawa assessment tool.

Results

A total of 411 articles were identified and screened. After duplicate removal, 106 full-texts were analyzed. Eventually, 14 studies fulfilled the defined inclusion criteria including one randomized controlled trial, one prospective and 12 retrospective cohort studies. All but one study were rated as of poor quality based on the RoB analysis, mainly due to lacking disclosure why which material (autologous vs. allogenic) was chosen and how GI was defined. The infection-related cranioplasty failure rate was 6.9% (125/1808) for autologous and 8.3% (63/761) for allogenic implants resulting in an OR 0.81, 95% CI 0.58 to 1.13 (Z ​= ​1.24; p ​= ​0.22).

Conclusion

In respect to infection-related cranioplasty failure, autologous cranioplasty after decompressive craniectomy does not underperform compared to synthetic implants. This result must be interpreted in light of limitations of existing studies. Risk of graft infection does not seem a valid argument to prefer one implant material over the other. Offering an economically superior, biocompatible and perfect fitting cranioplasty implant, autologous cranioplasty can still have a role as the first option in patients with low risk of developing osteolysis or for whom BFR might not be of major concern.

Trial registration

This systematic review was registered in the international prospective register of systematic reviews. PROSPERO: CRD42018081720.

Traumatic Brain Injury: Contemporary Challenges and the Path to Progress

Traumatic brain injury (TBI) remains a leading cause of death and disability worldwide, and its incidence is increasing [...].

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

The Role of Decompressive Craniectomy on Functional Outcome, Mortality and Seizure Onset after Traumatic Brain Injury

BACKGROUND

Decompressive craniectomy (DC) to treat increased intracranial pressure after a traumatic brain injury (TBI) is a common but controversial choice in clinical practice. This study aimed to determine the impact of DC on functional outcomes, mortality and the occurrence of seizures in a large cohort of patients with TBI.

METHODS

This retrospective study included patients with TBI consecutively admitted for a 6-month neurorehabilitation program between 1 January 2009 and 31 December 2018. The radiological characteristics of brain injury were determined with the Marshall computed tomographic classification. The neurological status and rehabilitation outcome were assessed using the Glasgow Coma Scale (GCS) and the Functional Independence Measure (FIM), which were both assessed at baseline and on discharge. Furthermore, the GCS was recorded on arrival at the emergency department. The DC procedure, prophylactic antiepileptic drug (AED) use, the occurrence of early or late seizures (US, unprovoked seizures) and death during hospitalization were also recorded.

RESULTS

In our cohort of 309 adults with mild-to-severe TBI, DC was performed in 98 (31.7%) patients. As expected, a craniectomy was more frequently performed in patients with severe TBI (p < 0.0001). However, after adjusting for the confounding variables including GCS scores, age and the radiological characteristics of brain injury, there was no association between DC and poor functional outcomes or mortality during the inpatient rehabilitation period. In our cohort, the independent predictors of an unfavorable outcome at discharge were the occurrence of US (β = -0.14, p = 0.020), older age (β = -0.13, p = 0.030) and the TBI severity on admission (β = -0.25, p = 0.002). Finally, DC (OR 3.431, 95% CI 1.233-9.542, p = 0.018) and early seizures (OR = 3.204, 95% CI 1.176-8.734, p = 0.023) emerged as the major risk factors for US, independently from the severity of the brain injury and the prescription of a primary prophylactic therapy with AEDs.

CONCLUSIONS

DC after TBI represents an independent risk factor for US, regardless of the prescription of prophylactic AEDs. Meanwhile, there is no significant association between DC and mortality, or a poor functional outcome during the inpatient rehabilitation period.