Decompressive craniectomy in traumatic brain injury rationale and practice

Evaluation of the effect of endotracheal aspiration at different head heights on oxygenation of the brain by non-invasive method in intensive care patients

OBJECTIVES

To determine the effect of endotracheal aspiration at different head heights on oxygenation brain by non-invasive method in neurosurgery intensive care patients.

BACKGROUND

Head elevation of mechanical ventilator-dependent neurosurgery patients and the possible risks of endotracheal aspiration are closely related to the clinical conditions of the patients.

DESIGN

A prospective quasi-experimental study with repetitive measurements in a single group.

METHODS

In the study, neurosurgery intensive care patients were adjusted to a head height of 15, 30 and 45° (n = 46, power analysis %90). Cerebral oxygenation levels were determined with a non-invasive device at each head height before and in the 1st, 5th and 30th min of endotracheal aspiration. Data were collected with Patient Information Form and cerebral oxygenation device based on NIRS technology. This study performed according to the TREND reporting guidelines for non-randomized/quasi experimental study.

RESULTS

The highest cerebral oxygenation value was obtained at 30 min. The decrease in the cerebral oxygenation levels of the patients was highest in the 1st min after endotracheal aspiration, at a head height of 15 degrees for the right cerebral region and at a head height of 30 degrees for the left cerebral region. The increase in oxygenation of the right and left cerebral regions occurred highest at a head height of 45 degrees.

CONCLUSIONS

The ideal head height should be 45 degrees during and after endotracheal aspiration in regard to maintaining cerebral oxygenation in neurosurgery intensive care patients. It is extremely important to monitor the cerebral oxygenation status of patients, with non-invasive measurement tools during and after endotracheal aspiration, to prevent secondary complications.

RELEVANCE TO CLINICAL PRACTICE

This study reveals the importance of raising the head 45 degrees in the best preservation of cerebral oxygenation values in neurosurgery intensive care patients. Intensive care nurses should pay attention to maintaining this head height.

The impact of time from injury to surgery in functional recovery of traumatic acute subdural hematoma

Background

The time from injury to surgery (TIS) is critical in the functional recovery of individuals with traumatic acute subdural hematoma (TASDH). However, only few studies have confirmed such notion.

Methods

The data of TASDH patients who were surgically treated in Chia-Yi Christian Hospital between January 2008 and December 2015 were collected. The significance of variables, including age, sex, traumatic mechanism, coma scale, midline shift on brain computed tomography (CT) scan, and TIS, in functional recovery was assessed using the student’s t-test, Mann-Whitney U test, chi-square test, univariate and multivariate models, and receiver operating characteristic (ROC) curve.

Results

A total of 37 patients achieved functional recovery (outcome scale score of 4 or 5) and 33 patients had poor recovery (outcome scale score of 1–3) after at least 1 year of follow-up. No significant difference was observed in terms of age, sex, coma scale score, traumatic mechanism, or midline shift on brain CT scan between the functional and poor recovery groups. TIS was found to be significantly shorter in the functional recovery group than in the poor recovery group (145.5 ± 27.0 vs. 181.9 ± 54.5 min, P-value = 0.002). TIS was a significant factor for functional outcomes in the univariate and multivariate regression models. The analysis of TIS with the ROC curve between these two groups showed that the threshold time for functional recovery in comatose patients and those with TASDH who were surgically treated was 2 h and 57.5 min.

Conclusions

TIS is an important factor l for the functional recovery of comatose TASDH patients who underwent surgery.

Decompressive hemicraniectomy without clot evacuation in spontaneous intracranial hemorrhage: A systematic review

OBJECTIVE

Decompressive hemicraniectomy (DH) effectively alleviates increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) and malignant middle cerebral artery (MCA) infarction. Its role in the management of spontaneous intracranial hemorrhage (SICH) however remains uncertain. This study aims to review the efficacy and safety of DH without clot evacuation in SICH.

PATIENTS AND METHODS

A systematic literature search of PubMEd, EMBASE, Scopus and Cochrane Library Central Register of Control Trials was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and end points. Primary endpoint was overall mortality. Secondary endpoint was functional outcome using modified Rankin scale (mRs) or Glasgow outcome scale (GOS).

RESULTS

Nine studies with a total of 146 patients who underwent DH without clot evacuation include: 1 RCT, 3 cohort, 2 case series, and 3 case-control studies. Age range was 40-60 years, with majority of patients presenting with a relatively depressed preoperative sensorium (GCS 6-8), large hematoma volumes (>50 mL), and deep locations (basal ganglia and thalamus). Pooled analysis showed a favorable outcome in 53 %, a mortality rate of 26 % and a complication rate of 35.8 %.

CONCLUSION

DH without clot evacuation may offer functional and mortality benefit in patients with spontaneous ICH, based on limited and heterogeneous studies.

Outcomes of Ultra-Early Decompressive Craniectomy after Severe Traumatic Brain Injury-Treatment Outcomes after Severe TBI

Objective

The beneficial effect of decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial, but there is no debate that decompression should be performed before irreversible neurological deficit occurs. The aim of our study was to assess the value of ultra-early decompressive craniectomy in patients with severe TBI.

Methods

Total of 127 patients who underwent decompressive craniectomy from January 2007 to December 2013 was included in this study. Among them, 60 patients had underwent ultra-early (within 4 hours from injury) emergent operation for relief of increased intracranial pressure. Initial Glasgow coma scale, brain computed tomography (CT) scan features by Marshall CT classification, and time interval between injury and craniectomy were evaluated retrospectively. Clinical outcome was evaluated, using the modified Rankin score.

Results

The outcomes of ultra-early decompressive craniectomy group were not better than those in the comparison group (p=0.809). The overall mortality rate was 68.5% (87 patients). Six of all patients (4.7%) showed good outcomes, and 34 patients (26.8%) remained in a severely disabled or vegetative state. Forty of sixty patients (66.7%) had died, and two patients (3.3%) showed good outcomes at last follow-up.

Conclusion

Ultra-early decompressive craniectomy for intracranial hypertension did not improve patient outcome when compared with "early or late" decompressive craniectomy for managing severe TBI.

The impact of time to surgery on outcomes in patients with traumatic brain injury: a literature review

AIM

To review the relationship between the time interval to surgery and outcomes in patients with traumatic brain injury (TBI).

METHODS

A literature review was conducted by employing several search strategies, including electronic database searches and footnote chasing. The quality of the selected studies was assessed in terms of internal and external validity. Data regarding authors, publication year, sample size, surgical procedure, time interval to surgery, and outcome was extracted.

RESULTS

Among 16 finally selected studies, five studies (31.3%) found that patient outcome was significantly affected by the timing of surgery and 11 (68.7%) did not. The impact of time to surgery on outcomes was not significant in most (75%) of the studies targeting patients with severe TBI. The effect of time to surgery on outcome showed different findings depending on the type of surgical procedure. A significant effect of time to surgery on outcome was reported in one (14.2%) of the seven studies targeting patients who underwent haematoma evacuation and in four (44.4%) of the nine studies on patients who underwent decompressive craniectomy.

CONCLUSION

This review shows that current opinion is still divided regarding when to operate. Despite this discrepancy, most authors agree that the timing of decompression is crucial to outcome.