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Comparison of the Surgical Outcomes of Cranioplasty Using Titanium, Customized Polymethylmethacrylate, and Liquid Polymethylmethacrylate in Maharaj Nakhon Chiang Mai Hospital, Thailand. J Craniofac Surg 2022; 33:1521-1524. [PMID: 34999614 DOI: 10.1097/scs.0000000000008463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Cranioplasty is a standard procedure used to restore skull defects after craniectomy. Many different materials are used in cranioplasty. The study aim was to compare the surgical outcomes of cranioplasty using different materials: liquid polymethylmethacrylate (PMMA), customized PMMA, and titanium. The authors retrospectively reviewed the outcomes of cranioplasty performed from 2016 to 2021. Data collection included patient characteristics and complications, including postoperative infection, hematoma, implant exposure, and subgaleal cerebrospinal fluid collection. Eighty-five patients received cranioplasty with different materials: titanium, 14; customized PMMA, 31; and liquid PMMA, 40. There were no significant differences in the basic patient characteristics among the 3 cranioplasty groups except for lower age in the customized PMMA group. There were no significant differences between superficial and deep infections, implant exposure, postoperative hematoma, or seizure. However, subgaleal cerebrospinal fluid collection was more common in the liquid PMMA group than in the customized PMMA group (P = 0.02). This study showed that good outcomes were achieved by cranioplasty performed with different materials (titanium, customized PMMA, and liquid PMMA).
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Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, Ponsford J, Seppelt I, Reilly P, Wiegers E, Wolfe R. Patient Outcomes at Twelve Months after Early Decompressive Craniectomy for Diffuse Traumatic Brain Injury in the Randomized DECRA Clinical Trial. J Neurotrauma 2021; 37:810-816. [PMID: 32027212 PMCID: PMC7071071 DOI: 10.1089/neu.2019.6869] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients. We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. At 12 months, the odds ratio (OR) for worse functional outcomes in the craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes. Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased. Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive craniectomy did not improve outcomes and increased vegetative survivors.
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Affiliation(s)
- D James Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Lynnette Murray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yaseen M Arabi
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Andrew R Davies
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia.,Monash-Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Peter Reilly
- Neurosurgery Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eveline Wiegers
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Honeybul S. Balancing the short-term benefits and long-term outcomes of decompressive craniectomy for severe traumatic brain injury. Expert Rev Neurother 2020; 20:333-340. [PMID: 32075441 DOI: 10.1080/14737175.2020.1733416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: The role of decompressive craniectomy in the management of neurological emergencies remains controversial. There is evidence available that it can reduce intracranial pressure, but it will not reverse the effects of the pathology that precipitated the neurological crisis, so there has always been concern that any reduction in mortality will result in an increase in the number of survivors with severe disability.Areas covered: The results of recent randomised controlled trials investigating the efficacy of the procedure are analyzed in order to determine the degree to which the short-term goals of reducing mortality and the long-term goals of a good functional outcome are achieved.Expert opinion: Given the results of the trials, there needs to be a change in the clinical decision-making paradigm such that decompression is reserved for patients who develop intractable intracranial hypertension and who are thought unlikely to survive without surgical intervention. In these circumstances, a more patient-centered discussion is required regarding the possibility and acceptability or otherwise of survival with severely impaired neurocognitive function.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Perth, Western Australia, Australia
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Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Abstract
BACKGROUND The aim of this study was to identify risk factors and explore the possible prevention measures for seizures following cranioplasty. METHODS The authors performed a retrospective review of 142 consecutive patients who underwent cranioplasty following craniectomy for trauma or cerebral hemorrhage in Dezhou People's Hospital between January 2010 and January 2017. Patients who were diagnosed with aneurysms, arteriovenous malformations, cerebral infarction, and tumors (14), had seizures prior to cranioplasty (9) and those lost to follow-up (7) were excluded. Patients did not use antiepilepsy drugs from treatment of postcranioplasty seizures. The median follow-up time was 51.11 ± 31.59 months (range: 17-98 months). Analyses were performed on a database tracking age, sex, reason for craniectomy, operative time, time between operations, presence of dural substitute, diabetic status, hypertensive status, tobacco use, alcohol use, location of cranioplasty, classification, time and times of seizures following cranioplasty development. RESULTS One hundred twelve patients met study criteria. The overall rate of seizures following cranioplasty was 35.7% (40 out of 112 patients). There were no statistically significant associations between postcranioplasty seizures and sex, age, location of cranioplasty, cranioplasty materials, or dural substitute used in craniectomy. Postcranioplasty seizure frequency differed significantly according to reasons for depressive craniectomy. The incidence of postcranioplasty seizures was significantly higher in the first year than in later years. Incidence decreased progressively in subsequent years. CONCLUSION Incidence of seizures following cranioplasty was associated with the reason for depressive craniectomy.
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Tsaousi GG, Marocchi L, Sergi PG, Pourzitaki C, Santoro A, Bilotta F. Early and late clinical outcomes after decompressive craniectomy for traumatic refractory intracranial hypertension: a systematic review and meta-analysis of current evidence. J Neurosurg Sci 2018; 64:97-106. [PMID: 30356035 DOI: 10.23736/s0390-5616.18.04527-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Decompressive craniectomy (DC) to control refractory intracranial hypertension in patients with traumatic brain injury (TBI), has been listed as possible but controversial therapeutic approach in the latest version of TBI management guidelines. This study aimed to perform a systematic review and meta-analysis on efficacy and safety of DC compared to standard care in TBI patients. EVIDENCE ACQUISITION A database search from 2011 to 2017 was conducted to identify studies pertinent to DC compared to standard care after TBI. The primary outcomes were mortality and functional outcome upon hospital discharge and at 6 and 12 months after intervention, whereas secondary outcomes were intracranial pressure (ICP) control, hospitalization data and occurrence of adverse events. EVIDENCE SYNTHESIS Three randomized controlled trials and two observational studies enrolling 3451 patients were selected for qualitative analysis, among which four were included in the meta-analysis. DC-treated patients showed a significant reduction of overall mortality (RR, 0.57; 95% CI: 0.5-0.66; P<0.001; I2=17%) with no profound beneficial effect on functional outcome (RR, 0.89; 95% CI: 0.78-1.02; P=0.09; I2=58%) compared to those receiving standard care. A more efficient ICP reduction and a tendency towards shorter duration of hospitalization were recorded in DC versus standard care group. Adverse events are more common in DC-treated patients. CONCLUSIONS It seems that, in TBI patients with intracranial hypertension, the use of DC is associated with survival benefit when compared to medical therapy alone, but with no clear improvement of functional outcome. Yet no definite conclusion can be drawn due to limited quantity and considerable heterogeneity of available data.
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Affiliation(s)
- Georgia G Tsaousi
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece -
| | - Lorenzo Marocchi
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
| | - Paola G Sergi
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
| | - Chryssa Pourzitaki
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonio Santoro
- Department of Neurosurgery, Sapienza University, Rome, Italy
| | - Federico Bilotta
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
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Beez T, Steiger HJ, Etminan N. Pharmacological targeting of secondary brain damage following ischemic or hemorrhagic stroke, traumatic brain injury, and bacterial meningitis - a systematic review and meta-analysis. BMC Neurol 2017; 17:209. [PMID: 29212462 PMCID: PMC5719738 DOI: 10.1186/s12883-017-0994-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The effectiveness of pharmacological strategies exclusively targeting secondary brain damage (SBD) following ischemic stroke, aneurysmal subarachnoid hemorrhage, aSAH, intracerebral hemorrhage (ICH), traumatic brain injury (TBI) and bacterial meningitis is unclear. This meta-analysis studied the effect of SBD targeted treatment on clinical outcome across the pathological entities. METHODS Randomized, controlled, double-blinded trials on aforementioned entities with 'death' as endpoint were identified. Effect sizes were analyzed and expressed as pooled risk ratio (RR) estimates with 95% confidence intervals (CI). 123 studies fulfilled the criteria, with data on 66,561 patients. RESULTS In the pooled analysis, there was a minor reduction of mortality for aSAH [RR 0.93 (95% CI:0.85-1.02)], ICH [RR 0.92 (95% CI:0.82-1.03)] and bacterial meningitis [RR 0.86 (95% CI:0.68-1.09)]. No reduction of mortality was found for ischemic stroke [RR 1.05 (95% CI:1.00-1.11)] and TBI [RR 1.03 (95% CI:0.93-1.15)]. Additional analysis of "poor outcome" as endpoint gave similar results. Subgroup analysis with respect to effector mechanisms showed a tendency towards a reduced mortality for the effector mechanism category "oxidative metabolism/stress" for aSAH with a risk ratio of 0.86 [95% CI: 0.73-1.00]. Regarding specific medications, a statistically significant reduction of mortality and poor outcome was confirmed only for nimodipine for aSAH and dexamethasone for bacterial meningitis. CONCLUSIONS Our results show that only a few selected SBD directed medications are likely to reduce the rate of death and poor outcome following aSAH, and bacterial meningitis, while no convincing evidence could be found for the usefulness of SBD directed medications in ischemic stroke, ICH and TBI. However, a subtle effect on good or excellent outcome might remain undetected. These results should lead to a new perspective of secondary reactions following cerebral injury. These processes should not be seen as suicide mechanisms that need to be fought. They should be rather seen as well orchestrated clean-up mechanisms, which may today be somewhat too active in a few very specific constellations, such as meningitis under antibiotic treatment and aSAH after surgical or endovascular exclusion of the aneurysm.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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Khan AD, Elseth AJ, Head B, Rostas J, Dunn JA, Schroeppel TJ, Gonzalez RP. Indicators of Survival and Favorable Functional Outcomes after Decompressive Craniectomy: A Multi-Institutional Retrospective Study. Am Surg 2017. [DOI: 10.1177/000313481708300832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The role of decompressive craniectomy (DC) for severe traumatic brain injury (STBI) remains controversial. The purpose of this study was to identify factors that are indicators of survival and improved functional outcome in patients who undergo DC for STBI. A retrospective review of STBI patients who underwent DC was performed at four trauma centers during a 45-month period. Data collected included age, gender, mechanism of injury, Injury Severity Score (ISS), admission Glasgow Coma Scale (GCS), time from admission to DC, mortality, and extended Glasgow Outcome Score before discharge. Sixty-nine STBI patients were treated with DC during the study period. A higher initial GCS, lower ISS, and longer time to DC were all statistically significant for improved survival after DC. A younger age, higher initial GCS, and lower ISS were all statistically significant for a favorable functional outcome after DC. Patients with a higher initial GCS and lower ISS are more likely to survive DC and have a favorable functional outcome, whereas a longer time to DC was indicative of improved survival after DC.
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Affiliation(s)
- Abid D. Khan
- Department of Trauma and Acute Care Surgery, University of Colorado Health-Memorial Hospital, Colorado Springs, Colorado
| | - Anna J. Elseth
- Department of Trauma and Acute Care Surgery, University of Colorado Health-Memorial Hospital, Colorado Springs, Colorado
| | - Brian Head
- Division of Trauma, Burn, Surgical Critical Care and Acute Care Surgery, Department of Surgery, University of South Alabama, Mobile, Alabama
| | - Jack Rostas
- Division of Trauma, Burn, Surgical Critical Care and Acute Care Surgery, Department of Surgery, University of South Alabama, Mobile, Alabama
| | - Julie A. Dunn
- Department of Trauma and Acute Care Surgery, Medical Center of the Rockies, Fort Collins, Colorado
| | - Thomas J. Schroeppel
- Department of Trauma and Acute Care Surgery, University of Colorado Health-Memorial Hospital, Colorado Springs, Colorado
| | - Richard P. Gonzalez
- Department of Surgery, Division of Trauma and Acute Care Surgery, Loyola University Medical Center, Maywood, Illinois
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Moon JW, Hyun DK. Decompressive Craniectomy in Traumatic Brain Injury: A Review Article. Korean J Neurotrauma 2017; 13:1-8. [PMID: 28512611 PMCID: PMC5432443 DOI: 10.13004/kjnt.2017.13.1.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/05/2017] [Accepted: 04/17/2017] [Indexed: 11/23/2022] Open
Abstract
The importance of treating traumatic brain injury (TBI) is well known worldwide. Although many studies have been conducted in this topic, there is still much uncertainty about the effectiveness of surgical treatment in TBI. Recently, good randomized controlled trial (RCT) papers about the effectiveness of decompressive craniectomy (DC) in TBI has been published. In this article, we will review the overall contents of the DC (historical base, surgical technic, rationale, complications) and the results of the recently published RCT paper.
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Affiliation(s)
- Ji Won Moon
- Department of Neurosurgery, Inha University School of Medicine and Hospital, Incheon, Korea
| | - Dong Keun Hyun
- Department of Neurosurgery, Inha University School of Medicine and Hospital, Incheon, Korea
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Honeybul S, Ho KM, Gillett GR. Reconsidering the role of decompressive craniectomy for neurological emergencies. J Crit Care 2017; 39:185-189. [PMID: 28285834 DOI: 10.1016/j.jcrc.2017.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE There is little doubt that decompressive craniectomy can reduce mortality. However, there is concern that any reduction in mortality comes at an increase in the number of survivors with severe neurological disability. METHOD Over the past decade there have been several randomised controlled trials comparing surgical decompression with standard medical therapy in the context of ischaemic stroke and severe traumatic brain injury. The results of each trial are evaluated. RESULTS There is now unequivocal evidence that a decompressive craniectomy reduces mortality in the context of "malignant" middle infarction and following severe traumatic brain injury. However, it has only been possible to demonstrate an improvement in outcome by categorizing a mRS of 4 and upper severe disability as favourable outcome. This is contentious and an alternative interpretation is that surgical decompression reduces mortality but exposes a patient to a greater risk of survival with severe disability. CONCLUSION It would appear unlikely that further randomised controlled trials will be possible given the significant reduction in mortality achieved by surgical decompression. It may be that observational cohort studies and outcome prediction models may provide data to determine those patients most likely to benefit from surgical decompression.
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Affiliation(s)
- S Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Western Australia, Australia.
| | - K M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
| | - G R Gillett
- Dunedin Hospital and Otago Bioethics Centre, University of Otago, Dunedin, New Zealand
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Starke RM, Komotar RJ, Sander Connolly E. Decompressive Craniectomy for Traumatic Intracranial Hypertension. Neurosurgery 2017; 80:N10-N11. [PMID: 28426865 DOI: 10.1093/neuros/nyx234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Robert M. Starke
- Department of Neurosurgery ,University of Miami School of Medicine, Miami, Florida, USA
| | - Ricardo J. Komotar
- Department of Neurosurgery ,University of Miami School of Medicine, Miami, Florida, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, USA
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Predicted Unfavorable Neurologic Outcome Is Overestimated by the Marshall Computed Tomography Score, Corticosteroid Randomization After Significant Head Injury (CRASH), and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) Models in Patients with Severe Traumatic Brain Injury Managed with Early Decompressive Craniectomy. World Neurosurg 2017; 101:554-558. [PMID: 28223249 DOI: 10.1016/j.wneu.2017.02.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/08/2017] [Accepted: 02/09/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is of public health interest and produces significant mortality and disability in Colombia. Calculators and prognostic models have been developed to establish neurologic outcomes. We tested prognostic models (the Marshall computed tomography [CT] score, International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT), and Corticosteroid Randomization After Significant Head Injury) for 14-day mortality, 6-month mortality, and 6-month outcome in patients with TBI at a university hospital in Colombia. METHODS A 127-patient cohort with TBI was treated in a regional trauma center in Colombia over 2 years and bivariate and multivariate analyses were used. Discriminatory power of the models, their accuracy, and precision was assessed by both logistic regression and area under the receiver operating characteristic curve (AUC). Shapiro-Wilk, χ2, and Wilcoxon test were used to compare real outcomes in the cohort against predicted outcomes. RESULTS The group's median age was 33 years, and 84.25% were male. The injury severity score median was 25, and median Glasgow Coma Scale motor score was 3. Six-month mortality was 29.13%. Six-month unfavorable outcome was 37%. Mortality prediction by Marshall CT score was 52.8%, P = 0.104 (AUC 0.585; 95% confidence interval [CI] 0 0.489-0.681), the mortality prediction by CRASH prognosis calculator was 59.9%, P < 0.001 (AUC 0.706; 95% CI 0.590-0.821), and the unfavorable outcome prediction by IMPACT was 77%, P < 0.048 (AUC 0.670; 95% CI 0.575-0.763). CONCLUSIONS In a university hospital in Colombia, the Marshall CT score, IMPACT, and Corticosteroid Randomization After Significant Head Injury models overestimated the adverse neurologic outcome in patients with severe head trauma.
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Brown DA, Wijdicks EFM. Decompressive craniectomy in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:299-318. [PMID: 28187804 DOI: 10.1016/b978-0-444-63600-3.00016-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Decompressive surgery to reduce pressure under the skull varies from a burrhole, bone flap to removal of a large skull segment. Decompressive craniectomy is the removal of a large enough segment of skull to reduce refractory intracranial pressure and to maintain cerebral compliance for the purpose of preventing neurologic deterioration. Decompressive hemicraniectomy and bifrontal craniectomy are the most commonly performed procedures. Bifrontal craniectomy is most often utilized with generalized cerebral edema in the absence of a focal mass lesion and when there are bilateral frontal contusions. Decompressive hemicraniectomy is most commonly considered for malignant middle cerebral artery infarcts. The ethical predicament of deciding to go ahead with a major neurosurgical procedure with the purpose of avoiding brain death from displacement, but resulting in prolonged severe disability in many, are addressed. This chapter describes indications, surgical techniques, and complications. It reviews results of recent clinical trials and provides a reasonable assessment for practice.
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Affiliation(s)
- D A Brown
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
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Huang HW, Zhang GB, Zhou JX. Would decompressive craniectomy really bring the hope to severe traumatic brain injury? J Thorac Dis 2016; 8:E1505-E1507. [PMID: 28066644 DOI: 10.21037/jtd.2016.11.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing100050, China
| | - Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100050, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing100050, China
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Shutter LA, Timmons SD. Intracranial Pressure Rescued by Decompressive Surgery after Traumatic Brain Injury. N Engl J Med 2016; 375:1183-4. [PMID: 27604048 DOI: 10.1056/nejme1609722] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Lori A Shutter
- From the Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh (L.A.S.), and the Department of Neurosurgery, Penn State University Milton S. Hershey Medical Center, Hershey (S.D.T.) - both in Pennsylvania
| | - Shelly D Timmons
- From the Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh (L.A.S.), and the Department of Neurosurgery, Penn State University Milton S. Hershey Medical Center, Hershey (S.D.T.) - both in Pennsylvania
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Khanna R, Ferrara L. Dynamic telescopic craniotomy: a cadaveric study of a novel device and technique. J Neurosurg 2016; 125:674-82. [DOI: 10.3171/2015.6.jns15706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The authors assessed the feasibility of the dynamic decompressive craniotomy technique using a novel cranial fixation plate with a telescopic component. Following a craniotomy in human cadaver skulls, the telescopic plates were placed to cover the bur holes. The plates allow constrained outward movement of the bone flap upon an increase in intracranial pressure (ICP) and also prevent the bone flap from sinking once the ICP normalizes. The authors compared the extent of postcraniotomy ICP control after an abrupt increase in intracranial volume using the dynamic craniotomy technique versus the standard craniotomy or hinge craniotomy techniques.
METHODS
Fixation of the bone flap after craniotomy was performed in 5 cadaver skulls using 3 techniques: 1) dynamic telescopic craniotomy, 2) hinge craniotomy, and 3) standard craniotomy with fixed plates. The ability of each technique to allow for expansion during intracranial hypertension was evaluated by progressively increasing intracranial volume. Biomechanical evaluation of the telescopic plates with load-bearing tests was also undertaken.
RESULTS
Both the dynamic craniotomy and the hinge craniotomy techniques provided significant control of ICP during increases in intracranial volume as compared with the standard craniotomy technique. With the standard craniotomy, ICP increased from a mean of 11.4 to 100.1 mm Hg with the addition of 120 ml of intracranial volume. However, with the dynamic craniotomy, the addition of 120 ml of intracranial volume increased the ICP from a mean of 2.8 to 13.4 mm Hg, maintaining ICP within the normal range as compared with the standard craniotomy (p = 0.04). The dynamic craniotomy was also superior in controlling ICP as compared with the hinge craniotomy, providing expansion for an additional 40 ml of intracranial volume while maintaining ICP within a normal range (p = 0.008). Biomechanical load-bearing tests for the dynamic telescopic plates revealed rigid restriction of bone-flap sinking as compared with standard fixation plates and clamps.
CONCLUSIONS
The dynamic telescopic craniotomy technique with the novel cranial fixation plate provides superior control of ICP after an abrupt increase in intracranial volume as compared with the standard craniotomy and hinge craniotomy techniques.
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Affiliation(s)
- Rohit Khanna
- 1Neurosurgery Service, Halifax Health
- 2Florida State University College of Medicine, Daytona Beach, Florida; and
| | - Lisa Ferrara
- 3OrthoKinetic Technologies LLC, Southport, North Carolina
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Uncertainty, conflict and consent: revisiting the futility debate in neurotrauma. Acta Neurochir (Wien) 2016; 158:1251-7. [PMID: 27143027 DOI: 10.1007/s00701-016-2818-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
The concept of futility has been debated for many years, and a precise definition remains elusive. This is not entirely unsurprising given the increasingly complex and evolving nature of modern medicine. Progressively more complex decisions are required when considering increasingly sophisticated diagnostic and therapeutic interventions. Allocating resources appropriately amongst a population whose expectations continue to increase raises a number of ethical issues not least of which are the difficulties encountered when consideration is being given to withholding "life-preserving" treatment. In this discussion we have used decompressive craniectomy for severe traumatic brain injury as a clinical example with which to frame an approach to the concept. We have defined those issues that initially lead us to consider futility and thereafter actually provoke a significant discussion. We contend that these issues are uncertainty, conflict and consent. We then examine recent scientific advances in outcome prediction that may address some of the uncertainty and perhaps help achieve consensus amongst stakeholders. Whilst we do not anticipate that this re-framing of the idea of futility is applicable to all medical situations, the approach to specify patient-centred benefit may assist those making such decisions when patients are incompetent to participate.
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Zhang K, Jiang W, Ma T, Wu H. Comparison of early and late decompressive craniectomy on the long-term outcome in patients with moderate and severe traumatic brain injury: a meta-analysis. Br J Neurosurg 2016; 30:251-7. [PMID: 26828333 DOI: 10.3109/02688697.2016.1139052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Several studies have searched whether early decompressive craniectomy (DC) can improve the long-term outcome of patients with moderate and severe traumatic brain injury (TBI). However, the effects of early DC remain unclear. The purpose of this meta-analysis was to assess whether early DC (time to surgery after injury <24 h) is better than late DC (>24 h) after moderate and severe TBI. METHOD Two reviewers independently searched Pubmed, Embase, ISI web of science, the Cochrane Library and Scopus databases from inception to 4 November 2014. Studies comparing the long-term outcome of patients following early and late DC after TBI were included. The long-term outcomes were evaluated by Glasgow Outcome Score, Extended Glasgow Outcome Score. Newcastle-Ottawa Scale was used to assess the methodological quality of included studies. Characteristics of the selected studies were extracted. Pooled results were presented by odds ratios (ORs) with 95% CIs. I(2) was used to test heterogeneity. Pearson correlation coefficient was used to detect the relationship between bilateral pupil abnormality and unfavourable outcome. RESULTS Five articles were eligible for this meta-analysis. The pooled results of comparison of unfavourable outcome and mortality revealed no significant difference in the early and late groups (ORs: 1.469; 95% CIs: 0.495-4.362; p > 0.05; I(2 )=70.5% and ORs: 1.262; 95% CIs: 0.385-4.137; p > 0.05; I(2 )=77.6%, respectively). Pearson correlation coefficient indicated that bilateral pupil abnormality was positive related to the unfavourable outcomes and mortality (r = 0.833; p < 0.05) (0.829; p < 0.05). CONCLUSION Bilateral pupil abnormality is positive related to unfavourable outcome and mortality in the patients following DC after moderate and severe TBI. Early DC may be more helpful to improve the long-term outcome of patients with refractory raised intracranial cerebral pressure after moderate and severe TBI. However, more RCTs with better control of patients with bilateral pupil abnormality divided into the early and late groups are needed in the future.
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Affiliation(s)
- Kai Zhang
- a Department of General Surgery , the Second Affiliated Hospital of Soochow University , Soochow , Jiangsu , P.R. China ;,b Department of Hepatobiliary Surgery , the Affiliated Yixing Hospital of Jiangsu University , Yixing , Jiangsu , P.R. China
| | - Wenjie Jiang
- c Department of Anesthesiology , the Affiliated Yixing Hospital of Jiangsu University , Yixing , Jiangsu , P.R. China
| | - Tieliang Ma
- d Central Laboratory , the Affiliated Yixing Hospital of Jiangsu University , Yixing , Jiangsu , P.R. China
| | - Haorong Wu
- a Department of General Surgery , the Second Affiliated Hospital of Soochow University , Soochow , Jiangsu , P.R. China
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Honeybul S, Gillett GR, Ho KM, Janzen C, Kruger K. Long-term survival with unfavourable outcome: a qualitative and ethical analysis. JOURNAL OF MEDICAL ETHICS 2015; 41:963-969. [PMID: 24965718 DOI: 10.1136/medethics-2013-101960] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 06/03/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To assess the issue of 'retrospective consent' among a cohort of patients who had survived with unfavourable outcome and to assess attitudes among next of kin regarding their role as surrogate decision makers. METHODS Twenty patients who had survived for at least 3 years with an unfavourable outcome following a decompressive craniectomy for severe traumatic brain injury were assessed with their next of kin. During the course of a semistructured interview, participants were asked whether they would have provided consent if they had known their eventual outcome. They were also asked for general comments regarding all aspects of the clinical journey. Eighteen patients had next of kin who were available for interview. For two patients, there was no longer any family involvement. RESULTS Of the 20 patients, 13 were able to provide a response and 11 felt that they would have provided consent even if they had known their eventual outcome. Of the 18 next of kin who were able to express an opinion, 10 felt that they would have provided retrospective consent. CONCLUSIONS Many patients appeared to have adapted to a level of disability that competent individuals might deem unacceptable. This does not necessarily mean that such outcomes should be regarded as 'favourable', nor that decompressive craniectomy must be performed for patients with predicted poor outcome. Nevertheless, those burdened with the initial clinical decisions and thereafter the long-term care of these patients may draw some support from the knowledge that unfavourable may not necessarily be unacceptable.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Perth, Western Australia, Australia
| | - Grant R Gillett
- Dunedin Hospital and Otago Bioethics Centre, University of Otago, Dunedin, New Zealand
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Perth, Western Australia, Australia
| | - Courtney Janzen
- Department of Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Kate Kruger
- Department of Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Tan TK, Cheng MH, Sim EY. Options for managing raised intracranial pressure. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815598444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
This article reviews the current monitoring and management options for raised intracranial pressure (ICP), primarily in traumatic head injuries, in line with current literature and guidelines. The use of ICP monitoring is useful in managing, predicting outcomes, following the progression and guiding interventions of neurological disease states. Patients with raised ICP should be monitored closely in a neurocritical care setting where appropriate interventions can be instituted based on available monitoring parameters. Various first- and second-tier methods should be considered, with the primary goal to decrease secondary insult to brain tissue for best outcomes.
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Affiliation(s)
- Tong Khee Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Ming Hua Cheng
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Eileen Yilin Sim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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Abstract
There are widely acknowledged ethical issues in enrolling unconscious patients in research trials, particularly in intensive care unit (ICU) settings. An analysis of those issues shows that, by and large, patients are better served in units where research is actively taking place for several reasons: i) they do not fall prey to therapeutic prejudices without clear evidential support, ii) they get a chance of accessing new and potentially beneficial treatments, iii) a climate of careful monitoring of patients and their clinical progress is necessary for good clinical research and affects the care of all patients and iv) even those not in the treatment arm of a trial of a new intervention must receive best current standard care (according to international evidence-based treatment guidelines). Given that we have discovered a number of 'best practice' regimens of care that do not optimise outcomes in ICU settings, it is of great benefit to all patients (including those participating in research) that we are constantly updating and evaluating what we do. Therefore, the practice of ICU-based clinical research on patients, many of whom cannot give prospective informed consent, ticks all the ethical boxes and ought to be encouraged in our health system. It is very important that the evaluation of protocols for ICU research should not overlook obvious (albeit probabilistic) benefits to patients and the acceptability of responsible clinicians entering patients into well-designed trials, even though the ICU setting does not and cannot conform to typical informed consent procedures and requirements.
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Affiliation(s)
- G R Gillett
- Dunedin Hospital and Otago Bioethics Centre, University of Otago, Dunedin, New Zealand
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Honeybul S, Ho K. The role of evidence based medicine in neurotrauma. J Clin Neurosci 2015; 22:611-6. [DOI: 10.1016/j.jocn.2014.08.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 07/17/2014] [Accepted: 08/03/2014] [Indexed: 10/24/2022]
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Abstract
PURPOSE OF REVIEW Intracranial pressure (ICP) control is a mainstay of traumatic brain injury (TBI) management. However, development of intracranial hypertension (ICH) may be affected by factors outside of the cranial vault in addition to the local effects of the TBI. This review will examine the pathophysiology of multiple compartment syndrome (MCS) and current treatment considerations for patients with TBI given the effects of MCS. RECENT FINDINGS Elevated intra-abdominal pressure (IAP) is associated with ICP elevation, and decompressive laparotomy in patients with concurrent elevations in IAP and ICP can reduce ICP. Elevated intrathoracic pressure may be similarly associated with ICP elevation, although the ideal ventilator management strategy for TBI patients when considering MCS is unclear. SUMMARY In MCS, intracranial, intrathoracic and intra-abdominal compartment pressures are interrelated. TBI patient care should include ICP control as well as minimization of intrathoracic and intra-abdominal pressure as clinically possible.
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Kim SP, Kang DS, Cheong JH, Kim JH, Song KY, Kong MH. Clinical analysis of epidural fluid collection as a complication after cranioplasty. J Korean Neurosurg Soc 2014; 56:410-8. [PMID: 25535519 PMCID: PMC4273000 DOI: 10.3340/jkns.2014.56.5.410] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 07/08/2014] [Accepted: 07/10/2014] [Indexed: 11/27/2022] Open
Abstract
Objective The epidural fluid collection (EFC) as a complication of cranioplasty is not well-described in the literature. This study aimed to identify the predictive factors for the development of EFC as a complication of cranioplasty, and its outcomes. Methods From January 2004 to December 2012, 117 cranioplasty were performed in our institution. One-hundred-and-six of these patients were classified as either having EFC, or not having EFC. The two groups were compared to identify risk factors for EFC. Statistical significance was tested using the t-test and chi-square test, and a logistic regression analysis. Results Of the 117 patients undergoing cranioplasty, 59 (50.4%) suffered complications, and EFC occurred in 48 of the patients (41.0%). In the t-test and chi-test, risk factors for EFC were size of the skull defect (p=0.003) and postoperative air bubbles in the epidural space (p<0.001). In a logistic regression, the only statistically significant factor associated with development of EFC was the presence of postoperative air bubbles. The EFC disappeared or regressed over time in 30 of the 48 patients (62.5%), as shown by follow-up brain computed tomographic scan, but 17 patients (35.4%) required reoperation. Conclusion EFC after cranioplasty is predicted by postoperative air bubbles in the epidural space. Most EFC can be treated conservatively. However, reoperation is necessary to resolve about a third of the cases. During cranioplasty, special attention is required when the skull defect is large, since EFC is then more likely.
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Affiliation(s)
- Seung Pil Kim
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Dong Soo Kang
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Jung Hee Kim
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Kwan Young Song
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Min Ho Kong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
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Honeybul S, Ho KM. Decompressive craniectomy for severe traumatic brain injury: the relationship between surgical complications and the prediction of an unfavourable outcome. Injury 2014; 45:1332-9. [PMID: 24704150 DOI: 10.1016/j.injury.2014.03.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 02/20/2014] [Accepted: 03/12/2014] [Indexed: 02/02/2023]
Abstract
OBJECT To assess the impact that injury severity has on complications in patients who have had a decompressive craniectomy for severe traumatic brain injury (TBI). METHODS This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia from 2004 to 2012. All complications were recorded during this period. The clinical and radiological data of the patients on initial presentation were entered into a web-based model prognostic model, the CRASH (Corticosteroid Randomization After Significant Head injury) collaborators prediction model, to obtain the predicted risk of an unfavourable outcome which was used as a measure of injury severity. RESULTS Complications after decompressive craniectomy for severe TBI were common. The predicted risk of unfavourable outcome was strongly associated with the development of neurological complications such as herniation of the brain outside the skull bone defects (median predicted risk of unfavourable outcome for herniation 72% vs. 57% without herniation, p=0.001), subdural effusion (median predicted risk of unfavourable outcome 67% with an effusion vs. 57% for those without an effusion, p=0.03), hydrocephalus requiring ventriculo-peritoneal shunt (median predicted risk of unfavourable outcome 86% for those with hydrocephalus vs. 59% for those without hydrocephalus, p=0.001), but not infection (p=0.251) or resorption of bone flap (p=0.697) and seizures (0.987). We did not observe any associations between timing of cranioplasty and risk of infection or resorption of bone flap after cranioplasty. CONCLUSIONS Mechanical complications after decompressive craniectomy including herniation of the brain outside the skull bone defects, subdural effusion, and hydrocephalus requiring ventriculo-peritoneal shunt were more common in patients with a more severe form of TBI when quantified by the CRASH predicted risk of unfavourable outcome. The CRASH predicted risk of unfavourable outcome represents a useful baseline characteristic of patients in observational and interventional trials involving patients with severe TBI requiring decompressive craniectomy.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Western Australia, Australia.
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
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Ho KM, Honeybul S, Yip CB, Silbert BI. Prognostic significance of blood-brain barrier disruption in patients with severe nonpenetrating traumatic brain injury requiring decompressive craniectomy. J Neurosurg 2014; 121:674-9. [PMID: 25036202 DOI: 10.3171/2014.6.jns132838] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors assessed the risk factors and outcomes associated with blood-brain barrier (BBB) disruption in patients with severe, nonpenetrating, traumatic brain injury (TBI) requiring decompressive craniectomy. METHODS At 2 major neurotrauma centers in Western Australia, a retrospective cohort study was conducted among 97 adult neurotrauma patients who required an external ventricular drain (EVD) and decompressive craniectomy during 2004-2012. Glasgow Outcome Scale scores were used to assess neurological outcomes. Logistic regression was used to identify factors associated with BBB disruption, defined by a ratio of total CSF protein concentrations to total plasma protein concentration > 0.007 in the earliest CSF specimen collected after TBI. RESULTS Of the 252 patients who required decompressive craniectomy, 97 (39%) required an EVD to control intracranial pressure, and biochemical evidence of BBB disruption was observed in 43 (44%). Presence of disruption was associated with more severe TBI (median predicted risk for unfavorable outcome 75% vs 63%, respectively; p = 0.001) and with worse outcomes at 6, 12, and 18 months than was absence of BBB disruption (72% vs 37% unfavorable outcomes, respectively; p = 0.015). The only risk factor significantly associated with increased risk for BBB disruption was presence of nonevacuated intracerebral hematoma (> 1 cm diameter) (OR 3.03, 95% CI 1.23-7.50; p = 0.016). Although BBB disruption was associated with more severe TBI and worse long-term outcomes, when combined with the prognostic information contained in the Corticosteroid Randomization after Significant Head Injury (CRASH) prognostic model, it did not seem to add significant prognostic value (area under the receiver operating characteristic curve 0.855 vs 0.864, respectively; p = 0.453). CONCLUSIONS Biochemical evidence of BBB disruption after severe nonpenetrating TBI was common, especially among patients with large intracerebral hematomas. Disruption of the BBB was associated with more severe TBI and worse long-term outcomes, but when combined with the prognostic information contained in the CRASH prognostic model, this information did not add significant prognostic value.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital
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Talbott JF, Gean A, Yuh EL, Stiver SI. Calvarial fracture patterns on CT imaging predict risk of a delayed epidural hematoma following decompressive craniectomy for traumatic brain injury. AJNR Am J Neuroradiol 2014; 35:1930-5. [PMID: 24948502 DOI: 10.3174/ajnr.a4001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The development of a delayed epidural hematoma as a result of decompressive craniectomy represents an urgent and potentially lethal complication in traumatic brain injury. The goal of this study was to determine the incidence of delayed epidural hematoma and whether patterns of skull fractures on the preoperative CT scan could predict risk of a delayed epidural hematoma. MATERIALS AND METHODS We retrospectively evaluated medical records and imaging studies for patients with acute traumatic brain injury who underwent a decompressive craniectomy during a 9-year period. We compared patterns of skull fractures contralateral to the side of the craniectomy with the occurrence of a postoperative delayed epidural hematoma. RESULTS In a series of 203 patients undergoing decompressive craniectomy for acute traumatic brain injury, the incidence of a delayed epidural hematoma complication was 6% (12 of 203). All 12 patients who developed a delayed epidural hematoma had a contralateral calvarial fracture on preoperative CT at the site where the delayed epidural hematoma subsequently formed. A contralateral calvarial fracture has perfect sensitivity (100%) for subsequent development of delayed epidural hematoma in our study population. Moreover, a contralateral calvarial fracture involving 2 or more bone plates had an especially high diagnostic odds ratio of 41 for delayed epidural hematoma. CONCLUSIONS Recognition of skull fracture patterns associated with delayed epidural hematoma following decompressive craniectomy may reduce morbidity and mortality by prompting early postoperative intervention in high-risk situations.
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Affiliation(s)
- J F Talbott
- From the Department of Radiology and Biomedical Imaging (J.F.T., A.G., E.L.Y.) Brain and Spine Injury Center (J.F.T., A.G., E.L.Y.), San Francisco General Hospital, San Francisco, California
| | - A Gean
- From the Department of Radiology and Biomedical Imaging (J.F.T., A.G., E.L.Y.) Brain and Spine Injury Center (J.F.T., A.G., E.L.Y.), San Francisco General Hospital, San Francisco, California Department of Neurological Surgery (A.G., S.I.S.), University of California, San Francisco, California
| | - E L Yuh
- From the Department of Radiology and Biomedical Imaging (J.F.T., A.G., E.L.Y.) Brain and Spine Injury Center (J.F.T., A.G., E.L.Y.), San Francisco General Hospital, San Francisco, California
| | - S I Stiver
- Department of Neurological Surgery (A.G., S.I.S.), University of California, San Francisco, California
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Honeybul S. Neurological susceptibility to a skull defect. Surg Neurol Int 2014; 5:83. [PMID: 25024883 PMCID: PMC4093740 DOI: 10.4103/2152-7806.133886] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 04/07/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There continues to be considerable interest in the use of decompressive craniectomy in the management of neurological emergencies. The procedure is technically straightforward; however, it is becoming increasingly apparent that it is associated with significant complications. One complication that has received relatively little attention is the neurological dysfunction that can occur due to the absence of the bone flap and the subsequent distortion of the brain under the scalp as cerebral swelling subsides. The aim of this narrative review was to examine the literature available regarding the clinical features described, outline the proposed pathophysiology for these clinical manifestations and highlight the implications that this may have for rehabilitation of patients with a large skull defect. METHODS A literature search was performed in the MEDLINE database (1966 to June 2012). The following keywords were used: Hemicraniectomy, decompressive craniectomy, complications, syndrome of the trephined, syndrome of the sinking scalp flap, motor trephined syndrome. The bibliographies of retrieved reports were searched for additional references. RESULTS Various terms have been used to describe the different neurological signs and symptoms with which patients with a skull defect can present. These include; syndrome of the trephined, posttraumatic syndrome, syndrome of the sinking scalp flap, and motor trephined syndrome. There is, however, considerable overlap between the conditions described and a patient's individual clinical presentation. CONCLUSION It is becoming increasingly apparent that certain patients are particularly susceptible to the presence of a large skull defect. The term "Neurological Susceptibility to a Skull Defect" (NSSD) is therefore suggested as a blanket term to describe any neurological change attributable to the absence of cranial coverage.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Western Australia
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31
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Decompressive Craniectomy - A narrative review and discussion. Aust Crit Care 2014; 27:85-91. [DOI: 10.1016/j.aucc.2013.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 05/14/2013] [Accepted: 06/17/2013] [Indexed: 11/17/2022] Open
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Honeybul S, Ho KM, Lind CRP, Gillett GR. Validation of the CRASH model in the prediction of 18-month mortality and unfavorable outcome in severe traumatic brain injury requiring decompressive craniectomy. J Neurosurg 2014; 120:1131-7. [DOI: 10.3171/2014.1.jns131559] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The goal in this study was to assess the validity of the corticosteroid randomization after significant head injury (CRASH) collaborators prediction model in predicting mortality and unfavorable outcome at 18 months in patients with severe traumatic brain injury (TBI) requiring decompressive craniectomy. In addition, the authors aimed to assess whether this model was well calibrated in predicting outcome across a wide spectrum of severity of TBI requiring decompressive craniectomy.
Methods
This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia between 2004 and 2012 and for whom 18-month follow-up data were available. Clinical and radiological data on initial presentation were entered into the Web-based model and the predicted outcome was compared with the observed outcome. In validating the CRASH model, the authors used area under the receiver operating characteristic curve to assess the ability of the CRASH model to differentiate between favorable and unfavorable outcomes.
Results
The ability of the CRASH 6-month unfavorable prediction model to differentiate between unfavorable and favorable outcomes at 18 months after decompressive craniectomy was good (area under the receiver operating characteristic curve 0.85, 95% CI 0.80–0.90). However, the model's calibration was not perfect. The slope and the intercept of the calibration curve were 1.66 (SE 0.21) and −1.11 (SE 0.14), respectively, suggesting that the predicted risks of unfavorable outcomes were not sufficiently extreme or different across different risk strata and were systematically too high (or overly pessimistic), respectively.
Conclusions
The CRASH collaborators prediction model can be used as a surrogate index of injury severity to stratify patients according to injury severity. However, clinical decisions should not be based solely on the predicted risks derived from the model, because the number of patients in each predicted risk stratum was still relatively small and hence the results were relatively imprecise. Notwithstanding these limitations, the model may add to a clinician's ability to have better-informed conversations with colleagues and patients' relatives about prognosis.
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Affiliation(s)
- Stephen Honeybul
- 1Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital
| | - Kwok M. Ho
- 2Department of Intensive Care Medicine and School of Population Health, and
| | - Christopher R. P. Lind
- 1Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital
- 3School of Surgery, University of Western Australia, Perth, Western Australia, Australia; and
| | - Grant R. Gillett
- 4Dunedin Hospital and Otago Bioethics Centre, University of Otago, Dunedin, New Zealand
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Abstract
Decompressive craniectomy (DC) for the management of severe traumatic brain injury (TBI) has a long history but remains controversial. Although DC has been shown to improve both survival and functional outcome in patients with malignant cerebral infarctions, evidence of benefit in patients with TBI is decidedly more mixed. Craniectomy can clearly be life-saving in the presence of medically intractable elevations of intracranial pressure. Craniectomy also has been consistently demonstrated to reduce "therapeutic intensity" in the ICU, to reduce the need for intracranial-pressure-directed and brain-oxygen-directed interventions, and to reduce ICU length of stay. Still, the only randomized trial of DC in TBI failed to demonstrate any benefit. Studies of therapies for TBI, including hemicraniectomy, are challenging owing to the inherent heterogeneity in the pathophysiology observed in this disease. Craniectomy can be life-saving for patients with severe TBI, but many questions remain regarding its ideal application, and the outcome remains highly correlated with the severity of the initial injury.
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Study of the long-term results of decompressive craniectomy after severe traumatic brain injury based on a series of 60 consecutive cases. ScientificWorldJournal 2014; 2014:207585. [PMID: 24719566 PMCID: PMC3956416 DOI: 10.1155/2014/207585] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 01/16/2014] [Indexed: 11/19/2022] Open
Abstract
Background. Decompressive craniectomy can be proposed in the management of severe traumatic brain injury. Current studies report mixed results, preventing any clear conclusions on the place of decompressive craniectomy in traumatology. Methods. The objective of this retrospective study was to evaluate the results of all decompressive craniectomies performed between 2005 and 2011 for refractory intracranial hypertension after severe traumatic brain injury. Sixty patients were included. Clinical parameters (Glasgow scale, pupillary examination) and radiological findings (Marshall CT scale) were analysed. Complications, clinical outcome, and early and long-term Glasgow Outcome Scale (GOS) were evaluated after surgery. Finally, the predictive value of preoperative parameters to guide the clinician's decision to perform craniectomy was studied. Results. Craniectomy was unilateral in 58 cases and the mean bone flap area was 100 cm2. Surgical complications were observed in 6.7% of cases. Mean followup was 30 months and a favourable outcome was obtained in 50% of cases. The initial Glasgow Scale was the only statistically significant predictive factor for long-term outcome. Conclusion. Despite the discordant results in the literature, this study demonstrates that decompressive craniectomy is useful for the management of refractory intracranial hypertension after severe traumatic brain injury.
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Honeybul S, Janzen C, Kruger K, Ho KM. Decompressive craniectomy for severe traumatic brain injury: is life worth living? J Neurosurg 2013; 119:1566-75. [PMID: 24116729 DOI: 10.3171/2013.8.jns13857] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object of this study was to assess the long-term outcome and quality of life of patients who have survived with severe disability following decompressive craniectomy for severe traumatic brain injury (TBI). METHODS The authors assessed outcome beyond 3 years among a cohort of 39 patients who had been adjudged either severely disabled or in vegetative state 18 months after decompressive craniectomy for TBI. Assessments performed included the Extended Glasgow Outcome Scale, modified Barthel Index (mBI), Zarit Burden Interview, and 36-Item Short-Form Health Survey (SF-36). The issue of retrospective consent for surgery was also assessed. RESULTS Of the 39 eligible patients, 7 died, 12 were lost to follow-up, and 20 patients or their next of kin consented to participate in the study. Among those 20 patients, 5 in a vegetative state at 18 months remained so beyond 3 years, and the other 15 patients remained severely disabled after a median follow-up of 5 years. The patients' average daily activity per the mBI (Pearson correlation coefficient [r] = -0.661, p = 0.01) and SF-36 physical score (r = -0.543, p = 0.037) were inversely correlated with the severity of TBI. However, the SF-36 mental scores of the patients were reasonably high (median 46, interquartile range 37-52). The majority of patients and their next of kin believed that they would have provided consent for surgical decompression even if they had known the eventual outcome. CONCLUSIONS Substantial physical recovery beyond 18 months after decompressive craniectomy for severe TBI was not observed; however, many patients appeared to have recalibrated their expectations regarding what they believed to be an acceptable quality of life.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital
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Honeybul S, Ho KM. The influence of clinical evidence on surgical practice. J Eval Clin Pract 2013; 19:825-8. [PMID: 22568805 DOI: 10.1111/j.1365-2753.2012.01857.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Given the considerable interest in the use of evidence-based medicine to guide clinical practice, it is surprising that the results of a recent randomized controlled trial have been met with such a limited response. The DECompressive CRAniectomy study investigators have recently published the results of a landmark trial in neurosurgery, comparing early decompressive craniectomy with standard medical therapy in patients who developed intracranial hypertension after diffuse closed traumatic brain injury (TBI). This is the first ever randomized controlled trial investigating the surgical management of adult patients with severe TBI. The trial clearly demonstrated that early decompression did not provide clinical benefit; however, rather than having a significant impact on clinical practice, it has been almost uniformly criticized. While there were some problems with randomization and crossover, we feel that the trial has been somewhat misinterpreted and in this article we address some of the key issues.
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Affiliation(s)
- S Honeybul
- Consultant Neurosurgeon, Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Perth, Western Australia, Australia Consultant Intensivist, Department of Intensive Care Medicine, Royal Perth Hospital and School of Population Health, University of Western Australia, Perth, Western Australia, Australia
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Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Walcott BP, Kwon CS, Sheth SA, Fehnel CR, Koffie RM, Asaad WF, Nahed BV, Coumans JV. Predictors of cranioplasty complications in stroke and trauma patients. J Neurosurg 2013; 118:757-62. [DOI: 10.3171/2013.1.jns121626] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Decompressive craniectomy mandates subsequent cranioplasty. Complications of cranioplasty may be independent of the initial craniectomy, or they may be contingent upon the craniectomy. Authors of this study aimed to identify surgery- and patient-specific risk factors related to the development of surgical site infection and other complications following cranioplasty.
Methods
A consecutive cohort of patients of all ages and both sexes who had undergone cranioplasty following craniectomy for stroke or trauma at a single institution in the period from May 2004 to May 2012 was retrospectively established. Patients who had undergone craniectomy for infectious lesions or neoplasia were excluded. A logistic regression analysis was performed to model and predict determinants related to infection following cranioplasty.
Results
Two hundred thirty-nine patients met the study criteria. The overall rate of complication following cranioplasty was 23.85% (57 patients). Complications included, predominantly, surgical site infection, hydrocephalus, and new-onset seizures. Logistic regression analysis identified previous reoperation (OR 3.25, 95% CI 1.30–8.11, p = 0.01) and therapeutic indication for stroke (OR 2.45, 95% CI 1.11–5.39, p = 0.03) as significantly associated with the development of cranioplasty infection. Patient age, location of cranioplasty, presence of an intracranial device, bone flap preservation method, cranioplasty material, booking method, and time interval > 90 days between initial craniectomy and cranioplasty were not predictive of the development of cranioplasty infection.
Conclusions
Cranioplasty complications are common. Cranioplasty infection rates are predicted by reoperation following craniectomy and therapeutic indication (stroke). These variables may be associated with patient-centered risk factors that increase cranioplasty infection risk.
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Affiliation(s)
- Brian P. Walcott
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Churl-Su Kwon
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sameer A. Sheth
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Corey R. Fehnel
- 2Department of Neurology, Brown University Alpert Medical School and Rhode Island Hospital; and
| | - Robert M. Koffie
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wael F. Asaad
- 3Department of Neurosurgery and Brown Institute for Brain Science, Providence, Rhode Island
| | - Brian V. Nahed
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jean-Valery Coumans
- 1Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Li X, von Holst H, Kleiven S. Decompressive craniectomy causes a significant strain increase in axonal fiber tracts. J Clin Neurosci 2013; 20:509-13. [DOI: 10.1016/j.jocn.2012.04.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 04/17/2012] [Accepted: 04/22/2012] [Indexed: 11/28/2022]
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Escobedo LVS, Habboushe J, Kaafarani H, Velmahos G, Shah K, Lee J. Traumatic brain injury: A case-based review. World J Emerg Med 2013; 4:252-9. [PMID: 25215128 PMCID: PMC4129904 DOI: 10.5847/wjem.j.issn.1920-8642.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 10/11/2013] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Traumatic brain injuries are common and costly to hospital systems. Most of the guidelines on management of traumatic brain injuries are taken from the Brain Trauma Foundation Guidelines. This is a review of the current literature discussing the evolving practice of traumatic brain injury. DATA SOURCES A literature search using multiple databases was performed for articles published through September 2012 with concentration on meta-analyses, systematic reviews, and randomized controlled trials. RESULTS The focus of care should be to minimize secondary brain injury by surgically decompressing certain hematomas, maintain systolic blood pressure above 90 mmHg, oxygen saturations above 93%, euthermia, intracranial pressures below 20 mmHg, and cerebral perfusion pressure between 60-80 mmHg. CONCLUSION Much is still unknown about the management of traumatic brain injury. The current practice guidelines have not yet been sufficiently validated, however equipoise is a major issue when conducting randomized control trials among patients with traumatic brain injury.
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Affiliation(s)
| | - Joseph Habboushe
- Department of Emergency Medicine, Beth Israel Medical Center, New York, NY, USA
| | - Haytham Kaafarani
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - George Velmahos
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Kaushal Shah
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Jarone Lee
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Walcott BP, Kahle KT, Simard JM. The DECRA trial and decompressive craniectomy in diffuse traumatic brain injury: is decompression really ineffective? World Neurosurg 2012; 79:80-1. [PMID: 23159659 DOI: 10.1016/j.wneu.2012.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 11/09/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Brian P Walcott
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
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Different sham procedures for rats in traumatic brain injury experiments induce corresponding increases in levels of trauma markers. J Surg Res 2012; 179:138-44. [PMID: 23122667 DOI: 10.1016/j.jss.2012.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 09/01/2012] [Accepted: 09/07/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND In traumatic brain injury animal models, sham or naïve control groups are often used for the analysis of injured animals; however, the existence and/or significance of differences in the control groups has yet to be studied. In addition, recent controversies regarding the decompressive craniectomy trial in which decompressive craniectomies in patients with severe traumatic brain injury and refractory increased intracranial pressure remains unsettled. Although the report demonstrated that the procedure may result in less favorable long-term outcomes despite the decrease in intracranial pressure and shorter length of intensive care unit stay, the study has been criticized, and the debate is still inconclusive partly because of a lack of mechanistic explanation. We have recently discovered epithelial and endothelial tyrosine kinase (Etk) to exhibit upregulation after traumatic neural injury and will compare the effects of craniectomy procedure with those of other procedures inducing different levels of severity. MATERIALS AND METHODS Four groups of rats receiving different procedures (controlled cortical impact, craniectomy, bicortical drilling, and unicortical drilling [UD]) were compared. Polymerase chain reaction, Western blot analysis, and immunoflorescence staining of Etk, S100, and glial fibrillary acidic protein levels were used to analyze the results and compare the different groups. RESULTS Etk upregulation was statistically significant between craniectomy and UD groups. The level of change for glial fibrillary acidic protein and S100 was only significant when cortex was impacted. CONCLUSIONS UD may be preferable as a sham control procedure over craniectomy or bicortical drilling. Increases in the expression of Etk in the craniectomy group suggest a possible mechanism by which unfavorable outcome occurs in patients receiving craniectomy procedures.
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What can be learned from the DECRA study. World Neurosurg 2012; 79:159-61. [PMID: 23022646 DOI: 10.1016/j.wneu.2012.08.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 04/25/2012] [Accepted: 08/11/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND There has been a resurgence of interest in the use of decompressive craniectomy for severe traumatic brain injury (TBI). Numerous studies have shown that the procedure can consistently reduce intracranial pressure (ICP), and a significant number of patients achieve a good long-term functional recovery. However, there has been debate regarding clinical indications and patient selection. METHODS The DECRA (Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury) study compared patients who underwent early decompressive craniectomy for diffuse TBI with patients who received standard medical therapy. Of patients, 70% in the craniectomy group had an unfavourable outcome versus 51% in the standard care group (odds ratio 2.21 [95% confidence interval 1.14-4.26]; P=0.02). Based on these results, the authors concluded that decompressive craniectomy was associated with more unfavorable outcomes and that by adopting standard medical therapy rather than surgical decompression the health care system would save millions of dollars. These conclusions are not really supported by closer examination of the basic data. There were problems with randomization such that the patients in the surgical arm appeared to have sustained a more severe primary TBI, the ICP threshold of >20 mm Hg for >15 minutes did not reflect clinical practice, and there was a high crossover rate from the standard care arm to the surgical arm. Because of these problems, the DECRA trial has received a great deal of criticism, and some authorities have claimed that the results should have no influence on clinical practice. This claim is perhaps unfair, and an alternative interpretation is offered. RESULTS Overall, the results of the DECRA study showed that a relatively transient and mild increase in ICP (>20 mm Hg for 15 minutes as recruitment criterion) does not imply that there is significant ongoing secondary brain injury, and any potential improvement obtained by surgical decompression may well be offset by surgical morbidity. CONCLUSIONS The role of decompressive craniectomy when ICP continues to increase ≥20 mm Hg remains to be established. The ongoing RESCUEicp (Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intra-Cranial Pressure) study hopes to address this issue.
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Cerebral blood flow, brain tissue oxygen, and metabolic effects of decompressive craniectomy. Neurocrit Care 2012; 16:478-84. [PMID: 22396191 DOI: 10.1007/s12028-012-9685-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Decompressive craniectomy (DC) is used for patients with traumatic brain injury (TBI), malignant edema from middle cerebral artery infarction, aneurysmal subarachnoid hemorrhage, and non-traumatic intracerebral or cerebellar hemorrhage. The objective of the procedure is to relieve intractable intracranial hypertension and/or to prevent or reverse cerebral herniation. Decompressive craniectomy has been shown to decrease mortality in selected patients with large hemispheric infarction and to control intracranial pressure in addition to improving pressure-volume compensatory reserve after TBI. The clinical effectiveness of DC in patients with TBI is under evaluation in ongoing randomized clinical trials. There are several unresolved controversies regarding optimal candidate selection, timing, technique, and post-operative management and complications. The nature and temporal progression of alterations in cerebral blood flow, brain tissue oxygen, and microdialysis markers have only recently been researched. Elucidating the pathophysiology of pressure-flow and cerebral hemodynamic consequences of DC could assist in optimizing clinical decision making and further defining the role of decompressive craniectomy.
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Rosenfeld JV, Maas AI, Bragge P, Morganti-Kossmann MC, Manley GT, Gruen RL. Early management of severe traumatic brain injury. Lancet 2012; 380:1088-98. [PMID: 22998718 DOI: 10.1016/s0140-6736(12)60864-2] [Citation(s) in RCA: 349] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Severe traumatic brain injury remains a major health-care problem worldwide. Although major progress has been made in understanding of the pathophysiology of this injury, this has not yet led to substantial improvements in outcome. In this report, we address present knowledge and its limitations, research innovations, and clinical implications. Improved outcomes for patients with severe traumatic brain injury could result from progress in pharmacological and other treatments, neural repair and regeneration, optimisation of surgical indications and techniques, and combination and individually targeted treatments. Expanded classification of traumatic brain injury and innovations in research design will underpin these advances. We are optimistic that further gains in outcome for patients with severe traumatic brain injury will be achieved in the next decade.
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Affiliation(s)
- Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Monash University, Melbourne, Australia.
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Holst H, Li X, Kleiven S. Increased strain levels and water content in brain tissue after decompressive craniotomy. Acta Neurochir (Wien) 2012; 154:1583-93. [PMID: 22648479 DOI: 10.1007/s00701-012-1393-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 05/14/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND At present there is a debate on the effectiveness of the decompressive craniotomy (DC). Stretching of axons was speculated to contribute to the unfavourable outcome for the patients. The quantification of strain level could provide more insight into the potential damage to the axons. The aim of the present study was to evaluate the strain level and water content (WC) of the brain tissue for both the pre- and post-craniotomy period. METHODS The stretching of brain tissue was quantified retrospectively based on the computerised tomography (CT) images of six patients before and after DC by a non-linear image registration method. WC was related to specific gravity (SG), which in turn was related to the Hounsfield unit (HU) value in the CT images by a photoelectric correction according to the chemical composition of brain tissue. RESULTS For all the six patients, the strain level showed a substantial increase in the brain tissue close to the treated side of DC compared with that found at the pre-craniotomy period and ranged from 24 to 55 % at the post-craniotomy period. Increase of strain level was also observed at the brain tissue opposite to the treated side, however, to a much lesser extent. The mean area of craniotomy was found to be 91.1 ± 12.7 cm(2). The brain tissue volume increased from 27 to 127 ml, corresponding to 1.65 % and 8.13 % after DC in all six patients. Also, the increased volume seemed to correlate with increased strain level. Specifically, the overall WC of brain tissue for two patients evaluated presented a significant increase after the treatment compared with the condition seen before the treatment. Furthermore, the Glasgow Coma Scale (GCS) improved in four patients after the craniotomy, while two patients died. The GCS did not seem to correlate with the strain level. CONCLUSIONS We present a new numerical method to quantify the stretching or strain level of brain tissue and WC following DC. The significant increase in strain level and WC in the post-craniotomy period may cause electrophysiological changes in the axons, resulting in loss of neuronal function. Hence, this new numerical method provides more insight of the consequences following DC and may be used to better define the most optimal size and area of the craniotomy in reducing the strain level development.
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Ahmadian A, Baa J AA, Garcia M, Carey C, Rodriguez L, Storrs B, Tuite GF. Decompressive craniectomy with massive intractable intraoperative cerebral edema: utilization of silicone sheet for temporary scalp closure. J Neurosurg Pediatr 2012; 10:195-9. [PMID: 22793163 DOI: 10.3171/2012.6.peds11567] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present a case of extreme brain herniation encountered during decompressive craniectomy in a 21-month-old boy who suffered a trauma event that necessitated temporary scalp closure in which a sterile silicone sheet was placed. Although the clinical situation is usually expected to lead to brain death or severe disability, the patient's 3-year follow-up examination revealed a highly functional child with a good quality of life. The authors discuss the feasibility and advantages of temporary scalp expansion as a treatment option when extreme brain herniation is encountered during craniotomy.
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Affiliation(s)
- Amir Ahmadian
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
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Controversies in the management of adults with severe traumatic brain injury. AACN Adv Crit Care 2012; 23:188-203. [PMID: 22543492 DOI: 10.1097/nci.0b013e31824db4f3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite progress in the management of adults with severe traumatic brain injury, several controversies persist. Among the unresolved issues of greatest concern to neurocritical care clinicians and scientists are the following: (1) the best use of technological advances and the data obtained from multimodality monitoring; (2) the use of mannitol and hypertonic saline in the management of increased intracranial pressure; (3) the use of decompressive craniectomy and barbiturate coma in refractory increased intracranial pressure; (4) therapeutic hypothermia as a neuroprotectant; (5) anemia and the role of blood transfusion; and (6) venous thromboembolism prophylaxis in severe traumatic brain injury. Each of these strategies for managing severe traumatic brain injury, including the postulated mechanism(s) of action and beneficial effects of each intervention, adverse effects, the state of the science, and critical care nursing implications, is discussed.
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Affiliation(s)
- Roland Torres
- Department of Neurosurgery, Stanford Univ. Medical School, Stanford, USA
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