Surgical decompression for traumatic brain swelling: indications and results

Long-term survival after primary decompressive craniectomy for severe traumatic brain injury: an observational study from 1 to 17 years

Primary decompressive craniectomy (DC) is carried out to prevent intracranial hypertension after removal of mass lesions resulting from traumatic brain injury (TBI). While primary DC can be a life-saving intervention, significant mortality risks persist during the follow-up period. This study was undertaken to investigate the long-term survival rate and ascertain the risk factors of mortality in TBI patients who underwent primary DC. We enrolled 162 head-injured patients undergoing primary DC in this retrospective study. The primary focus was on long-term mortality, which was monitored over a range of 12 to 209 months post-TBI. We compared the clinical parameters of survivors and non-survivors, and used a multivariate logistic regression model to adjust for independent risk factors of long-term mortality. For the TBI patients who survived the initial hospitalization period following surgery, the average duration of follow-up was 106.58 ± 65.45 months. The recorded long-term survival rate of all patients was 56.2% (91/162). Multivariate logistic regression analysis revealed that age (odds ratio, 95% confidence interval = 1.12, 1.07-1.18; p < 0.01) and the status of basal cisterns (absent versus normal; odds ratio, 95% confidence interval = 9.32, 2.05-42.40; p < 0.01) were the two independent risk factors linked to long-term mortality. In conclusion, this study indicated a survival rate of 56.2% for patients subjected to primary DC for TBI, with at least a one-year follow-up. Key risk factors associated with long-term mortality were advanced age and absent basal cisterns, critical considerations for developing effective TBI management strategies.

Unveiling the "Kebab" technique: A case report on a two-stage reconstruction method for repeated complex cranioplasty

RATIONALE

Cranioplasty after decompressive craniectomy provides brain protection and improves cerebral hemodynamics. However, recurrent infection and sinking skin flap syndrome after cranioplasty remain cumbersome complications that require a well-planned reconstruction strategy.

PATIENT CONCERNS

A 74-year-old man presented with traumatic subdural hematoma and underwent decompressive craniectomy. Cranioplasty using an original bone flap, bone cement with wires, and a titanium mesh were complicated and resulted in recalcitrant infection and sinking skin flap syndrome.

DIAGNOSES

Recurrent infection and sinking skin flap syndrome post-cranioplasty.

INTERVENTIONS

We designed a two-stage "kebab" reconstruction technique using a combination of free latissimus dorsi myocutaneous flap and delayed non-vascularized free rib graft. A well-vascularized musculocutaneous flap can obliterate dead space in skull defects and reduce bacterial inoculation in deep infections. Subsequently, delayed rib grafts act as the scaffold to expand the sunken scalp flap.

OUTCOMES

At the 3-year follow-up, the patient showed improvement in headache, without evidence of surgical site infection.

LESSONS

The novel "kebab" technique using a combination of a free myocutaneous flap and delayed rib graft can eliminate bacterial growth in infected calvarial defects, reverse sinking skin flap syndrome, and minimize potential donor-site morbidity, and is therefore suitable for patients who require multiple cranioplasties and are unable to withstand major reconstructions.

Comparative Study of Cerebral Perfusion in Different Types of Decompressive Surgery for Traumatic Brain Injury

Introduction Computed tomography perfusion (CTP) brain usefulness in the treatment of traumatic brain injury (TBI) is still being investigated. Comparative research of CTP in the various forms of decompressive surgery has not yet been reported to our knowledge. Patients with TBI who underwent decompressive surgery were studied using pre- and postoperative CTP. CTP findings were compared with patient's outcome.

Materials and Methods This was a single-center, prospective cohort study. A prospective analysis of patients who were investigated with CTP from admission between 2019 and 2021 was undertaken. The patients in whom decompressive surgery was required for TBI, were included in our study after applying inclusion and exclusion criteria. CTP imaging was performed preoperatively and 5 days after decompressive surgery to measure cerebral perfusion. Numbers of cases included in the study were 75. Statistical analysis was done.

Results In our study, cerebral perfusion were improved postoperatively in the all types of decompressive surgery (p-value < 0.05). But association between type of surgery with improvement in cerebral perfusion, Glasgow Coma Scale at discharge, and Glasgow Outcome Scale-extended at 3 months were found to be statistically insignificant (p-value > 0.05).

Conclusion CTP brain may play a role as a prognostic tool in TBI patients undergoing decompressive surgery.

PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is associated with poor neurological outcome and high mortality. A major factor influencing morbidity and mortality is brain swelling in the acute phase. Decompressive craniectomy (DC) is currently used as an option in order to reduce intractably elevated intracranial pressure (ICP). However, execution and optimal timing of DC remain unclear.

METHODS

PICASSO resembles a multicentric, prospective, 1:1 randomized standard treatment-controlled trial which analyzes whether primary DC (pDC) performed within 24 h combined with the best medical treatment in patients with poor-grade SAH reduces mortality and severe disability in comparison to best medical treatment alone and secondary craniectomy as ultima ratio therapy for elevated ICP. Consecutive patients presenting with poor-grade SAH, defined as grade 4-5 according to the World Federation of Neurosurgical Societies (WFNS), will be screened for eligibility. Two hundred sixteen patients will be randomized to receive either pDC additional to best medical treatment or best medical treatment alone. The primary outcome is the clinical outcome according to the modified Rankin Scale (mRS) at 12 months, which is dichotomized to favorable (mRS 0-4) and unfavorable (mRS 5-6). Secondary outcomes include morbidity and mortality, time to death, length of intensive care unit (ICU) stay and hospital stay, quality of life, rate of secondary DC due to intractably elevated ICP, effect of size of DC on outcome, use of duraplasty, and complications of DC.

DISCUSSION

This multicenter trial aims to generate the first confirmatory data in a controlled randomized fashion that pDC improves the outcome in a clinically relevant endpoint in poor-grade SAH patients.

TRIAL REGISTRATION

DRKS DRKS00017650. Registered on 09 June 2019.

Impact of decompressive craniectomy on functional outcome of severe acquired brain injuries patients, at discharge from intensive inpatient rehabilitation

PURPOSE

Decompressive craniectomy (DC) is a life-saving procedure conducted to treat refractory intracranial hypertension. Although DC reduces mortality of severe Acquired Brain Injury (sABI) survivors, it has been associated with severe long-term disability. This observational study compares functional outcomes at discharge from an Intensive Rehabilitative Unit (IRU) between sABI patients with and without DC.

MATERIAL AND METHODS

sABI patients undergoing DC before entering the Don Gnocchi Foundation IRU were compared with a group of sABI patients who did not undergo DC (No-DC group), after matching it by age, sex, aetiology, time post-onset, and clinical status. Inclusion criteria were: diagnosis of sABI, age 18+, time from the event <90 days.

RESULTS

A total of 87 (DC: 47) patients were included (median age: 60.5 [IQR = 17.47]). The two groups did not differ for admission clinical features except for the tracheostomy presence (more frequent in DC, p < 0.001). No significant differences were also found at discharge. DC group presented a significantly longer length-of-stay than No-DC group (p < 0.001) and a longer time to tracheostomy removal (p = 0.036). DC was not found to influence outcomes as consciousness improvement, tracheostomy removal, oral intake and functional independence.

CONCLUSIONS

sABI patients with DC improved after rehabilitation as much as No-DC patients did but they required a longer stay.Implications for RehabilitationDecompressive craniectomy (DC) is practiced during the acute phase after hemorrhagic, ischemic, traumatic severe brain injury as a life-saving procedure to treat refractory intracranial hypertensionDC has been associated with follow-up severe long-term disability, but no study yet addressed whether DC may affect intensive rehabilitation outcomes.Undergoing a DC is not a negative prognostic factor for achieving rehabilitation goals after a severe acquired brain injuryDC must be taken into account when customizing rehabilitation pathway especially because these patients required a longer time to reach the outcomes.

Role of the optic nerve sheath diameter in the assessment of the effectiveness of decompressive surgery after malignant middle cerebral artery infarction

BACKGROUND

After a case of stroke, intracranial pressure (ICP) must be measured and monitored, and the gold standard method for that is through an invasive technique using an intraventricular or intraparenchymal device. However, The ICP can also be assessed through a non-invasive method, comprised of the measurement of the optic nerve sheath diameter (ONSD) through ultrasound (US).

OBJECTIVE

To evaluate the ICP of patients who underwent wide decompressive craniectomy after middle cerebral artery (MCA) infarction via preoperative and postoperative ONSD measurements.

METHODS

A total of 17 patients, aged between 34 and 70 years, diagnosed with malignant MCA infarction with radiological edema and mid-line shift, who underwent decompressive surgery, were eligible. From the records, we collected data on age, sex, preoperative and postoperative Glasgow Coma Scale (GCS) scores, National Institutes of Health Stroke Scale (NIHSS) score, the degree of disability in the preoperative period and three months postoperatively through the scores on the Modified Rankin Scale (MRS), and the preoperative and postoperative midline shift measured by computed tomography (CT) scans of the brain.

RESULTS

Preoperatively, the mean GCS score was of 8 (range: 7.7-9.2), whereas it was found to be of 12 (range 10-14) on the first postoperative day (p = 0.001). The mean preoperative NIHSS score was of 21.36 ± 2.70 and, on the first postoperative day, it was of 5.30 ± 0.75 (p < 0.001). As for the midline shift, the mean preoperative value was of 1.33 ± 0.75 cm, and, on the first postoperative day, 0.36 ± 0.40 cm (p < 0.001). And, regarding the ONSD, the mean preoperative measurement was of 5.5 ± 0.1 mm, and, on the first postoperative day, it was of 5 ± 0.9 mm (p < 0.001).

CONCLUSION

The ocular US measurement of the ONSD for the preoperative and postoperative monitoring of the ICP seems to be a practical and useful method.

ASNM and ASN joint guidelines for transcranial Doppler ultrasonic monitoring: An update

Today, it seems prudent to reconsider how ultrasound technology can be used for providing intraoperative neurophysiologic monitoring that will result in better patient outcomes and decreased length and cost of hospitalization. An extensive and rapidly growing literature suggests that the essential hemodynamic information provided by transcranial Doppler (TCD) ultrasonography neuromonitoring (TCDNM) would provide effective monitoring modality for improving outcomes after different types of vascular, neurosurgical, orthopedic, cardiovascular, and cardiothoracic surgeries and some endovascular interventional or diagnostic procedures, like cardiac catheterization or cerebral angiography. Understanding, avoiding, and preventing peri- or postoperative complications, including neurological deficits following abovementioned surgeries, endovascular intervention, or diagnostic procedures, represents an area of great public and economic benefit for society, especially considering the aging population. The American Society of Neurophysiologic Monitoring and American Society of Neuroimaging Guidelines Committees formed a joint task force and developed updated guidelines to assist in the use of TCDNM in the surgical and intensive care settings. Specifically, these guidelines define (1) the objectives of TCD monitoring; (2) the responsibilities and behaviors of the neurosonographer during monitoring; (3) instrumentation and acquisition parameters; (4) safety considerations; (5) contemporary rationale for TCDNM; (6) TCDNM perspectives; and (7) major recommendations.

Changes in Blood Pressure and Heart Rate during Decompressive Craniectomy

Objective

Rapid increase in intracranial pressure (ICP) can result in hypertension, bradycardia and apnea, referred to as the Cushing phenomenon. During decompressive craniectomy (DC), rapid ICP decreases can cause changes in mean atrial blood pressure (mABP) and heart rate (HR), which may be an indicator of intact autoregulation and vasomotor reflex.

Methods

A total of 82 patients who underwent DC due to traumatic brain injury (42 cases), hypertensive intracerebral hematoma (19 cases), or major infarction (21 cases) were included in this prospective study. Simultaneous ICP, mABP, and HR changes were monitored in one minute intervals during, prior to and 5–10 minutes following the DC.

Results

After DC, the ICP decreased from 38.1±16.3 mmHg to 9.5±14.2 mmHg (p<0.001) and the mABP decreased from 86.4±14.5 mmHg to 72.5±11.4 mmHg (p<0.001). Conversly, overall HR was no significantly changed in HR, which was 100.1±19.7 rate/min prior to DC and 99.7±18.2 rate/min (p=0.848) after DC. Notably when the HR increased after DC, it correlated with a favorable outcome (p<0.001), however mortality was increased (p=0.032) when the HR decreased or remained unchanged.

Conclusion

In this study, ICP was decreased in all patients after DC. Changes in HR were an indicator of preserved autoregulation and vasomotor reflex. The clinical outcome was improved in patients with increased HR after DC.

Variation in neurosurgical intervention for severe traumatic brain injury: The challenge of measuring quality in trauma center verification

BACKGROUND

Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution.

METHODS

We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval).

RESULTS

We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement.

CONCLUSION

Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification.

LEVEL OF EVIDENCE

Epidemiological, level III; Care management/Therapeutic level III.

The Retroauricular Incision as an Effective and Safe Alternative Incision for Decompressive Hemicraniectomy

BACKGROUND

The reverse question mark (RQM) incision has been traditionally utilized to perform decompressive hemicraniectomies (DHC) to relieve refractory intracranial hypertension. Alternative incisions have been proposed in the literature but have not been compared directly.

OBJECTIVE

To present the retroauricular (RA) incision as an alternative incision that we hypothesize will increase calvarium exposure to maximize the removal of the hemicranium and will decrease wound-related complications compared to the RQM incision.

METHODS

This study is a retrospective review of all DHCs performed at our institution over a span of 34 mo, stratified based on the type of scalp incision. The surface areas of the cranial defects were calculated, normalizing to their respective skull diameters. For those patients surviving beyond 1 wk, complications were examined from both cohorts.

RESULTS

A total of 63 patients in the RQM group and 43 patients in the RA group were included. The average surface area for the RA and RQM incisions was 117.0 and 107.8 cm2 (P = .0009), respectively. The ratio of average defect size to skull size for RA incision was 0.81 compared to 0.77 for the RQM group (P = .0163). Of those who survived beyond 1 wk, the absolute risk for surgical site complications was 14.0% and 8.3% for RQM and RA group (P = .5201), respectively.

CONCLUSION

The RA incision provides a safe and effective alternative incision to the traditional RQM incision used for DHC. This incision affords a potentially larger craniectomy while mitigating postoperative wound complications.

Outcome of Decompressive Craniectomy for Traumatic Brain Injury: An Institutional-Based Analysis from Nepal

Objective:

Decompressive craniectomy (DC) is one of the commonly used treatment modalities for refractory intracranial hypertension after traumatic brain injury. The objective of this study is to assess the functional outcome following DC in closed traumatic brain injury based on Glasgow Outcome Scale (GOS).

Materials and Methods:

This is a retrospective study conducted at Nepal Mediciti Hospital, Nepal, from September 2017 to October 2019. Data of the patients who had undergone DC for closed traumatic brain injury were reviewed from medical record files. Patients who had DC for nontraumatic causes were excluded from the study. Functional outcome was assessed using GOS at 3 months of follow-up.

Results:

Of the 52 decompressive craniectomies, 46 were included in the study. The majority was male (71.7%). The mean age and the mean Glasgow Coma Scale (GCS) score at presentation were 41.87 (standard deviation [SD] ± 15.29) and 7.59 (SD ± 2.97), respectively. The most common mode of injury was road traffic accident (76.1%). 60.9% had GCS score ≤8 while 39.1% had >8 GCS on admission. 34.8% had both the pupils reactive while 58.7% were anisocoric. Majority had Marshall IV and above grade of injury (67.4%). Sixteen (34.8%) had inhospital mortality. Favorable outcome was seen in 39.1%. GCS score >8 at presentation (72.2%, P < 0.001), bilaterally intact pupillary reflexes (75%, P < 0.001), Marshall grade injury ≤3 on computed tomography scan (90%, P < 0.001), and age <50 years (50%, P = 0.039) were significantly associated with favorable outcome. Procedure-related complications were seen in 36.9%.

Conclusion:

Favorable outcome was seen in 39.1%. Age <50 years, higher GCS score at presentation (>8), intact pupillary reflexes, and lower Marshall grade injuries were associated with favorable outcome. We recommend a larger prospective study to assess the long-term functional outcome after DC using extended GOS.

Death after discharge: prognostic model of 1-year mortality in traumatic brain injury patients undergoing decompressive craniectomy

Background

Despite advances in decompressive craniectomy (DC) for the treatment of traumatic brain injury (TBI), these patients are at risk of having a poor long-term prognosis. The aim of this study was to predict 1-year mortality in TBI patients undergoing DC using logistic regression and random tree models.

Methods

This was a retrospective analysis of TBI patients undergoing DC from January 1, 2015, to April 25, 2019. Patient demographic characteristics, biochemical tests, and intraoperative factors were collected. One-year mortality prognostic models were developed using multivariate logistic regression and random tree algorithms. The overall accuracy, sensitivity, specificity, and area under the receiver operating characteristic curves (AUCs) were used to evaluate model performance.

Results

Of the 230 patients, 70 (30.4%) died within 1 year. Older age (OR, 1.066; 95% CI, 1.045–1.087; P < 0.001), higher Glasgow Coma Score (GCS) (OR, 0.737; 95% CI, 0.660–0.824; P < 0.001), higher d-dimer (OR, 1.005; 95% CI, 1.001–1.009; P = 0.015), coagulopathy (OR, 2.965; 95% CI, 1.808–4.864; P < 0.001), hypotension (OR, 3.862; 95% CI, 2.176–6.855; P < 0.001), and completely effaced basal cisterns (OR, 3.766; 95% CI, 2.255–6.290; P < 0.001) were independent predictors of 1-year mortality. Random forest demonstrated better performance for 1-year mortality prediction, which achieved an overall accuracy of 0.810, sensitivity of 0.833, specificity of 0.800, and AUC of 0.830 on the testing data compared to the logistic regression model.

Conclusions

The random forest model showed relatively good predictive performance for 1-year mortality in TBI patients undergoing DC. Further external tests are required to verify our prognostic model.

Paradoxical Contralateral Herniation Detected by Pupillometry in Acute Syndrome of the Trephined

Severe traumatic brain injury has historically been a non-survivable injury. Recent advances in neurosurgical care, however, have demonstrated that these patients not only can survive, but they also can recover functionally when they undergo appropriate cerebral decompression within hours of injury. At the present, general surgeons are deployed further forward than neurosurgeons (Role 2 compared to Role 3) and have been provided with guidelines that stipulate conditions where they may have to perform decompressive craniectomies. Unfortunately, Role 2 medical facilities do not have access to computed tomography imaging or intracranial pressure monitoring capabilities rendering the decision to proceed with craniectomy based solely on exam findings. Utilizing a case transferred from downrange to our institution, we demonstrate the utility of a small, highly portable quantitative pupillometer to obtain reliable and reproducible data about a patient's intracranial pressures. Following the case presentation, the literature supporting quantitative pupillometry for surgical decision-making is reviewed.

Neurocritical Management of Traumatic Acute Subdural Hematomas

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.

Primary decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage: long-term outcome in a single-center study and systematic review of literature

Primary decompressive craniectomy (PDC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in order to decrease elevated intracranial pressure (ICP) is controversially discussed. The aim of this study was to analyze the effect of PDC on long-term clinical outcome in these patients in a single-center cohort and to perform a systematic review of literature. Eighty-seven consecutive poor-grade SAH patients (World Federation of Neurosurgical Societies (WFNS) grades IV and V) were analyzed between October 2012 and August 2017 at the author’s institution. PDC was performed due to clinical signs of herniation or brain swelling according to the treating surgeon. Outcome was analyzed according to the modified Rankin Scale (mRS). Literature was systematically reviewed up to August 2019, and data of poor-grade aSAH patients who underwent PDC was extracted for statistical analyses. Of 87 patients with poor-grade aSAH in the single-center cohort, 38 underwent PDC and 49 did not. Favorable outcome at 2 years post-hemorrhage did not differ significantly between the two groups (26% versus 20%). Systematic literature review revealed 9 studies: Overall, a favorable outcome could be achieved in nearly half of the patients (49%), with an overall mortality of 24% (median follow-up 11 months). Despite a worse clinical status at presentation (significantly higher rate of mydriasis and additional ICH), poor-grade aSAH patients with PDC achieve favorable outcome in a significant number of patients. Therefore, treatment and PDC should not be omitted in this severely ill patient collective. Prospective controlled studies are warranted.

The impact of implant material and patient age on the long-term outcome of secondary cranioplasty following decompressive craniectomy for severe traumatic brain injury

Background

Secondary cranioplasty (CP) is considered to support the neurological recovery of patients after decompressive craniectomy (DC), but the treatment success might be limited by complications associated to confounders, which are not yet fully characterized. The aim of this study was to identify the most relevant factors based on the necessity to perform revision surgeries.

Methods

Data from 156 patients who received secondary CP following DC for severe traumatic brain injury (TBI) between 1984 and 2015 have been retrospectively analyzed and arranged into cohorts according to the occurrence of complications requiring surgical intervention.

Results

Cox regression analysis revealed a lower revision rate in patients with polymethylmethacrylate (PMMA) implants than in patients with autologous calvarial bone (ACB) implants (HR 0.2, 95% CI 0.1 to 1.0, p = 0.04). A similar effect could be observed in the population of patients aged between 18 and 65 years, who had a lower risk to suffer complications requiring surgical treatment than individuals aged under 18 or over 65 years (HR 0.4, 95% CI 0.2 to 0.9, p = 0.02). Revision rates were not influenced by the gender (p = 0.88), timing of the CP (p = 0.53), the severity of the TBI (p = 0.86), or the size of the cranial defect (p = 0.16).

Conclusions

In this study, the implant material and patient age were identified as the most relevant parameters independently predicting the long-term outcome of secondary CP. The use of PMMA was associated with lower revision rates than ACB and might provide a therapeutic benefit for selected patients with traumatic cranial defects.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04243-7) contains supplementary material, which is available to authorized users.

Post-traumatic hydrocephalus following decompressive hemicraniectomy: Incidence and risk factors in a prospective cohort of severe TBI patients

BACKGROUND

In severe traumatic brain injury (TBI) patients undergoing decompressive hemicraniectomy (DHC), the rate of post-traumatic hydrocephalus (PTH) is high at 12-36%. Early diagnosis and shunt placement can improve outcomes. Herein, we examined the incidence of and predictors of PTH after craniectomy.

METHODS

A retrospective analysis of prospectively collected database of severe TBI patients at a single U.S. Level 1 trauma center from May 2000 to July 2014 was performed. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), bleeding pattern and time-to-cranioplasty were analyzed. Glasgow Outcome Scale (GOS) scores at 6 and 12-months were studied. Statistical significance was assessed at p < 0.05.

RESULTS

A total of 402 patients were enrolled and 105 patients had DHC. Twenty-two (21.0%) of 105 required ventriculoperitoneal shunt (VPS), compared to 18 (6%) of 297 patients without DHC. There was increased odds ratio for shunting after DHC at 3.62 (95%CI:1.62-8.07; p < 0.01). Mean age at time of DHC was 43.8 ± 17.7 years old, and 81.9% were male. Subdural hematoma (SDH) was most common at 57.1%. Median time from admission to cranioplasty was 63 days. Patients who experienced PTH after DHC were younger (35.5 ± 17.7 versus 46.0 ± 17.7 years, p < 0.01) and had higher ISS scores (35 versus 26, p = 0.04) compared to patients without shunt after DHC.

CONCLUSIONS

After severe TBI requiring hemicraniectomy, shunt-dependent hydrocephalus was 21%. Younger patients and higher ISS score were associated with PTH. Shunt-dependent patients achieved similar 6- and 12-month outcomes as those without PTH. Early diagnosis and shunt placement can enhance long-term neurological recovery.

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

BACKGROUND

High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy).

OBJECTIVES

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

SEARCH METHODS

The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts.

SELECTION CRITERIA

We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care.

DATA COLLECTION AND ANALYSIS

We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach.

MAIN RESULTS

We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I² = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I² = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I² value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I² = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I² = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events.

AUTHORS' CONCLUSIONS

Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.

Prognostic significance of subdural hygroma for post-traumatic hydrocephalus after decompressive craniectomy in the traumatic brain injury setting: a systematic review and meta-analysis

Post-traumatic hydrocephalus (PTH) is a potentially morbid sequela of decompressive craniectomy for traumatic brain injury (TBI). Subdural hygromas are commonly identified following decompressive craniectomy, but the clinical relevance and predictive relationship with PTH in this patient cohort is not completely understood. Survey of seven electronic databases from inception to June 2019 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate hazard ratios (HRs) for PTH by the presence of subdural hygroma were extracted and pooled by meta-analysis of proportions with random effects modeling. We systematically identified nine pertinent studies describing outcomes of 1010 TBI patients managed by decompressive craniectomy. Of the overall cohort, there were 211 (21%) females and median age was 37.5 years (range 33-53). On presentation, median Glasgow Coma Scale was 7 (range, 5-8). In sum, PTH was reported in 228/840 (27%) cases, and subdural hygroma was reported in 449/1010 (44%) cases across all studies. Pooling multivariate-derived HRs indicated that subdural hygroma was a significant, independent predictor of PTH (HR, 7.1; 95% CI, 3.3-15.1). The certainty of this association was deemed low due to heterogeneity concerns. The presence of subdural hygroma is associated with increased risk of PTH after decompressive craniectomy among TBI patients based on the current literature and may mandate closer clinical surveillance when detected. Prospective studies, including those of intracranial hydrodynamics following decompressive craniectomy in the setting of TBI, will better validate the certainty of these findings.

Bone Flap Changes after Cranioplasty Using Frozen Autologous Bone Flaps: A Three-Dimensional Volumetric Reconstruction Study

PURPOSE

Bone flap resorption (BFR) after cranioplasty with an autologous bone flap (ABF) is well known. However, the prevalences and degrees of BFR remain unclear. This study aimed to evaluate changes in ABFs following cranioplasty and to investigate factors related with BFR.

MATERIALS AND METHODS

We retrospectively reviewed 97 patients who underwent cranioplasty with frozen ABF between January 2007 and December 2016. Brain CT images of these patients were reconstructed to form three-dimensional (3D) images, and 3D images of ABF were separated using medical image editing software. ABF volumes on images were measured using 3D image editing software and were compared between images in the immediate postoperative period and at postoperative 12 months. Risk factors related with BFR were also analyzed.

RESULTS

The volumes of bone flaps calculated from CT images immediately after cranioplasty ranged from 55.3 cm³ to 175 cm³. Remnant bone flap volumes at postoperative 12 months ranged from 14.2% to 102.5% of the original volume. Seventy-five patients (77.3%) had a BFR rate exceeding 10% at 12 months after cranioplasty, and 26 patients (26.8%) presented severe BFR over 40%. Ten patients (10.3%) underwent repeated cranioplasty due to severe BFR. The use of a 5-mm burr for central tack-up sutures was significantly associated with BFR (p<0.001).

CONCLUSION

Most ABFs after cranioplasty are absorbed. Thus, when using frozen ABF, patients should be adequately informed. To prevent BFR, making holes must be kept to a minimum during ABF grafting.

The Role of Decompressive Craniectomy in the Context of Severe Traumatic Brain Injury: Summary of Results and Analysis of the Confidence Level of Conclusions From Systematic Reviews and Meta-Analyses

Introduction: Traumatic brain injury (TBI) is a global epidemic. The incidence of TBI in low and middle-income countries (LMICs) is three times greater than in high-income countries (HICs). Decompressive craniectomy (DC) is a surgical procedure to reduce intracranial pressure (ICP) and prevent secondary injury. Multiple comparative studies, and several randomized controlled trials (RCTs) have been conducted to investigate the influence of DC for patients with severe TBI on outcomes such as mortality, ICP, neurological outcomes, and intensive care unit (ICU) and hospital length of stay. The results of these studies are inconsistent. Systematic reviews and meta-analyses have been conducted in an effort to aggregate the data from the individual studies, and perhaps derive reliable conclusions. The purpose of this project was to conduct a review of the reviews about the effectiveness of DC to improve outcomes.

Methods: We conducted a systematic search of the literature to identify reviews and meta-analyses that met our pre-determined criteria. We used the AMSTAR 2 instrument to assess the quality of each of the included reviews, and determine the level of confidence.

Results: Of 973 citations from the original search, five publications were included in our review. Four of them included meta-analyses. For mortality, three reviews found a positive effect of DC compared to medical management and two found no significant difference between groups. The four reviews that measured neurological outcome found no benefit of DC. The two reviews that assessed ICP both found DC to be beneficial in reducing ICP. DC demonstrated a significant reduction in ICU length of stay in the one study that measured it, and a significant reduction in hospital length of stay in the two studies that measured it. According to the AMSTAR 2 criteria, the five reviews ranged in levels of confidence from low to critically low.

Conclusion: Systematic reviews and meta-analyses are important approaches for aggregating information from multiple studies. Clinicians rely of these methods for concise interpretation of scientific literature. Standards for quality of systematic reviews and meta-analyses have been established to support the quality of the reviews being produced. In the case of DC, more attention must be paid to quality standards, in the generation of both individual studies and reviews.

Chapter 12: Decompressive Craniectomy: Long Term Outcome and Ethical Considerations

Decompressive craniectomy (DC) for the treatment of severe traumatic brain injury (TBI) has been established to decrease mortality. Despite the conclusion of the two largest randomized clinical trials associating the effectiveness of decompressive craniectomy vs. medical management for patients with traumatic brain injury (TBI), there is still clinical equipoise concerning the usefulness of DC in the management of refractory intracranial hypertension. Primary outcome data from these studies reveal either potential harm or that decreased mortality only leads to an upsurge in survivors with severe neurologic incapacity. In this chapter, we seek to review the results of the most recent clinical trials, highlight the prevailing controversies, and offer potential solutions to address this dilemma.

The History of Decompressive Craniectomy in Traumatic Brain Injury

Decompressive craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.

Functional and aesthetic evaluation after cranial reconstruction with polymethyl methacrylate prostheses using low-cost 3D printing templates in patients with cranial defects secondary to decompressive craniectomies: A prospective study

Background:

Cranial reconstruction surgery is a procedure used as an attempt to reestablish the cranial bone anatomy. This study evaluates the symptomatic and aesthetic improvement of patients with cranial defects secondary to decompressive craniectomies after cranial reconstruction with customized polymethyl methacrylate (PMMA) prostheses. Secondly, we aim to divide our experience in the production of these prostheses with a low-cost method.

Methods:

A prospective study was carried out with patients submitted to cranioplasty at the Hospital da Restauração between 2014 and 2017. A total of 63 cranioplasties were performed using customized PMMA prosthesis produced by 3D impression molds. All patients underwent a functional and aesthetic evaluation questionnaire in the preoperative period and in the sixth postoperative month.

Results:

Sixty-three patients underwent cranioplasty with a mean age of 33 years, ranging from 13 to 58 years, 55 males and 8 females. The mean area of the defect was 147 cm². The mean postoperative follow-up of the patients was 21 months, ranging from 6 to 33 months. Fifty-five patients attended the 6-month postoperative consultation. All patients presented symptomatic improvement after reconstruction of the skull. The infection rate was 3.2%, 4.8% of extrusion, 1.6% of prosthesis fracture, 7.9% of extradural hematoma, 17.4% of reoperation, 5% of wound dehiscence, and 4.8% of removal of the prosthesis.

Conclusion:

Cranioplasty, with a customized PMMA prosthesis, improved the symptoms and aesthetic appearance of all operated patients. The use of prototypes to customize cranial prostheses facilitated the operative technique and allowed the recovery of a cranial contour very close to normal.

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

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

Hypertonic Solutions in Traumatic Brain Injury: A Systematic Review and Meta-Analysis

This study aims to evaluate the efficacy of hypertonic saline versus crystalloids (normal Saline/lactated Ringers) in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and grey literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies and prospective cohort studies on decompressive craniectomy in TBI (>18-year-old). Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS), Extended GCOS, and mortality. Data were extracted to Review Manager Software. A total of 115 articles that met the inclusion criteria were retrieved and analyzed. Ultimately, five studies were included in our meta-analysis, which revealed that patients with TBI who had hypertonic saline had no statistically significant likelihood of having a good outcome at discharge or 6 months than those who had crystalloid (odds ratio [OR]: 0.01; 95% confidence interval (CI): 0.03–0.05; P = 0.65). The relative risk (RR) of mortality in hypertonic saline versus the crystalloid at discharge or 6-month is RR: 0.80; 95% CI: 0.64–0.99; P = 0.04. The subgroup analysis showed that the group who had hypertonic solution significantly decreases the number of interventions versus the crystalloid group OR: 0.53; 95% CI: 0.48–0.59; P < 0.00001 and also reduces the length of intensive care unit stay (OR: 0.46; 95% CI: 0.21–1.01; P = 0.05). Hypertonic saline decreases the financial burden, but neither impacts the clinical outcome nor reduces the mortality. However, further clinical trials are required to prove if hypertonic saline has any role in improving the clinical and neurological status of patients with TBI versus the normal saline/lactated Ringers.

Risk factors predicting prognosis and outcome of elderly patients with isolated traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI), particularly in the elderly patient population, is known to be the single largest cause of death and disability worldwide. The purpose of this retrospective study was to evaluate clinical factors predicting poor outcome with special emphasis on the impact of respiratory failure (RF) on mortality in elderly patients with isolated severe TBI.

METHODS

All elderly patients (age ≥ 65 years) with isolated severe head injury, admitted to this level I trauma center, during a period of 18 years (from January 1992 to December 2010) were identified from the trauma registry. The medical records were reviewed for demographics, mechanism of injury (MOI), GCS score at admission, RF, pupillary light reflex (LR), CT findings (subdural hematoma, subarachnoid hematoma, edema, midline-shift), and whether there was conservative treatment or surgical intervention and the Glasgow Outcome Score (GOS) at hospital discharge. Stepwise logistic regression analysis was used to identify risk factors for a poor prognosis and outcome.

RESULTS

The following variables influenced the mortality: respiratory failure, pupillary response, and the injury severity score (ISS). A significant increased risk of death was also found for patients with a midline shift of over 15 mm.

CONCLUSIONS

The present study predicts a strong correlation between respiratory failure, pathological pupillary response, a higher ISS, and substantial midline shift with poor outcomes in elderly patients sustaining an isolated severe TBI.

TRIAL REGISTRATION

Clinical trials: ID: NCT02386865 . Registered 12 March 2015-retrospectively registered.

Relationship between Clinical Outcomes and Superior Sagittal Sinus to Bone Flap Distance during Unilateral Decompressive Craniectomy in Patients with Traumatic Brain Injury: Experience at a Single Trauma Center

Objective

This retrospective study was conducted to investigate the relationship between the superior sagittal sinus (SSS) to bone flap distance and clinical outcome in patients with traumatic brain injury (TBI) who underwent decompressive craniectomy (DC).

Methods

A retrospective review of medical records identified 255 adult patients who underwent DC with hematoma removal to treat TBI at our hospital from 2016 through 2017; of these, 68 patients met the inclusion criteria and underwent unilateral DC. The nearest SSS to bone flap distances were measured on postoperative brain computed tomography images, and patients were divided into groups A (distance ≥20 mm) and B (distance <20 mm). The estimated blood loss (EBL) and operation time were evaluated using anesthesia records, and the time spent in an intensive care unit (ICU) was obtained by chart review. The clinical outcome was rated using the extended Glasgow Outcome Scale (GOS-E) at 3 and 6 months postoperatively.

Results

The male to female ratio was 15:2 and the mean subject age was 55.12 years (range, 18–79 years). The mean EBL and operation times were significantly different between groups A and B (EBL: 655.26 vs. 1803.33 mL, p<0.001; operation time: 125.92 vs. 144.83 min, p<0.001). The time spent in the ICU and GOS-E scores did not differ significantly between the groups.

Conclusion

We recommend that when DC is indicated due to TBI, an SSS to bone flap distance of at least 20 mm should be maintained, considering the EBL, operation time, and other outcomes.

Adhesion sutures for seroma reduction in cranial reconstructions with polymethyl methacrylate prosthesis in patients undergoing decompressive craniectomy: A clinical trial

Background:

Cranial reconstruction with polymethyl methacrylate (PMMA) prosthesis is used for calvarial defects secondary to decompressive craniectomies. Seroma is one of the most frequent complications of this procedure and can lead to the dehiscence, extrusion, infection, and loss of the prosthesis. The objective of the study is to analyze the effectiveness of the tacking sutures between the prosthesis and the scalp flap in reducing the seroma.

Methods:

This is a prospective study with 63 patients submitted to cranioplasty between 2014 and 2017 for defects resulting from decompressive craniectomies. All patients were followed up postoperatively for at least 3 months and the diagnosis of seroma was made clinically. In the first 22 patients, the conventional technique was applied and, in the following 41, the technique with tacking sutures was used. The incidence of seroma was collected for both groups.

Results:

The overall incidence of seroma was 65.1%. Compared to the conventional technique, the use of tacking sutures was associated with a statistically significant reduction in the incidence of seroma from 90.9% to 51.2% (P = 0.002).

Conclusion:

The use of the tacking sutures in cranioplasties with PMMA prosthesis reduced the incidence of seroma postoperatively.

Long-Term Effects of Decompressive Craniectomy on Functional Outcomes after Traumatic Brain Injury: A Multicenter Study

Decompressive craniectomy (DC) is a surgical modality sometimes used in the management of elevated intracranial pressure. Questions remain as to its long-term benefits in traumatic brain injury patients. The extended Glasgow Outcome Scale (eGOS) is a scoring system based on a structured interview that allows for consistent and reproducible measurement of long-term functional outcomes. The purpose of this study was to determine the eGOS score of post-craniectomy patients after discharge and stratify survivors based on outcome. A multicenter review of patients who underwent DC was performed. Survivors underwent a phone survey at which time the eGOS was calculated. Patients with an eGOS ≥ 5 were considered to have a good functional outcome. Fifty-four patients underwent DC. Age (OR 1.038; confidence interval 1.003–1.074) and Glasgow Coma Scale (OR 0677; confidence interval 0.527–0.870) were predictors of mortality. Patients who were available for follow-up (n = 13) had poor functional outcomes at discharge (eGOS = 3); however, this improved at the time of follow-up survey (eGOS = 5; P = 0.005). DC is a controversial operation with high mortality and uncertain benefit. Among our cohort, the eGOS score was significantly higher at follow-up survey than it was at discharge. Although the mortality was high, if patients survived to discharge, most had a good functional outcome at follow-up survey.

Large retrospective study of artificial dura substitute in patients with traumatic brain injury undergo decompressive craniectomy

Background

Decompressive craniectomy is widely used for treating patients with traumatic brain injury (TBI). Usually patients have dura mater defect due to surgery or injury itself. The defective area may left open or repaired by artificial dura substitutes. A variety of artificial dura substitutes have been used for this purpose.

Objective

This study aimed to evaluate bovine-derived pericardium membrane as artificial dural material for patients with decompressive craniectomy.

Methods

Totally 387 patients with severe TBI in our hospital were included in this study. Among them, 192 patients were treated with standard decompressive craniectomy without dura repair (control group). One hundred and ninety-five TBI patients were treated with dura repair by artificial dura materials (ADM). Nonlyophilized bovine pericardium membranes were used as artificial dura material. The postoperative complications were compared in both groups, including infection, seizure, and cerebrospinal fluid (CSF) leakage.

Results

Patients in control group have higher complication rates than patients in ADM group, including subcutaneous hematoma (13.02% in control vs. 4.01% in ADM group, p = .004), infection (12.5% in control vs. 5.64% in ADM group, p = .021), CSF leakage (13.02% in control vs. 5.13% in ADM group, p = .012), and seizure (10.42% in control vs. 3.08% in ADM group, p = .007). Patients in ADM group are only associated with higher incidence of foreign body reaction (6 of 195 patients in ADM vs. none from control group).

Conclusion

Bovine-derived pericardium membranes are successfully used as artificial dural substitutes for decompressive craniectomy. Patients with ADM have better clinical outcome than control group.

Decompressive Craniectomy in Diffuse Traumatic Brain Injury: An Industrial Hospital Study

CONTEXT

High intracranial pressure is the most frequent cause of mortality and disability after severe traumatic brain injury (TBI) which is treated by first-line therapeutic measures. When these measures fail, second-line therapies are started. Among second-line therapies, decompressive craniectomy (DC) has been used. It improves the functional outcome in these patients.

AIM

This study aims to analyze the clinicoradiological factors associated with the prognosis of severe TBI in patients undergoing DC.

SETTINGS AND DESIGN

It was a retrospective case series study from April 2014 to March 2016.

SUBJECTS AND METHODS

A total of 85 patients (admitted at Tata Main Hospital, Jamshedpur) with severe diffuse TBI with clinical and radiological evidence of intracranial hypertension who were refractory to first-tier therapies and required DC were included in our study. Cases excluded were patients with age <10 years and polytrauma patients.

RESULTS

Out of 85 cases, 55 were males, and thirty were females (male:female = 1.8:1) with the age ranging from 17 to 68 years. Road traffic accident was the leading cause of injury in 69.5% cases. A total of 49 (58%) patients were of Glasgow coma scale (GCS) 4-6 whereas 36 (42%) patients had GCS 7-8. Computed tomography (CT) scan brain was classified as per Marshall CT classification. Bifrontotemporal DC was done in 29% cases, and unilateral frontotemporoparietal craniectomy was done in 71%.

CONCLUSIONS

Patients with younger age, early surgical intervention, better preoperative GCS score, and with low Marshall CT score have better prognosis.

Efficiency and Limitations of Decompressive Craniectomy in Patients after Traumatic Brain Injury – Preliminary Results

Introduction: Decompressive craniectomy (DC) has been recently proven effective tier II therapeutic procedure in the treatment of refractory posttraumatic intracranial hypertension. However, its full potential and effectivity is yet to be described and this surgery remains controversial. The goals of our study include analysis of efficiency of DC and description of risk factors associated with unfavourable outcome.

Methods: 24 patients who underwent DC at the Clinic of Neurosurgery, JFM CU in Martin, during years 2015–2016 were prospectively observed. Selected demographic, clinical, and radiographic factors were analysed and compared with patient’s GOS (Glasgow Outcome Scale) at the time of their first ambulatory control (after 3.5 months in average).

Results: We observed mortality of 29.17 %. Good outcome (GOS 4–5) was achieved by 29.17 % of the patients as well. Preoperative GCS ≤ 5 (p = 0.049), intraventricular bleeding (p = 0.0268), midline shift ≥ 15 mm (p = 0.0067), and the volume of intracranial lesion (R = −0.41, p = 0.046), especially its extracerebral component (R = −0.46, p = 0.02), were identified as statistically significant negative prognostic factors.

Conclusion: DC is effective in the management of patients with traumatic brain injury. Good outcome is achieved by 29.17 % of the patients. Described negative prognostic factors (preoperative GCS ≤ 5, intraventricular bleeding, midline shift ≥ 15 mm, and increasing the volume of traumatic mass lesion) could help in targeting this surgery only to patients who are expected to benefit from it.

Aspects on the Physiological and Biochemical Foundations of Neurocritical Care

Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood-brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.

Factors associated with shunt-dependent hydrocephalus after decompressive craniectomy for traumatic brain injury

OBJECTIVE Posttraumatic hydrocephalus (PTH) affects 11.9%-36% of patients undergoing decompressive craniectomy (DC) and is an important cause of morbidity after traumatic brain injury (TBI). Early diagnosis and treatment of PTH can prevent further neurological compromise in patients who are recovering from TBI. There is limited data on predictors of shunting for PTH after DC for TBI. METHODS Prospectively collected data from the erythropoietin severe TBI randomized controlled trial were studied. Demographic, clinical, and imaging data were analyzed for enrolled patients who underwent a DC. All head CT scans during admission were reviewed and assessed for PTH by the Gudeman criteria or the modified Frontal Horn Index ≥ 33%. The presence of subdural hygromas was categorized as unilateral/bilateral hemispheric or interhemispheric. Using L1-regularized logistic regression to select variables, a multiple logistic regression model was created with ventriculoperitoneal shunting as the binary outcome. Statistical significance was set at p < 0.05. RESULTS A total of 60 patients who underwent DC were studied. Fifteen patients (25%) underwent placement of a ventriculoperitoneal shunt for PTH. The majority of patients underwent unilateral decompressive hemicraniectomy (n = 46, 77%). Seven patients (12%) underwent bifrontal DC. Unilateral and bilateral hemispheric hygromas were noted in 31 (52%) and 7 (11%) patients, respectively. Interhemispheric hygromas were observed in 19 patients (32%). The mean duration from injury to first CT scan showing hemispheric subdural hygroma and interhemispheric hygroma was 7.9 ± 6.5 days and 14.9 ± 11.7 days, respectively. The median duration from injury to shunt placement was 43.7 days. Multivariate analysis showed that the presence of interhemispheric hygroma (OR 63.6, p = 0.001) and younger age (OR 0.78, p = 0.009) were significantly associated with the need for a shunt after DC. CONCLUSIONS The presence of interhemispheric subdural hygromas and younger age were associated with shunt-dependent hydrocephalus after DC in patients with severe TBI.

Early decompressing craniectomy in patients with traumatic brain injury and cerebral edema

Background: Decompressing craniectomy (DC) is an important method for the management of severe traumatic brain injury (TBI).

Objective: To analyze the effect of prophylactic DC within 24 hours after head trauma TBI.

Methods: Seventy-two patients undergoing prophylactic DC for severe TBI were included in this retrospective study. Both of the early and late outcomes were studied and the prognostic factors were analyzed.

Results: In this series, cumulative death in the first 30 days after DC was 26%, and 28 (53%) of 53 survivors in the first month had a good outcomes. The factors including Glasgow Coma Score (GCS) score at admission, whether the patient had an abnormal pupil response and whether the midline shift was greater than 5 mm were most important prognostic factors for the prediction of death in the first 30 days and the final outcome at 6 months after DC.

Conclusion: Prophylactic DC plays an important role in the management of highly elevated ICP, especially when other methods of reduction of ICP are unavailable.

Prognostication of traumatic brain injury outcomes in older trauma patients: A novel risk assessment tool based on initial cranial CT findings

Introduction:

Advanced age has been traditionally associated with worse traumatic brain injury (TBI) outcomes. Although prompt neurosurgical intervention (NSI, craniotomy or craniectomy) may be life-saving in the older trauma patient, it does not guarantee survival and/or return to preinjury functional status. The aim of this study was to determine whether a simple score, based entirely on the initial cranial computed tomography (CCT) is predictive of the need for NSI and key outcome measures (e.g., morbidity and mortality) in the older (age 45+ years) TBI patient subset. We hypothesized that increasing number of categorical CCT findings is independently associated with NSI, morbidity, and mortality in older patients with severe TBI.

Methods:

After IRB approval, a retrospective study of patients 45 years and older was performed using our Regional Level 1 Trauma Center registry data between June 2003 and December 2013. Collected variables included patient demographics, Injury Severity Score (ISS), Abbreviated Injury Scale Head (AISh), brain injury characteristics on CCT, Glasgow Coma Scale (GCS), Intensive Care Unit (ICU) and hospital length of stay (LOS), all-cause morbidity and mortality, functional independence scores, as well as discharge disposition. A novel CCT scoring tool (CCTST, scored from 1 to 8+) was devised, with one point given for each of the following findings: subdural hematoma, epidural hematoma, subarachnoid blood, intraventricular blood, cerebral contusion/intraparenchymal blood, skull fracture, pneumocephalus, brain edema/herniation, midline shift, and external (skin/face) trauma. Descriptive statistics and univariate analyses were conducted with 30-day mortality, in-hospital morbidity, and need for NSI as primary end-points. Secondary end-points included the length of stay in the ICU (ICULOS), step-down unit (SDLOS), and the hospital (HLOS) as well as patient functional outcomes, and postdischarge destination. Factors associated with the need for NSI were determined using matched NSI (n = 310) and non-NSI (n = 310) groups. All other analyses examined the combined patient sample (n = 620). Variables achieving a significance level of P < 0.20 were included in the logistic regression. Receiver operating characteristic curves, with corresponding area under the curve (AUC) determinations, were also analyzed. Statistical significance was set at α = 0.05. Data are presented as percentages, mean ± standard deviation, or adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs).

Results:

A total of 620 patients were analyzed, including 310 patients who underwent NSI and 310 age- and ISS-matched non-NSI controls. Average patient age was 72.8 ± 13.4 years (64.1% male, 99% blunt trauma, mean ISS 25.1 ± 8.68, and mean AISh/GCS of 4.63/10.9). CCTST was the only variable independently associated with NSI (AOR 1.23, 95% CI 1.06–1.42) and was inversely proportional to initial GCS and functional outcome scores on discharge. Increasing CCTST was associated with greater mortality, morbidity, HLOS, SDLOS, ICULOS, and ventilator days. On multivariate analysis, factors independently associated with mortality included AISh (AOR 2.70, 95% CI 1.21–6.00), initial GCS (AOR 1.14, 1.07–1.22), and CCTST (AOR 1.31, 1.09–1.58). Variables independently associated with in-hospital morbidity included CCTST (AOR 1.16, 1.02–1.34), GCS (AOR 1.05, 1.01–1.09), and NSI (AOR 2.62, 1.69–4.06). Multivariate models incorporating factors independently associated with each respective outcome displayed good overall predictive characteristics for mortality (AUC 0.787) and in-hospital morbidity (AUC 0.651). Finally, modified CCTST demonstrated good overall predictive ability for NSI (AUC 0.755).

Conclusion:

This study found that the number of discrete findings on CCT is independently associated with major TBI outcome measures, including 30-day mortality, in-hospital morbidity, and NSI. Of note, multivariate models with best predictive characteristics incorporate both CCTST and GCS. CCTST is easy to calculate, and this preliminary investigation of its predictive utility in older patients with TBI warrants further validation, focusing on exploring prognostic synergies between CCTST, GCS, and AISh. If independently confirmed to be predictive of clinical outcomes and the need for NSI, the approach described herein could lead to a shift in both operative and nonoperative management of patients with TBI.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis

OBJECTIVE

To examine the clinical and neurological outcome of patients who sustained a severe non-penetrating traumatic brain injury (TBI) and underwent unilateral decompressive craniectomy (DC) for refractory intracranial hypertension.

DESIGN

Single center, retrospective, observational.

SETTING

Level I Trauma Center in Portland, Maine.

PATIENTS

31 patients aged 16-72 of either sex who sustained a severe, non-penetrating TBI and underwent a unilateral DC for evacuation of parenchymal or extra-axial hematoma or for failure of medical therapy to control intracranial pressure (ICP).

INTERVENTIONS

Review of the electronic medical record of patients undergoing DC for severe TBI and assessment of extended Glasgow Outcome Score (e-GOS) at 6-months following DC.

MEASUREMENTS AND MAIN RESULTS

The mean age was 39.3y ± 14.5. The initial GCS was 5.8 ± 3.2, and the ISS was 29.7 ± 6.3. Twenty-two patients underwent DC within the first 24 h, two within the next 24 h and seven between the 3rd and 7th day post injury. The pre-DC ICP was 30.7 ± 10.3 and the ICP was 12.1 ± 6.2 post-DC. Cranioplasty was performed in all surviving patients 1-4 months post-DC. Of the 29 survivors following DC, the e-GOS was 8 in seven patients, and 7 in ten patients. The e-GOS was 5-6 in 6 others. Of the 6 survivors with poor outcomes (e-GOS = 2-4), five were the initial patients in the series.

CONCLUSIONS

In patients with intractable cerebral hypertension following TBI, unilateral DC in concert with practice guideline directed brain resuscitation is associated with good functional outcome and acceptable-mortality.

Predicting long-term neurological outcomes after severe traumatic brain injury requiring decompressive craniectomy: A comparison of the CRASH and IMPACT prognostic models

BACKGROUND

Predicting long-term neurological outcomes after severe traumatic brain (TBI) is important, but which prognostic model in the context of decompressive craniectomy has the best performance remains uncertain.

METHODS

This prospective observational cohort study included all patients who had severe TBI requiring decompressive craniectomy between 2004 and 2014, in the two neurosurgical centres in Perth, Western Australia. Severe disability, vegetative state, or death were defined as unfavourable neurological outcomes. Area under the receiver-operating-characteristic curve (AUROC) and slope and intercept of the calibration curve were used to assess discrimination and calibration of the CRASH (Corticosteroid-Randomisation-After-Significant-Head injury) and IMPACT (International-Mission-For-Prognosis-And-Clinical-Trial) models, respectively.

RESULTS

Of the 319 patients included in the study, 119 (37%) had unfavourable neurological outcomes at 18-month after decompressive craniectomy for severe TBI. Both CRASH (AUROC 0.86, 95% confidence interval 0.81-0.90) and IMPACT full-model (AUROC 0.85, 95% CI 0.80-0.89) were similar in discriminating between favourable and unfavourable neurological outcome at 18-month after surgery (p=0.690 for the difference in AUROC derived from the two models). Although both models tended to over-predict the risks of long-term unfavourable outcome, the IMPACT model had a slightly better calibration than the CRASH model (intercept of the calibration curve=-4.1 vs. -5.7, and log likelihoods -159 vs. -360, respectively), especially when the predicted risks of unfavourable outcome were <80%.

CONCLUSIONS

Both CRASH and IMPACT prognostic models were good in discriminating between favourable and unfavourable long-term neurological outcome for patients with severe TBI requiring decompressive craniectomy, but the calibration of the IMPACT full-model was better than the CRASH model.