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Abstract
This review examines how lessons learned from United States military conflicts, beginning with the United States Civil War through the engagements in Iraq and Afghanistan, have shaped current traumatic brain injury (TBI) care in the United States military, influenced congressional mandates and directives, and led to best practices in caring for the warfighter. Prior to the most recent war, emphasis was placed on improving the surgical and medical care of service members (SM) with severe and especially penetrating brain injuries. However, during the Iraq and Afghanistan conflicts, also known as the Global War on Terrorism (GWOT), blast injury from improvised explosive devices most often caused mild TBI (mTBI), an injury that was not always recognized and was labelled the "signature wound" of the GWOT. This has led to extensive research on objective diagnostic technologies for mTBI, the association of mTBI with post-traumatic stress disorder (PTSD), and the long term consequences of mTBI. Here we summarize the key findings and most important advances from those efforts, and discuss the way forward regarding future military conflicts.
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Affiliation(s)
- Megan A. Lindberg
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- Credence Management Solutions, LLC, Vienna, Virginia, USA
| | | | - Donald W. Marion
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
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Kolias AG, Adams H, Timofeev IS, Corteen EA, Hossain I, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Posti JP, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ, Hutchinson PJ. Evaluation of Outcomes Among Patients With Traumatic Intracranial Hypertension Treated With Decompressive Craniectomy vs Standard Medical Care at 24 Months: A Secondary Analysis of the RESCUEicp Randomized Clinical Trial. JAMA Neurol 2022; 79:664-671. [PMID: 35666526 PMCID: PMC9171657 DOI: 10.1001/jamaneurol.2022.1070] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Importance Trials often assess primary outcomes of traumatic brain injury at 6 months. Longer-term data are needed to assess outcomes for patients receiving surgical vs medical treatment for traumatic intracranial hypertension. Objective To evaluate 24-month outcomes for patients with traumatic intracranial hypertension treated with decompressive craniectomy or standard medical care. Design, Setting, and Participants Prespecified secondary analysis of the Randomized Evaluation of Surgery With Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) randomized clinical trial data was performed for patients with traumatic intracranial hypertension (>25 mm Hg) from 52 centers in 20 countries. Enrollment occurred between January 2004 and March 2014. Data were analyzed between 2018 and 2021. Eligibility criteria were age 10 to 65 years, traumatic brain injury (confirmed via computed tomography), intracranial pressure monitoring, and sustained and refractory elevated intracranial pressure for 1 to 12 hours despite pressure-controlling measures. Exclusion criteria were bilateral fixed and dilated pupils, bleeding diathesis, or unsurvivable injury. Interventions Patients were randomly assigned 1:1 to receive a decompressive craniectomy with standard care (surgical group) or to ongoing medical treatment with the option to add barbiturate infusion (medical group). Main Outcomes and Measures The primary outcome was measured with the 8-point Extended Glasgow Outcome Scale (1 indicates death and 8 denotes upper good recovery), and the 6- to 24-month outcome trajectory was examined. Results This study enrolled 408 patients: 206 in the surgical group and 202 in the medical group. The mean (SD) age was 32.3 (13.2) and 34.8 (13.7) years, respectively, and the study population was predominantly male (165 [81.7%] and 156 [80.0%], respectively). At 24 months, patients in the surgical group had reduced mortality (61 [33.5%] vs 94 [54.0%]; absolute difference, -20.5 [95% CI, -30.8 to -10.2]) and higher rates of vegetative state (absolute difference, 4.3 [95% CI, 0.0 to 8.6]), lower or upper moderate disability (4.7 [-0.9 to 10.3] vs 2.8 [-4.2 to 9.8]), and lower or upper severe disability (2.2 [-5.4 to 9.8] vs 6.5 [1.8 to 11.2]; χ27 = 24.20, P = .001). For every 100 individuals treated surgically, 21 additional patients survived at 24 months; 4 were in a vegetative state, 2 had lower and 7 had upper severe disability, and 5 had lower and 3 had upper moderate disability, respectively. Rates of lower and upper good recovery were similar for the surgical and medical groups (20 [11.0%] vs 19 [10.9%]), and significant differences in net improvement (≥1 grade) were observed between 6 and 24 months (55 [30.0%] vs 25 [14.0%]; χ22 = 13.27, P = .001). Conclusions and Relevance At 24 months, patients with surgically treated posttraumatic refractory intracranial hypertension had a sustained reduction in mortality and higher rates of vegetative state, severe disability, and moderate disability. Patients in the surgical group were more likely to improve over time vs patients in the medical group. Trial Registration ISRCTN Identifier: 66202560.
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Affiliation(s)
- Angelos G. Kolias
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge, United Kingdom,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Hadie Adams
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge, United Kingdom,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ivan S. Timofeev
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge, United Kingdom,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth A. Corteen
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge, United Kingdom,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Iftakher Hossain
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge, United Kingdom,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jake Timothy
- Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom
| | - Ian Anderson
- Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom
| | | | - Antonio Belli
- University of Birmingham, Birmingham, United Kingdom
| | - C. Andrew Eynon
- University Hospital Southampton, Southampton, United Kingdom
| | - John Wadley
- Department of Neurosurgery, Royal London Hospital, London, United Kingdom
| | - A. David Mendelow
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom
| | - Patrick M. Mitchell
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom
| | - Mark H. Wilson
- Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St Mary’s Hospital, London, United Kingdom
| | - Giles Critchley
- Department of Neurosurgery, University Hospitals Sussex, Brighton, United Kingdom
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jussi P. Posti
- Department of Neurosurgery and Turku Brain Injury Centre, Turku University Hospital, University of Turku, Turku, Finland
| | - Franco Servadei
- Department of Biomedical Science, Humanitas University, Milan, Italy,Department of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico Humanitas Research Hospital, Milan, Italy
| | | | - John D. Pickard
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge, United Kingdom,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - David K. Menon
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge, United Kingdom,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Gordon D. Murray
- Department of Community Health Sciences, Usher Institute, University of Edinburgh Medical School, Edinburgh, Scotland
| | | | - Peter J. Hutchinson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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Ammar R, Chelly H, Kolsi F, Smaoui M, Hamida CB, Bahloul M, Boudawara Z, Bouaziz M. Decompressive craniectomy after traumatic brain injury: An observational study of 147 patients admitted in a Tunisian ICU. Interdisciplinary Neurosurgery 2022. [DOI: 10.1016/j.inat.2021.101421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Rubiano AM, Griswold DP, Adelson PD, Echeverri RA, Khan AA, Morales S, Sánchez DM, Amorim R, Soto AR, Paiva W, Paranhos J, Carreño JN, Monteiro R, Kolias A, Hutchinson PJ. International Neurotrauma Training Based on North-South Collaborations: Results of an Inter-institutional Program in the Era of Global Neurosurgery. Front Surg 2021; 8:633774. [PMID: 34395505 PMCID: PMC8358677 DOI: 10.3389/fsurg.2021.633774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 07/05/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Shortage of general neurosurgery and specialized neurotrauma care in low resource settings is a critical setback in the national surgical plans of low and middle-income countries (LMIC). Neurotrauma fellowship programs typically exist in high-income countries (HIC), where surgeons who fulfill the requirements for positions regularly stay to practice. Due to this issue, neurosurgery residents and medical students from LMICs do not have regular access to this kind of specialized training and knowledge-hubs. The objective of this paper is to present the results of a recently established neurotrauma fellowship program for neurosurgeons of LMICs in the framework of global neurosurgery collaborations, including the involvement of specialized parallel education for neurosurgery residents and medical students. Methods: The Global Neurotrauma Fellowship (GNTF) program was inaugurated in 2015 by a multi-institutional collaboration between a HIC and an LMIC. The course organizers designed it to be a 12-month program based on adapted neurotrauma international competencies with the academic support of the Barrow Neurological Institute at Phoenix Children's Hospital and Meditech Foundation in Colombia. Since 2018, additional support from the UK, National Institute of Health Research (NIHR) Global Health Research in Neurotrauma Project from the University of Cambridge enhanced the infrastructure of the program, adding a research component in global neurosurgery and system science. Results: Eight fellows from Brazil, Venezuela, Cuba, Pakistan, and Colombia have been trained and certified via the fellowship program. The integration of international competencies and exposure to different systems of care in high-income and low-income environments creates a unique environment for training within a global neurosurgery framework. Additionally, 18 residents (Venezuela, Colombia, Ecuador, Peru, Cuba, Germany, Spain, and the USA), and ten medical students (the United Kingdom, USA, Australia, and Colombia) have also participated in elective rotations of neurotrauma and critical care during the time of the fellowship program, as well as in research projects as part of an established global surgery initiative. Conclusion: We have shown that it is possible to establish a neurotrauma fellowship program in an LMIC based on the structure of HIC formal training programs. Adaptation of the international competencies focusing on neurotrauma care in low resource settings and maintaining international mentoring and academic support will allow the participants to return to practice in their home-based countries.
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Affiliation(s)
- Andrés M. Rubiano
- INUB-Meditech Research Group, Neuroscience Institute, Universidad El Bosque, Bogota, Colombia
- Meditech Foundation, Valle-Salud IPS Clinical Network, Cali, Colombia
- Division of Neurosurgery, National Institute of Health Research (NIHR) Global Health Research Group in Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
| | - Dylan P. Griswold
- Division of Neurosurgery, National Institute of Health Research (NIHR) Global Health Research Group in Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - P. David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Raul A. Echeverri
- Meditech Foundation, Valle-Salud IPS Clinical Network, Cali, Colombia
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
| | - Ahsan A. Khan
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
- Neurological Surgery Service, Aga Khan University, Karachi, Pakistan
| | - Santiago Morales
- Meditech Foundation, Valle-Salud IPS Clinical Network, Cali, Colombia
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
| | - Diana M. Sánchez
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
- Neurosurgery Training Program, Universidad de Ciencias Médicas, Havana, Cuba
| | - Robson Amorim
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
- Neurosurgery Program, Federal University of Amazonas, Manaus, Brazil
| | - Alvaro R. Soto
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
- Neurosurgery Service, UROS Clinic, Neiva, Colombia
| | - Wellingson Paiva
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
- Neurosurgery Service, University of São Paulo Medical School, São Paulo, Brazil
| | - Jorge Paranhos
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
- Neurosurgery Service, Hospital Santa Casa, Sao Joao del Rei, Brazil
| | - José N. Carreño
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
- Neurosurgery Service, Santa Fe Foundation Hospital, Bogota, Colombia
| | - Ruy Monteiro
- Meditech Foundation, Neurotrauma and Global Surgery Fellowship Program, Cali, Colombia
- Neurosurgery Service, Hospital Miguel Couto, Rio de Janeiro, Brazil
| | - Angelos Kolias
- Division of Neurosurgery, National Institute of Health Research (NIHR) Global Health Research Group in Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Division of Neurosurgery, National Institute of Health Research (NIHR) Global Health Research Group in Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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Iaccarino C, Lippa L, Munari M, Castioni CA, Robba C, Caricato A, Pompucci A, Signoretti S, Zona G, Rasulo FA. Management of intracranial hypertension following traumatic brain injury: a best clinical practice adoption proposal for intracranial pressure monitoring and decompressive craniectomy. Joint statements by the Traumatic Brain Injury Section of the Italian Society of Neurosurgery (SINch) and the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). J Neurosurg Sci 2021; 65:219-238. [PMID: 34184860 DOI: 10.23736/s0390-5616.21.05383-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.
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Affiliation(s)
- Corrado Iaccarino
- Division of Neurosurgery, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
| | - Laura Lippa
- Department of Neurosurgery, Ospedali Riuniti di Livorno, Livorno, Italy -
| | - Marina Munari
- Department of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Carlo A Castioni
- Department of Anesthesia and Intensive Care, IRCCS Istituto delle Scienze Neurologiche Bellaria Hospital, Bologna, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS San Martino University Hospital, Genoa, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Angelo Pompucci
- Department of Neurosurgery, S. Maria Goretti Hospital, Latina, Italy
| | - Stefano Signoretti
- Division of Emergency-Urgency, Unit of Neurosurgery, S. Eugenio Hospital, Rome, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, IRCCS San Martino University Hospital, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Frank A Rasulo
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University Hospital, Brescia, Italy.,Department of Surgical and Medical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Chakravarthi SS, Lyons L, Orozco AR, Verhey L, Mazaris P, Zacharia J, Singer JA. Combined Decompressive Hemicraniectomy and Port-Based Minimally Invasive Parafascicular Surgery for the Treatment of Subcortical Intracerebral Hemorrhage: Case Series, Technical Note, and Review of Literature. World Neurosurg 2020; 146:e1226-e1235. [PMID: 33271377 DOI: 10.1016/j.wneu.2020.11.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a neurosurgical emergency. Combined decompressive hemicraniectomy (DHC) and minimally invasive parafascicular surgery (MIPS) may provide a practical method of managing subcortical ICH. OBJECTIVE 1) To present a case series of combined DHC-MIPS for the treatment of subcortical-based ICH; 2) to describe technical nuances of DHC-MIPS; and 3) to provide a literature overview of MIPS for ICH. METHODS The following inclusion criteria were used: 1) Glasgow Coma Scale (GCS) score <3-4; 2) admission within 6 hours of onset; 3) increased intracranial pressure caused by hemorrhage; 4) patient unresponsive to medical management; 5) hemorrhage >30 cm3; 6) subcortical location; and 7) midline shift (mm). Before DHC, sulcal cannulation used the following coordinates: intersection of tragus-frontal bone and midpoint of midpupillary line and midline; coronal suture: 3-4 cm posterior to this point). RESULTS Three patients were selected: a 62-year old woman, a 45-year old woman, and a 36-year-old man. GCS and ICH scores on admission were 7 and 3, 3 and 4, and 3 and 4, respectively. ICH was located in left basal ganglia in patients 1 and 3 and right basal ganglia in patient 2, all with intraventricular extension. ICH volume was 81.7, 68.2, and 42.3 cm3, respectively. The postoperative GCS score was 11, 10, and 6, respectively. There were no intraoperative complications or mortalities. Evacuation was within 15 minutes in all patients. The modified Rankin Scale score was 3, 4, and 5, respectively, with semi-independence in case 1. CONCLUSIONS Combined DHC-MIPS, with the use of craniometric points, can provide a unique and simple surgical option for the management of subcortical ICH.
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Affiliation(s)
- Srikant S Chakravarthi
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Leah Lyons
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Andres Restrepo Orozco
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Leonard Verhey
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Paul Mazaris
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Joseph Zacharia
- Department of Neurocritical Care, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Justin A Singer
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA.
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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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