Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study

On Behalf Of The Center-Tbi Investigators And Participants ,Thomas A Van Essen,Wilco C Peul,Suzanne Polinder,David Menon,Andrew I R Maas,Hugo F Den Boogert,Godard C W De Ruiter,Ewout W Steyerberg,Hester F Lingsma,Maryse C Cnossen,Iain Haitsma

doi:10.1007/s00701-018-3761-z

Abstract

BackgroundNeurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe.MethodsA survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP).ResultsThe survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions.ConclusionDespite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care.

Highlights

Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence
The aim of this study was to explore differences in neurosurgical strategies for TBI across Europe to provide a context for CENTER-TBI, an up-to-date insight into European neurosurgical management of TBI, and to identify naturally occurring variation between trauma centers in order to identify substrates for neurosurgical research questions that might be answered using comparative effectiveness research (CER) in the study
Questionnaires were mainly completed by neurosurgeons (n = 53, 78%), followed by local CENTER-TBI investigators

Summary

Introduction

Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. The reported cut-off ICP for DC in refractory high ICP, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, for the threshold for ASDH surgery and DC for refractory raised ICP. Within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions

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