Craniectomy For Traumatic Brain Injury Research Articles

Cisternostomy associated with decompressive craniectomy for traumatic brain injury: a systematic review and meta-analysis.

Decompressive craniectomy (DC) has been the main surgical treatment of refractory high intracranial pressure (ICP) in traumatic brain injury (TBI) for decades. Basal cisternostomy emerged as a novel option in brain trauma, with results still unclear. We performed a systematic review and meta-analysis comparing cisternostomy added to conventional DC versus DC alone for the treatment of TBI. This study was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Three databases were systematically searched for studies comparing cisternostomy + DC versus DC alone. Primary outcomes were overall mortality, length of stay in ICU care, duration of mechanical ventilation. Review Manager was used for statistical analysis and I2 measured heterogeneity. A total of seven studies and 980 patients were included in this meta-analysis, 473 in the cisternostomy + DC group and 507 in the DC group. Age ranged from 14 to 69 years old, with 76% male patients. Overall mortality was significantly lower in the cisternostomy + DC group (OR 0.70; 95% CI 0.53-0.92; p = 0.01; I2 = 31%). Length of stay in ICU care was significantly reduced in the patients submitted to cisternostomy + DC (OR -4.58; CI -6.78, -2.37); p < 0.0001; I2 = 35%). The mean duration in mechanical ventilation was significantly lower in the group submitted to cisternostomy + DC (-3.49; 95% CI-6.79, -0.20; p = 0.04; I2 = 86%). Regarding functional outcomes, the scarce and heterogeneous data were not sufficient to make any conclusion about the effect of cisternostomy on functional outcomes, but tends to favor patients who underwent cisternostomy combined with DC. In this meta-analysis, the implementation of cisternostomy added to conventional DC was associated with lower mortality, days in mechanical ventilation and length of stay in ICU care. Larger prospective and randomized cohorts are necessary to recommend this procedure on a large scale.

Random Forest Prognostication of Survival and 6-Month Outcome In Pediatric Patients Following Decompressive Craniectomy For Traumatic Brain Injury

There is a dearth of literature regarding prognostic and predictive factors for outcome following pediatric decompressive craniectomy (DC) following traumatic brain injury (TBI). The aim of this study was to develop a random forest machine learning algorithm to predict outcomes following DC in pediatrics. This is a multi-institutional retrospective study assessing the 6-month postoperative outcome in pediatric patients that underwent DC. We developed a machine learning model using classification and survival random forest algorithms (CRF and SRF respectively) for the prediction of outcomes. Data was collected on clinical signs, radiographic studies, and laboratory studies. The outcome measures for the CRF were mortality and good or bad outcome based on Glasgow Outcome Scale (GOS) at 6-months. A GOS score of 4 or higher indicated a good outcome. The outcomes for the SRF model assessed mortality at during the follow-up period. A total of 40 pediatric patients were included. There was a hospital mortality rate of 27.5%, and 75.8% of survivors had a good outcome at 6-month follow up. The CRF for 6-month mortality had a ROC AUC of 0.984; whereas, the 6-month good/bad outcome had a ROC AUC of 0.873. The SRF was trained at the 6-month timepoint with a ROC AUC of 0.921. CRF and SRF models successfully predicted 6-month outcomes and mortality following DC in pediatric TBI patients. These results suggest random forest models may be efficacious for predicting outcome in this patient population.

Effects of Early and Late Cranioplasty on Neurocognitive Outcome and Cerebral Glucose Metabolism using PET Scan - A Comparative Study.

Brain protection and cosmetic aspects are the major indications of cranioplasty (CP) after decompressive craniectomy. CP can avoid the recurrence of brain damage, achieve the plastic effect, protect the patient from seizures, and relieve the syndrome of trephine. This was a prospective, observational study done over a period of 2 years from April 2017 to April 2019 in the Department of Neurosurgery at Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati. Patients of age group 20-60 years who underwent CP after decompressive craniectomy for traumatic brain injury or cerebrovascular accidents with refractory intracranial hypertension were included. The study population was divided into two groups: early and late CP groups. Neurocognitive assessment was done 72 h before and 3 months after CP by mini-mental state examination (MMSE), Glasgow outcome score (GOS), and PGI battery of brain dysfunction (PGIBBD) scores. Cerebral glucose metabolism was assessed by 18F-FDG PET scan. In both early and late CP groups, there was a highly significant difference between the mean pre- and postoperative values of MMSE, GOS, and PGIBBD, suggesting significant improvement in neurocognitive parameters of patients postoperatively. There was no significant difference between early and late CP groups for mean standard uptake values (SUVs) on PET scan for both affected (P-value- 0.40) and nonaffected (P-value- 0.30) sides. CP improves the cerebral metabolism and neurocognitive outcome, weather it is done early or late.

Posttraumatic Hydrocephalus Following Decompressive Craniectomy in Traumatic Brain Injury: Proportion and Risk Factors

Abstract Background Posttraumatic hydrocephalus (PTH) is an important cause of morbidity after decompressive craniectomy (DC) following traumatic brain injury (TBI). Early diagnosis and treatment of PTH can prevent further neurological compromise in patients who are recovering from TBI. Objective The aim of this study was to assess the proportion of patients who develop hydrocephalus after undergoing DC and to identify the factors associated with PTH requiring surgical treatment in patients undergoing DC for TBI. Methods Data of patients undergoing DC for TBI in the Trauma Neurosurgery Unit, Medical College Hospital, Trivandrum, between June and December 2020 were collected prospectively. Results A total of 48 patients who underwent DC were studied. Six (12.5%) patients developed PTH. The patients were divided into two groups: PTH (patients who developed hydrocephalus) and non-PTH (patients who did not develop hydrocephalus). Age, sex, mode of injury, severity of injury, and preoperative radiological findings were not associated with the development of PTH. A distance of craniectomy margin from the midline of less than 2.5 cm was found to be statistically significant. No statistical difference was found in the outcome among the PTH and non-PTH groups. Conclusion Craniectomy with a superior limit too close to the midline can predispose patients undergoing DC to the development of hydrocephalus. We therefore suggest performing wide DCs with the superior limit greater than 25 mm from the midline.

441 Glasgow Coma Scale Motor Score Predicts Need for Tracheostomy After Decompressive Craniectomy for Traumatic Brain Injury

INTRODUCTION: Traumatic brain injury (TBI) is a common problem worldwide. Severe TBI is sometimes treated with decompressive craniectomy. Many patients who survive require tracheostomy. The decision to proceed with tracheostomy and at what time is often ambiguous. Existing methods for predicting which patients with neurologic insult will require tracheostomy are aimed at stroke and spontaneous intracranial hemorrhage (ICH). METHODS: We performed a retrospective review of adult patients who underwent decompressive craniectomy for severe TBI at the University of Kansas Medical Center between 2007 and 2020. RESULTS: 100% of patients who have GCS motor score of 4 or less on POD 5 required tracheostomy. 80% of patients with GCS motor score of 5 on POD 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending proceeding with tracheostomy results in 86.7% sensitivity, 91.7% specificity, and 90.5% PPV with area under the receiver operator curve of 0.9101. CONCLUSIONS: GCS motor score of 5 or less on POD 5 from decompressive craniectomy for TBI is predictive of need for tracheostomy.

Early versus delayed cranioplasty after decompressive craniectomy in traumatic brain injury: a multicenter observational study within CENTER-TBI and Net-QuRe.

The aim of this study was to compare the outcomes of early (≤ 90 days) and delayed (> 90 days) cranioplasty following decompressive craniectomy (DC) in patients with traumatic brain injury (TBI). The authors analyzed participants enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and the Neurotraumatology Quality Registry (Net-QuRe) studies who were diagnosed with TBI and underwent DC and subsequent cranioplasty. These prospective, multicenter, observational cohort studies included 5091 patients enrolled from 2014 to 2020. The effect of cranioplasty timing on functional outcome was evaluated with multivariable ordinal regression and with propensity score matching (PSM) in a sensitivity analysis of functional outcome (Glasgow Outcome Scale-Extended [GOSE] score) and quality of life (Quality of Life After Brain Injury [QOLIBRI] instrument) at 12 months following DC. Among 173 eligible patients, 73 (42%) underwent early cranioplasty and 100 (58%) underwent delayed cranioplasty. In the ordinal logistic regression and PSM, similar 12-month GOSE scores were found between the two groups (adjusted odds ratio [aOR] 0.87, 95% CI 0.61-1.21 and 0.88, 95% CI 0.48-1.65, respectively). In the ordinal logistic regression, early cranioplasty was associated with a higher risk for hydrocephalus than that with delayed cranioplasty (aOR 4.0, 95% CI 1.2-16). Postdischarge seizure rates (early cranioplasty: aOR 1.73, 95% CI 0.7-4.7) and QOLIBRI scores (β -1.9, 95% CI -9.1 to 9.6) were similar between the two groups. Functional outcome and quality of life were similar between early and delayed cranioplasty in patients who had undergone DC for TBI. Neurosurgeons may consider performing cranioplasty during the index admission (early) to simplify the patient's chain of care and prevent readmission for cranioplasty but should be vigilant for an increased possibility of hydrocephalus. Clinical trial registration nos.: CENTER-TBI, NCT02210221 (clinicaltrials.gov); Net-QuRe, NTR6003 (trialsearch.who.int) and NL5761 (onderzoekmetmensen.nl).

Prolonged course of brain edema and neurological recovery in a translational model of decompressive craniectomy after closed head injury in mice.

The use of decompressive craniectomy in traumatic brain injury (TBI) remains a matter of debate. According to the DECRA trial, craniectomy may have a negative impact on functional outcome, while the RescueICP trial revealed a positive effect of surgical decompression, which is evolving over time. This ambivalence of craniectomy has not been studied extensively in controlled laboratory experiments. The goal of the current study was to investigate the prolonged effects of decompressive craniectomy (both positive and negative) in an animal model. Male mice were assigned to the following groups: sham, decompressive craniectomy, TBI and TBI followed by craniectomy. The analysis of functional outcome was performed at time points 3d, 7d, 14d and 28d post trauma according to the Neurological Severity Score and Beam Balance Score. At the same time points, magnetic resonance imaging was performed, and brain edema was analyzed. Animals subjected to both trauma and craniectomy presented the exacerbation of the neurological impairment that was apparent mostly in the early course (up to 7d) after injury. Decompressive craniectomy also caused a significant increase in brain edema volume (initially cytotoxic with a secondary shift to vasogenic edema and gliosis). Notably, delayed edema plus gliosis appeared also after decompression even without preceding trauma. In prolonged outcomes, craniectomy applied after closed head injury in mice aggravates posttraumatic brain edema, leading to additional functional impairment. This effect is, however, transient. Treatment options that reduce brain swelling after decompression may accelerate neurological recovery and should be explored in future experiments.

Glasgow Coma Scale Motor Score Predicts Need for Tracheostomy After Decompressive Craniectomy for Traumatic Brain Injury.

Many patients with severe traumatic brain injury (TBI) require a tracheostomy after decompressive craniectomy. Determining which patients will require tracheostomy is often challenging. The existing methods for predicting which patients will require tracheostomy are more applicable to stroke and spontaneous intracranial hemorrhage. The aim of this study was to investigate whether the Glasgow Coma Scale (GCS) motor score can be used as a screening method for predicting which patients who undergo decompressive craniectomy for severe TBI are likely to require tracheostomy. The neurosurgery census at the University of Kansas Medical Center was retrospectively reviewed to identify adult patients aged over 18 years who underwent decompressive craniectomy for TBI. Eighty patients met the inclusion criteria for the study. There were no exclusion criteria. The primary outcome of interest was the need for tracheostomy. The secondary outcome was the comparison of the total length of stay (LOS) and intensive care unit LOS between the early and late tracheostomy patient groups. All patients (100%) with a GCS motor score of 4 or less on post operative (POD) 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending tracheostomy resulted in 86.7% sensitivity, 91.7% specificity, and 90.5% positive predictive value, with an area under the receiver operator curve of 0.9101. GCS motor score of 5 or less on POD 5 of decompressive craniectomy is a useful screening threshold for selecting patients who may benefit from tracheostomy, or may be potential candidates for extubation.

Early Versus Late Cranioplasty After Decompressive Craniectomy In Traumatic Brain Injury

Early Versus Late Cranioplasty After Decompressive Craniectomy In Traumatic Brain Injury

Surgical Outcome of Decompressive Craniectomy in Traumatic Brain Injury: A study in a Tertiary Care Hospital of Bangladesh

Background: Traumatic Head injury is one of the most important causes of death. Decompressive craniectomy is said to be the best way to reduce otherwise intractable intracranial pressure and its complications in traumatic brain injury (TBI). But we have not enough information regarding the outcomes and effectiveness of decompressive craniectomy in TBI. Objectives: The aim was to assess the outcomes and effectiveness of decompressive craniectomy in TBI. Materials and Methods: Prospective observational study which conducted in Khwaja Yunus Ali Medical College and Hospital, Sirajganj and TMSS Medical College &amp; Hospital, Bogura, Bangladesh in collaboration with the Department of Neurosurgery, from July 2018 to December 2021. Total 32 patients with severe TBI diagnosed and treated in those hospitals who recruited as the samples and outcomes of the patients evaluated through Glasgow Coma Scale (on which scores range from 3 to 15, lower scores indicating reduced levels of consciousness). All patient data were collected, processed, analyzed then disseminated by using MS Office 2019 and SPSS version 23 programs. Results: Analyzing hospital staying we observed, the mean (±SD) days of mechanical ventilation, days of ICU staying, days of hospitalization were 8.88 ± 2.54, 10.21 ± 3.16 and 15.57 ± 4.51 days respectively. Finally, the mean (±SD) Extended Glasgow Outcome Scale score of all the patients was found as 9.1. and unfavorable Extended Glasgow Outcome Scale score (1 to 4) was found in 56% patients. In this study, finally death cases were 22%. Conclusion: Decompressive craniectomy ensures better outcome for survival but the limitation is quality of life issues after survival especially among poor GCS (3-6) group. Prompt hospitalization, early diagnosis, proper ICU and ventilation facilities can ensure more satisfactory outcomes in TBI. KYAMC Journal Vol. 13, No. 03, October 2022: 153-157

Patient Outcomes following Immediate Tracheostomy and Emergency Decompressive Craniectomy in the Same Setting

Early tracheostomy is recommended for patients with severe traumatic brain injury or stroke. Tracheostomy in the same setting as emergency decompressive craniectomy, on the other hand, has never been investigated. Our goal was to compare the outcomes related to the duration of mechanical ventilation in patients who had immediate (IT) vs. early (ET) tracheostomy following an emergency decompressive craniectomy in a Neurosurgical centre in Sabah, Malaysia. We reviewed 135 patients who underwent emergency decompressive craniectomy for traumatic brain injury (TBI) and stroke patients between January 2013 and January 2018 in this retrospective cohort study. The cohort included 49 patients who received immediate tracheostomy (IT), while the control group included 86 patients who received a tracheostomy within 7 days of decompressive surgery (ET). The duration of mechanical ventilation, length of stay (LOS) in the critical-care unit, and intravenous sedation were significantly shorter in the IT group compared to the ET group, according to the study. There was no significant difference between the two groups in the incidence of ventilator-associated pneumonia (VAP), tracheostomy-related complications, or 30-day mortality rate. In conclusion, compared to early tracheostomy, immediate tracheostomy in the same setting as emergency decompressive craniectomy is associated with a shorter duration of mechanical ventilation and LOS in critical-care units with acceptable morbidity and mortality rates. This practise could be used in busy centres with limited resources, such as those where mechanical ventilators, critical-care unit beds, or OT wait times are an issue.

Outcome of Decompressive Craniectomy for Traumatic Brain Injury: Ways to Better Evaluate Functional Outcome

Outcome of Decompressive Craniectomy for Traumatic Brain Injury: Ways to Better Evaluate Functional Outcome

Predictive factors for bone flap infection after cranioplasty

Bone flapinfection is often experienced as a complication of cranioplasty.The aim of this study was to investigate predictors of graft infection,including patient-specific and surgery-specific factors. We retrospectively reviewed cases at our institutionwho underwent cranioplasty following craniectomyfor traumatic brain injury, epidural hematoma, subdural hematoma, intracranial hemorrhage, cerebral infarction, subarachnoid hemorrhage, arteriovenous malformation, and bone flap infection after craniotomy. A total of 192 patients were included in this analysis.The graft infection rate was 8.3% (16/192).Smoking(odds ratio [OR] 3.09, 95% confidence interval [CI] 1.03–12.24; p = 0.04), allergy (OR 6.15, 95% CI 1.50–17.31; p < 0.01),and body temperature on postoperative day 1(OR 2.57, 95% CI 1.14–5.78; p = 0.02) were found to be independent predictors forgraft infection.Based on receiver operating characteristic analysis, a body temperature on postoperative day 1 higher than 38.0 °C was selected as the optimal cut-off value for predicting infection after cranioplasty. The sensitivity and specificity were 68% and 72%, respectively. Smoking, allergy, and body temperature on postoperative day 1predicted complications leading to graft infection. Patients with a fever of 38 °C or higher on day 1 after cranioplasty should be carefully monitored for graft infection.

Nomogram for predicting post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury.

This study aimed to develop and validate a practical nomogram to predict the occurrence of post-traumatic hydrocephalus in patients who have undergone decompressive craniectomy for traumatic brain injury. A total of 516 cases were enrolled and divided into the training (n=364) and validation (n=152) cohorts. Optimal predictors were selected through least absolute shrinkage and selection operator regression analysis of the training cohort then used to develop a nomogram. Receiver operating characteristic, calibration plot, and decision curve analysis, respectively, were used to evaluate the discrimination, fitting performance, and clinical utility of the resulting nomogram in the validation cohort. Preoperative subarachnoid hemorrhage Fisher grade, type of decompressive craniectomy, transcalvarial herniation volume, subdural hygroma, and functional outcome were all identified as predictors and included in the predicting model. The nomogram exhibited good discrimination in the validation cohort and had an area under the receiver operating characteristic curve of 0.80 (95%CI 0.72-0.88). The calibration plot demonstrated goodness-of-fit between the nomogram's prediction and actual observation in the validation cohort. Finally, decision curve analysis indicated significant clinical adaptability. The present study developed and validated a model to predict post-traumatic hydrocephalus. The nomogram that had good discrimination, calibration, and clinical practicality can be useful for screening patients at a high risk of post-traumatic hydrocephalus. The nomogram can also be used in clinical practice to develop better therapeutic strategies.

Effects of two different doses of 3% hypertonic saline with mannitol during decompressive craniectomy following traumatic brain injury: A prospective, controlled study.

Background and Aims:The current study was designed to compare the effects of two different doses of 3% hypertonic saline with mannitol on intraoperative events during decompressive craniectomy in traumatic brain injury (TBI). Primary outcome measures included assessment of intraoperative brain relaxation, hemodynamic variables, and serum electrolytes. Effect on the postoperative outcome, in terms of the Glasgow coma scale (GCS), length of stay in the ICU, and mortality were the secondary outcome measures.Material and Methods:Ninety patients with TBI undergoing craniotomy were enrolled. Patients were assigned to receive 300 mL (328 mOsm) of mannitol (n = 26, M) only or 300 mL of mannitol with 150 mL (482 mOsm) of 3% HS (n = 35, HS1) or with 300 mL (636 mOsm) of 3% HS (n = 29, HS2). Brain relaxation was assessed and if required, a rescue dose of mannitol (150 mL) was given. GCS was assessed preoperatively, 24 h postoperatively, and at the time of discharge from the ICU and total duration of stay was noted.Results:Acceptable brain relaxation was observed in 89.66% (n = 26, HS2) and 80% (n = 28, HS1) patients as compared to 46.1% (n = 12, M) patients (P < 0.001) with significantly less number of patients requiring rescue doses of mannitol in groups HS1 and HS2(n = 7 and 3, respectively) as compared to group M (n = 14) (P < 0.05). There was a significant improvement in GCS at 24 h and at the time of discharge from the ICU in patients with a severe head injury in group HS2 (P = 0.029). In patients with moderate head injury there was a significant improvement in GCS at the time of discharge among all the three groups (P < 0.05).Conclusion:Increasing osmotic load by addition of 3% HS to mannitol provides better intraoperative brain relaxation than mannitol alone during decompressive craniectomy. An addition of 300mL 3% HS was found to be more effective in improving GCS in patients with severe TBI.

In Reply to the Letter to the Editor Regarding “Decompressive Craniectomy in Traumatic Brain Injury—Craniectomy-Related and Cranioplasty-Related Complications in a Single Center”

Low-middle-income countries (LMICs) share a substantial proportion of global surgical complications. This is compounded by the seemingly deficient documentation of postsurgical complications and the lack of a national average for comparison. In this context, the implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) that compares hospital performance based on postsurgical complication data provided by a wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of the NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To our knowledge, this report is the first from an LMIC to report its postoperative neurosurgical complications in comparison with international benchmarks.Our hospital joined the NSQIP in 2019. Through a standardized ACS protocol, ACS-trained surgical clinical reviewers (SCRs) reviewed and extracted data from randomly assigned neurosurgical patients’ medical records from preoperative to postoperative (30-day) data using validated, standardized data definitions. SCRs entered deidentified data in an online Health Insurance Portability and Accountability Act web-based secure platform. The validated data were then consigned to the ACS NSQIP head office in the United States where the data were analyzed and compared with similar data from other centers registered with the NSQIP. In this way, our hospital was rated for each of the variables related to postsurgical complications after both spinal and cranial procedures, and the results were sent back to us in the form of text, tables, and graphs.Our initial report suggested a relatively higher odds ratio for sepsis and readmissions after spinal procedures at our hospital, and a similarly higher odds ratio for morbidity, sepsis, urinary tract infection, and surgical site infection for cranial procedures. For these variables, our hospital fell in the needs improvement category of the NSQIP. For the rest of the variables studied for both spinal and cranial procedures, the hospital fell in the as expected category of the NSQIP.Implementation of the NSQIP is an important first step in creating a culture of transparency, safety, and quality. This is the first report of NSQIP implementation in an LMIC, and we have shown comparable results to developed countries.

Decompressive craniectomy for traumatic brain injury: outcomes and their determinants

Decompressive craniectomy (DC) is a management option to control raised Intracranial pressure (ICP) in Traumatic Brain Injury (TBI) with inconsistent evidence for its outcomes and their determinants. The aim of this study was to assess the outcomes and determinants of outcomes of DC done in National Hospital of Sri Lanka (NHSL) at one year and three years of follow-up. Patients who underwent DC for TBI within 6 months period from 01/02/2016 to 31/07/2016 at Neurotrauma Centre, NHSL were included in the study. Data were retrieved from medical records. Outcomes were evaluated by interviewing patients/relatives over the telephone using standard questionnaire for extended Glasgow Outcome scale (GOS-E). Inclusion and exclusion criteria matched 118 patients were selected and 89 (75.42%) contactable patients were included in the analysis. Majority (86.4%) were males and median age was 45 years. There were 56 primary DCs and 33 secondary DCs. Favorable outcomes (GOS-E 5-8) were seen in 20.2% and in 24.7% at the end of one year and three years respectively. Younger age, good pupillary reaction and higher GCS on admission were associated with statistically significant favorable outcomes (P<0.05). Pupillary symmetry, timing of DC (primary or secondary), time elapsed from time of injury to performing primary DC, type of DC, whether CT shows an isolated lesion or multiple lesions, submission to tracheostomy, having medical comorbidities and post-operative infections were not predictive of the outcome. Favorable functional outcomes following DC for TBI is limited to 20-25%. Younger age, good pupillary reaction and higher GCS are predictors of favorable functional outcomes.

Surgical Site Infection After Autologous Cranioplasty for Decompressive Craniectomy in Traumatic Brain Injury: A Retrospective Review of Two Level 1 Trauma Centers.

Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI). A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05. A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate. The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible.

Cosmetic results of autologous bone cranioplasty after decompressive craniectomy for traumatic brain injury based on a patient questionnaire

BackgroundDecompressive craniectomy (DC) after traumatic brain injury (TBI) is a common surgical procedure. Cranioplasty (CP) is undertaken as a routine secondary operation following DC. In neurosurgical trauma centers, patients who require CPs compete with other patients who require emergency neurosurgical intervention and they are not given enough priority. MethodsA retrospective study was conducted of patients who had undergone autologous bone CP after DC for TBI over three years in a 3rd level trauma center in Mexico. All families were administered a questionnaire to assess how the patient judged the cosmetic result of CP. ResultsA total of 29 patients agreed to participate in this study. 25 patients (86.2%) were satisfied with the aesthetic result and 4 patients (13.8%) were no satisfied with their CP. 4 cases (13.8%) reported medical complications related to CP. Unsatisfied patients complained most likely about the dented aesthetic look, with a moderate negative correlation between this and cosmetic outcome (ρ = −0.483, P = 0.001). Patient age (ρ = 0.194, P = 0.314) and defect size (ρ = 0.156, P = 0.419) was not related to the assessment of the aesthetic result. A strong negative correlation between postoperative infection and the grade of satisfaction (ρ = −0.710, P = 0.001) was also observed. ConclusionsBased on our results, overall most of the patients were satisfied with their CP with an acceptable complication rate.

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.