Primary Decompressive Craniectomy Research Articles

Degree of basal cisterns compression predicting mortality and functional outcome after craniotomy and primary decompressive craniectomy in acute subdural hematoma population.

The compression of basal cisterns on CT is one of the signs of intracranial hypertension in TBI population. This study evaluates the relationship between the degree of basal cisterns effacement and outcomes in aSDH population. The study includes prospectively collected data from 290 patients who underwent osteoplastic craniotomy (OC) or primary decompressive craniectomy (pDC) for aSDH from 2016 to 2021. Univariate and multivariate regression analyses were performed to evaluate the association of baseline characteristics and extent of basal cisterns compression on pre-operative and post-operative CT scans with the outcomes at the time of discharge. Outcomes were dichotomized into mortality (and unfavourable (GOS 1-3 vs GOS 4-5). The degree of cisternal compression was evaluated using the cisternal effacement score of perimesencephalic and quadrigeminal cisternal components. Critical thresholds associated with the outcomes were calculated. Age and pre-/post-operative degree of cisternal compression were the strongest independent predictors of intrahospital mortality in a whole sample and separately in OC and pDC subgroups. The unfavourable outcome was independently predicted by age, pre-/post-operative status of cisternal compression and initial GCS. Critical thresholds associated with the mortality and poor functional outcome were, respectively, age ≥ 70 (OR 3.14 [CI 95% 1.82-5.46], p < 0.001) and ≥ 67 (OR 3.87 [CI 95% 2.33-6.54], p < 0.001), pre-operative cisternal effacement score ≥ 9 (OR 6.39 [CI 95% 3.62-11.53], p < 0.001) and ≥ 7 (OR 4.93 [CI 95% 2.96-8.38], p < 0.001), post-operative cisternal effacement score ≥ 6 (OR 20.6 [CI 95% 10.08-45.10], p < 0.001) and ≥ 3 (OR 7.47 [CI 95% 3.87-15.73], p < 0.001) and initial GCS ≤ 8 (OR 0.24 [CI 95% 0.13-0.43], p < 0.001 and OR 0.12 [CI 95% 0.07-0.21], p < 0.001). After adjusting for baseline characteristics, age and degree of cisternal compression remained the independent predictors of mortality, whereas unfavourable outcomes were associated with age, cisternal obliteration and GCS on presentation.

Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study

Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p<0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre=0.9 [95% CI 0.7-1.1], n=200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n=200]). We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.

Correlating Intracranial Pressure Following Decompressive Craniectomy With Neurological Outcomes in Severe Traumatic Brain Injury Patients: A Prospective Observational Study.

Introduction Decompressive craniectomies have been performed in settings with raised intracranial pressure (ICP) after severe traumatic brain injury (TBI). A decompressive craniectomy (DC) is an important salvage procedure for intracranial hypertension. The changes in the intracranial microenvironment after a primaryDC are significant in terms of the neurological outcome in the postoperative period. Materials and methods The study comprised 68 patients with severe TBIs who were undergoing primary DC; of these, 59% were male. Recorded data include demographic profiles, clinical features, and cranial computed tomography (CT) scans. All patients underwent a primary unilateral DC with augmentation duraplasty. Intracranial pressure was recorded in the first 24 hours at regular intervals, and the outcome was recorded using the Extended Glasgow Outcome Scale (GOS-E) at two-week and two-month intervals. Results Road traffic accidents (RTAs) are the most common cause of severe TBIs. Imaging studies and intraoperative findings suggest that acute subdural hematomas (SDHs) are the most common pathology leading to high ICP in the postoperative period. Mortality was strongly statistically associated with high ICP values postoperatively at all intervals. The average ICP for the patients who died was 11.871 mmHg higher than the patients who survived (p=0.0009). The Glasgow Coma Scale (GCS) at the time of admission is positively correlated with the neurological outcome at two weeks and two months, with a Pearson correlation coefficient of 0.4190 and 0.4235, respectively. There is a strong negative correlation between ICP in the postoperative period and the neurological outcome at two weeks and two months (Pearson correlation coefficients are -0.828 and -0.841, respectively). Conclusion The results indicate that RTAsare the most common cause of severe TBIs, and acute SDHsare the most common pathology leading to high ICPafter the surgery. ICP values in the postoperative period have a strong negative correlation with survival and neurological outcome.Preoperative GCS and postoperative ICP monitoring are important methods of prognostication and planning further management.

A 2-Year Prospective Study of Complication Rates After Cranioplasty: Is 8 Weeks’ Interval Associated with Increased Complications?

The commonly observed complications after cranioplasty include infections, intracranial hemorrhage, and seizures. The timing of cranioplasty after decompressive craniectomy (DC) is still under debate, with literature available for both early and delayed cranioplasties. The objectives of this study were to note the overall complication rates and more specifically compare complications between 2 different time intervals. This was a 24-month, single-center, prospective study. Since timing is the most debated variable, the study cohort was divided into 2 groups (≤8 weeks and >8 weeks). Furthermore, other variables such as age, gender, etiology of DC, neurologic condition, and blood loss were correlated with complications. A total of 104 cases were analyzed. Two thirds were traumatic etiology. The mean and median DC-cranioplasty intervals were 11.3 weeks (range 4-52 weeks) and 9 weeks, respectively. Seven complications (6.7%) were observed in 6 patients. There was no statistical difference observed between any of the variables and complications. We observed that performing cranioplasty within 8 weeks of the initial DC surgery is safe and noninferior to cranioplasty performed after 8 weeks. Therefore if the general condition of the patient is satisfactory, we are of the opinion that an interval of 6-8 weeks from the primary DC is safe and a reasonable time frame for performing cranioplasty.

Craniectomía descompresiva y compliance intracraneal en el traumatismo craneoencefálico grave pediátrico

ObjectiveTo show the effect of primary decompressive craniectomy on ICP, CPP, and intracranial compliance in a group of pediatric patients who suffered from severe head trauma. DesignDescriptive study. FrameworkPediatric intensive care. PatientsPediatric patients who underwent primary decompressive craniectomy due to severe head trauma, admitted to the pediatric intensive care unit of the “Roberto Rodríguez Fernandez” general teaching hospital in Morón, Ciego de Avila, Cuba between January 2003 and December 2017. ResultsDiffuse brain injury Grade IV, was the most frequent tomographic diagnosis at admission 18 (60%), with a predominance of shifts greater than 6mm in 24 cases (80%) and absent cisterns 15 (50%). Eighteen cases (60%) had normal ICP for their age after craniectomy, 20 (66.7%) cases showed normal cerebral perfusion pressure. There was a correlation between normal ICP and normal intracranial compliances. The pulse wave amplitude was used as a neuromonitoring method and qualitative representation of compliances. Twenty-two cases survived (73.3%), 18 (60%) of them without sequelae. Eight cases died (26.7%). ConclusionsPrimary DC was useful for the control of ICP and maintenance of CPP in the management of pediatric patients with severe TBI in the present study. The favorable effect of the procedure for the increase of intracranial compliance has been verified.

Improvised intracranial pressure monitoring devices for traumatic brain injury management in a low-income environment: A single-centre randomised study demonstrating feasibility

BackgroundThe high cost and non-availability of standard ICP monitoring devices limit their use in low- and middle-income countries like Nigeria. This study aims to demonstrate the use of an improvised intraventricular ICP monitoring device as a feasible alternative. Research questionAre improvised ICP Monitoring devices feasible and effective in resource-constrained settings? Materials and methodsThe study was a prospective single-institution investigation involving 54 adult patients that presented with severe TBI (GCS of 3–8) within 72 ​h of injury and required operative intervention. All patients underwent craniotomy or primary decompressive craniectomy (DC) to evacuate traumatic mass lesions. 14-day in-hospital mortality was used as a primary endpoint of the study. 25 patients had ICP monitoring postoperatively using the improvised device. ResultsThe modified ICP device was replicated using a feeding tube and a manometer with 0.9% saline as a coupling agent. Based on hourly ICP recording (up to 72 ​h), patients were observed as having high ICP (>27 ​cm H2O) and normal ICP (27 ​cm H2O). In the ICP-monitored group, raised ICP was detected more than in the clinically assessed group (84% vs 12% p= <0.001). Discussion and conclusionThere was a 3-time higher mortality rate among the non-ICP monitored participants (31%) compared to the ICP-monitored participants (12%), although this did not reach statistical significance due to the small sample size. This preliminary study has shown that this modified ICP monitoring system is a relatively feasible alternative for diagnosing and treating elevated ICP in severe TBI in resource-constrained environments.

Degree Of Cisternal Compression As An Independent Prognostic Factor For Outcome In Both Craniotomy and Primary Decompressive Craniectomy Groups In Acute Subdural Hematoma Population

Degree Of Cisternal Compression As An Independent Prognostic Factor For Outcome In Both Craniotomy and Primary Decompressive Craniectomy Groups In Acute Subdural Hematoma Population

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

BackgroundPoor-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.MethodsPICASSO 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.DiscussionThis 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 registrationDRKS DRKS00017650. Registered on 09 June 2019.

Primary Decompressive Craniectomy After Traumatic Brain Injury: A Literature Review.

Traumatic brain injuries (TBIs) still put a high burden on public health worldwide. Medical and surgical treatment strategies are continuously being studied, but the role and indications of primary decompressive craniectomy (DC)remain controversial. In medically refractory intracranial hypertension after severe traumatic brain injury, secondary decompressive craniectomy is a last resort treatment option to control intracranial pressure (ICP). Randomized controlled studies have been extensively performed on secondary decompressive craniectomy and its role in the management of severe traumatic brain injuries. Indications, prognostic factors, and long-term outcomes in primary decompressive craniectomy during the evacuation of an epidural, subdural, or intracerebral hematoma in the acute phase are still a matter of ongoing research and controversy to this day. Prospective trials have been designed, but the results are yet to be published. In isolated epidural hematoma without underlying brain injury, osteoplastic craniotomy is likely to be sufficient. In acute subdural hematoma (ASDH) with relevant brain swelling and preoperative CT signs such as effaced cisterns, overly proportional midline-shift compared to a relatively small acute subdural hematoma, and accompanying brain contusions as well as pupillary abnormalities, intraventricular hemorrhage, and coagulation disorder, primary decompressive craniectomy is more likely to be of benefit for patients with traumatic brain injury. The role of intracranial pressure monitoring after primary decompressive craniectomy is recommended, but prospective trials are pending. More refined guidelines and hopefully class I evidence will be established with the ongoing trials: randomized evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural hematoma (RESCUE-ASDH), prospective randomized evaluation of decompressive ipsilateral craniectomy for traumatic acute epidural hematoma (PREDICT-AEDH), and pragmatic explanatory continuum indicator summary (PRECIS).

Development and validation of a prediction nomogram for a 6-month unfavorable prognosis in traumatic brain-injured patients undergoing primary decompressive craniectomy: An observational study.

ObjectiveThis study was designed to develop and validate a risk-prediction nomogram to predict a 6-month unfavorable prognosis in patients with traumatic brain-injured (TBI) undergoing primary decompressive craniectomy (DC).MethodsThe clinical data of 391 TBI patients with primary DC who were admitted from 2012 to 2020 were reviewed, from which 274 patients were enrolled in the training group, while 117 were enrolled in the internal validation group, randomly. The external data sets containing 80 patients were obtained from another hospital. Independent predictors of the 6-month unfavorable prognosis were analyzed using multivariate logistic regression. Furthermore, a nomogram prediction model was constructed using R software. After evaluation of the model, internal and external validations were performed to verify the efficiency of the model using the area under the receiver operating characteristic curves and the calibration plots.ResultsIn multivariate analysis, age(p = 0.001), Glasgow Score Scale (GCS) (p < 0.001), operative blood loss of >750 ml (p = 0.045), completely effaced basal cisterns (p < 0.001), intraoperative hypotension(p = 0.001), and activated partial thromboplastin time (APTT) of >36 (p = 0.012) were the early independent predictors for 6-month unfavorable prognosis in patients with TBI after primary DC. The AUC for the training, internal, and external validation cohorts was 0.93 (95%CI, 0.89–0.96, p < 0.0001), 0.89 (95%CI, 0.82–0.94, p < 0.0001), and 0.90 (95%CI, 0.84–0.97, p < 0.0001), respectively, which indicated that the prediction model had an excellent capability of discrimination. Calibration of the model was exhibited by the calibration plots, which showed an optimal concordance between the predicted 6-month unfavorable prognosis probability and actual probability in both training and validation cohorts.ConclusionThis prediction model for a 6-month unfavorable prognosis in patients with TBI undergoing primary DC can evaluate the prognosis accurately and enhance the early identification of high-risk patients.

Intracranial Pressure after Closure of Dura Predicts Decompressive Craniectomy in Patients with Head Trauma.

This study aimed to address the risk factors of second decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) who initially underwent mass lesion evacuation, but no primary DC. Patients were enrolled if they had had a hospital visit to Xiangya Hospital, Central South University with acute closed TBI from January 1, 2017 to December 31, 2019 and had undergone craniotomic mass lesion evacuation. Sociodemographic information, computed tomography (CT) information, clinical profiles, and surgical information were obtained from an electronic database. Twenty-four patients who had undergone a second decompressive craniectomy (SDC) and 39 patients who had not (NSO) were included in the analysis. The prevailing lesions differed between the groups (p = 0.010). The SDC group had more compressed/obliterated basal cisterns than the NSO group (p = 0.028). After closure of the dura, the SDC group also had higher intracranial pressure (ICP) than the NSO group (10.9 mm Hg vs. 6.5 mm Hg, p = 0.005). Binary logistical regression indicated that ICP after dura closure was an independent predictor of second DC (odds ratio [OR] = 1.317, p = 0.011). A model using ICP after dura closure alone had an area under the curve value of 0.757 in its receiver operating characteristic curve. An ICP >10.5 mm Hg after closure of dura for the prediction of a second DC had a sensitivity of 56.3% and a specificity of 92.6%.

Decompressive Craniectomy Practice following Traumatic Brain Injury in Comparison with Randomized Trials: Harmonized, Multi-Center Cohort Studies in Europe, the United Kingdom, and Australia

High quality evidence shows decompressive craniectomy (DC) following traumatic brain injury (TBI) may improve survival but increase the number of severely disabled survivors. Contemporary international practice is unknown. We sought to describe international use of DC, and the alignment with evidence and clinical practice guidelines, by analyzing the harmonized Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Australia-Europe NeuroTrauma Effectiveness Research in Traumatic Brain Injury (OzENTER-TBI) core study datasets, which include patients admitted to intensive care units (ICUs) in Europe, the United Kingdom, and Australia between 2015 and 2017. Outcomes of interest were treatment with DC relative to clinical trial evidence and the Brain Trauma Foundation guidelines. Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13.7%): in 64/1422 (4.5%) patients with diffuse TBI and 195/640 (30.5%) patients with traumatic mass lesions. Secondary DC (for treatment of intracranial hypertension) was used infrequently in patients who met enrollment criteria of the two randomized clinical trials informing the guidelines-specifically, in 11/124 (8.9%) of those matching Decompressive Craniectomy in Diffuse Traumatic Brain Injury trial (DECRA) enrollment, and in 30/224 (13.4%) of those matching Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp). Of patients who underwent DC, 258/320 (80.6%) were ineligible for either trial: 149/320 (46.6%) underwent primary DC, 62/320 (19.4%) were outside the trials' age criteria, and 126/320 (39.4%) did not develop intracranial hypertension refractory to non-operative therapies prior to DC. Secondary DC was used infrequently in patients in whom it had been shown to increase survival with severe disability, indicating alignment between contemporaneous evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefited from DC remains unknown.

Abstract #30 Primary Decompressive Craniectomy for Acute Subdural Hematoma in a High Complexity Hospital: Tomographic Clinical Features and Outcomes

Abstract #30 Primary Decompressive Craniectomy for Acute Subdural Hematoma in a High Complexity Hospital: Tomographic Clinical Features and Outcomes

Decompressive craniectomy after traumatic brain injury: An observational study of 147 patients admitted in a Tunisian ICU

ObjectiveTo analyze clinical, epidemiological, radiological characteristics and outcome of patients undergoing decompressive craniectomy (DC) after traumatic brain injury (TBI) and to identity predictive factors associated with poor prognosis. MethodsDemographic, clinical, and radiologic data from a retrospective study on unilateral or bilateral DC following TBI, admitted to the Intensive Care Unit (ICU) of a university hospital (Sfax-Tunisia), were collected during a 9-year period. ResultsWe included 147 patients. Ninety-nine patients (67.7%) were younger than 45 years. GCS ≤ 8 was found in 100 patients (68%). Primary DC was done for 104 patients (70.74%) and secondary DC was done for 43 patients (29.25%). Surgery was done within the first 6 h for 94 patients (63.9%). A mortality rate was at 42.2%. Independent factors associated with mortality were age > 65 years (p = 0.001;OR8.9;CI95% [1.90–42.02]),GCS ≤ 8 (p = 0.001;OR3.8;CI95%[1.69–8.54]),SOFA score > 5 (p = 0.01;OR2.2; CI95%[1.13–4.32]), persistence anisocoria or mydriasis after surgery (p < 0.001;OR13.16; CI95%[5.00–34.6]), hypercapnia > 45 mmHg (p = 0.002;OR4.2; CI95%[1.62–10.9]), disseminated intravascular coagulation (p = 0.003;OR4.3;CI 95% [1.57–11.96]) and use of corticosteroids (p = 0.034; OR2.04;CI95%[1.05–3.97]). Independent factors associated with poor outcome at discharge were GCS ≤ 8 (p = 0.029; OR 2.72; CI95% [1.09–6.78]), hydrocephalus (p = 0.017; OR4.13; CI95% [1.21–14.1]) and hyponatremia < 135 mmol/l (p = 0.009; OR6.77; CI95% [1.38–33.1]). Independent factors associated with poor outcome at 6 months were GCS ≤ 8 (p = 0.014; OR 3.93; CI 95% [1.27–12.1]), systolic arterial pressure < 90 mmHg at admission (p = 0.029; OR 3.54; CI 95% [2.48–5.05]) and diffuse axonal injury (p = 0.009; OR 3.89; CI 95% [1.35–11.2]). ConclusionDC can be life-saving for patients with TBI with decrease of mortality. The control of secondary systemic insults may lead to good prognosis.

Intracranial Hypertension After Primary Decompressive Craniectomy for Head Trauma

Primary decompressive craniectomy (DC) is commonly performed for patients with traumatic brain injury (TBI). Some, but not all patients, will benefit from invasive monitoring of intracranial pressure (ICP) after surgery. We intended to identify risk factors for elevated ICP after primary DC to treat TBI. A retrospective chart review study identified all patients at our institution who underwent primary DC for TBI during the study period and who had ICP monitors placed at the time of surgery. Various preoperative and intraoperative variables were assessed for correlation with the presence of postoperative elevated ICP. Postoperative elevated ICP occurred in 36% of patients after DC. In univariate analysis, Glasgow Coma Scale <8, abnormal pupillary examination, and intraoperative brain swelling were all associated with elevated postoperative ICP. However, in multivariate analysis only intraoperative brain swelling was associated with elevated postoperative ICP (incidence 56% vs. 5%, P= 0.0043). Placement of an ICP monitor at the time of primary DC for patients with TBI should be considered if there is intraoperative brain swelling.

Роль і місце декомпресивної краніектомії в інтенсивній терапії рефрактерної внутрішньочерепної гіпертензії при тяжкій черепно-мозковій травмі

У даній роботі поданий огляд літератури, присвячений ролі і місцю декомпресивної краніектомії (ДК) в інтенсивній терапії рефрактерної внутрішньочерепної гіпертензії при тяжкій черепно-мозковій травмі. Подано визначення первинної декомпресивної і додаткової краніектомії. Показано, що дослідження ДК охоплює такі напрямки: 1) першочерговість ДК щодо медикаментозного забезпечення; 2) порівняння ДК різних розмірів; 3) порівняння ДК із краніотомією; 4) рання або пізня ДК — з точки зору їх впливу на смертність пацієнтів і функціональні результати. Резюме доказів подано 3 класами. Для оцінки якості сукупності доказів додатково рекомендовані шкала результатів Glasgow Outcome Scale (GOS) і розширена шкала результатів Glasgow Outcome Scale Extended (GOS-E), в якій позиції 3–5 GOS поділені на дві. GOS-E — це глобальна шкала результатів, що описує функціональну незалежність, роботу, соціальну та дозвільну діяльність, особисті відносини; шкали GOS і GOS-E використовують також для порівняння ефективності застосування методів інтенсивної терапії. З огляду на Guidelines for the Management of severe Traumatic Brain Injury 4th Еdition — 2016 подано рекомендації з ДК. Детально вивчено й адаптовано дослідження з рандомізованої оцінки операції ДК при неконтрольованому наростанні внутрішньочерепного тиску (RESCUEicp) для аналізу ефективності ДК як втручання останнього рівня в пацієнтів із черепно-мозковою травмою та рефрактерною внутрішньочерепною гіпертензією. Установлено, що через 6 місяців після черепно-мозкової травми в групі з ДК смертність була на 22 % нижчою, підвищувався відсоток пацієнтів у вегетативному статусі, відмічалися істотні і незначні за тяжкістю неврологічні порушення; сприятливі наслідки домінували на 13 % порівняно з медикаментозним лікуванням. Показники помірної інвалідності і добре відновлення були однаковими в обох групах.

Decompressive Craniectomy for Intracranial Hypertension

Decompressive craniectomy(DC)for intracranial hypertension after traumatic brain injury(TBI)can be divided into two treatment strategies: primary DC and secondary DC. DC has an important intracranial pressure-lowering effect; however, the standard treatment has not been established because the treatment policy with respect to surgical indication, optimal timing, and surgical method are often determined according to the empirical rules of each institution. In addition, the effects of DC on clinical outcomes remain unknown. Recently, the results of a large multicenter randomized controlled trial(RCT)about the effects of secondary DC for severe head trauma have been published. The study showed that secondary DC improved the mortality rate but had no effect on functional prognosis. Another RCT about the effects of primary DC for TBI is ongoing and the results are awaited. We herein describe the indications, surgical methods, and issues of DC for TBI based on the results of these clinical trials with a high level of evidence.

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.

Comparison of subcutaneous pocket with cryopreservation method for storing autologous bone flaps in developing surgical wound infection after Cranioplasty: A randomized clinical trial

BackgroundFollowing a decompressive craniectomy (DC), the harvested bone flap is stored for future cranioplasty. There are two different methods proposed for bone banking, namely subcutaneous pocketing (SP) in the abdominal wall and cryopreservation (CP) in a refrigerator. This study was designed to evaluate the risk of developing infection in each study group. MethodsIn this randomized clinical trial design, a total of 143 patients underwent a primary decompressive craniectomy. Thereafter, they were randomly allocated into two groups, as SP and CP, and they were then scheduled for a future cranioplasty. Next, 108 patients underwent cranioplasty using an autologous bone flap and then followed-up for 18 months. Some variables, including demographic data, indications for primary DC, rate of post-operative clinical infection, bacterial culture results, the interval between craniectomy and cranioplasty, post-operative hospitalization duration, new morbidities, mortality rate, bone flap resorption rate, and several possible associated risk factors, were also recorded. The obtained data were analyzed by an expert bio-statistician using proper bio-statistical methods. A P value < 0.05 was considered as statistically significant. ResultsFour patients in the cryopreservation group (n = 50) indicated post-operative bone flap infection (8%), which was statistically significant (P = 0.041). Accordingly, all of them were resulted as positive for Methicillin-Resistant-Staphylococcus aureus (MRSA). Using the subcutaneous pocket method, no post-operative infection was observed after cranioplasty. The overall postoperative infection rate was estimated as 4%. The mean of age in the post-operative infection group’s participants was 50.25 years old, and in the non-infected, it was 34.93 years old, which was also significant (P = 0.048). Bone flap resorption (BFR) rate was found to be higher by the use of CP method in comparison to SP technique (p = 0.0001). Of note, no other risk factor was found attributable to a higher BFR rate (p-values > 0.05). ConclusionsOlder age and cryopreservation method at higher storage temperature (-18C˚) may be associated with infection’s development after performing cranioplasty. BFR is more prevalent in the use of CP method rather than SP preservation technique.

Decompressive craniectomy in the treatment of supratentorial hypertensive intracerebral hematomas

The study objective is to evaluate feasibility and effectiveness of decompressive craniectomy (DC) for treatment оf supratentorial hypertensive intracerebral hematomas (ICH).Materials and methods. Between 1996 to 2019, 97 patients with supratentorial hypertensive ICHs underwent surgical treatment. DC was performed in 50 patients (primary - in 41, secondary - in 9). Putaminal hematomas were diagnosed in 30 patients, subcortical - in 20. The comparison group consisted of 47 patients, of which 20 had osteoplastic craniotomy (OPC) with microsurgical removal of ICH, and 27 had endoscopic aspiration (EA). The performed DCa were treated as unjustified (decreased brain dislocation without prolapse of the brain substance into the trepanation defect), ineffective (preservation of brain dislocation and absence of prolapse of the brain substance into the trepanation defect, as well as small size of the trepanation hole) and effective (prolapse of the brain substance into the trepanation defect and regression of transverse brain dislocation).Results. DC was effective only in 22 (44 %) patients (13 - primary, 9 - secondary). Among patients with subcortical ICH, mortality rate after DC was equal to that after OPC and EA. Among patients with putaminal ICH, the mortality rate after DC was significantly higher than after OPC and EA. Among the patients who underwent primary EA and delayed DC (due to recurrent ICH), postoperative mortality rate was significantly higher than among the patients who underwent repeated EA of recurrent ICH. However, there were no fatal outcomes among patients who underwent delayed DC due to increased edema and transverse dislocation of the brain without recurrent ICH.Conclusion. In the surgical treatment of supratentorial hypertensive ICH, decompressive effect of DC was achieved only in 44 % of patients. Open removal of putaminal hematomas in combination with DC was unjustified, mortality rate was 66 %. Primary DC with removal of ICH is indicated in patients with subcortical hematomas with a volume &gt;50 cm3 , with transverse dislocation &gt;7 mm, deep deafness or sopor. Delayed DC, regardless of the location of ICH, is recommended in case of increased edema and transverse dislocation of the brain in patients without recurrent hemorrhage.