Secondary Decompressive Craniectomy Research Articles

Indications and scientific support for supratentorial unilateral decompressive craniectomy for different subgroups of patients: A scoping review.

Even though supratentorial unilateral decompressive craniectomy (DC) has become the gold standard neurosurgical procedure aiming to provide long term relief of intractable intracranial hypertension, its indication has only been validated by high-quality evidence for traumatic brain injury and malignant middle cerebral artery infarction. This scoping review aims to summarize the available evidence regarding DC for these two recognized indications, but also for less validated indications that we may encounter in our daily clinical practice. A scoping review was conducted on Medline / Pubmed database from inception to present time looking for articles focused on 7 possible indications for DC indications. Studies' level of evidence was assessed using Oxford University level of evidence scale. Studies' quality was assessed using Newcastle-Ottawa scale for systematic reviews of cohort studies and Cochrane Risk of Bias Tool for randomized controlled trials. Two randomized trials (level 1b) reported the possible efficacy of unilateral DC and the mitigated efficiency of bifrontal DC in the trauma setting. Five systematic reviews meta-analyses (level 2a) supported DC for severely injured young patients with acute subdural hematoma probably responsible for intraoperative brain swelling, while one randomized controlled trial (level 1b) showed comparable efficacy of DC and craniotomy for ASH with intraoperative neutral brain swelling. Three randomized controlled trials (level 1b) and two meta-analyses (level 1a and 3a) supported DC efficacy for malignant ischemic stroke. One systematic review (level 3a) supported DC efficacy for malignant meningoencephalitis. One systematic review meta-analysis (level 3a) supported DC efficacy for malignant cerebral venous thrombosis. The mitigated results of one randomized trial (level 1b) did not allow to conclude for DC efficacy for intracerebral hemorrhage. One systematic review (level 3a) reported the possible efficacy of primary DC and the mitigated efficacy of secondary DC for aneurysmal subarachnoid hemorrhage. Too weak evidence (level 4) precluded from drawing any conclusion for DC efficacy for intracranial tumors. To date, there is some scientific background to support clinicians in the decision making for DC for selected cases of severe traumatic brain injury, acute subdural hematoma, malignant ischemic stroke, malignant meningoencephalitis, malignant cerebral venous thrombosis, and highly selected cases of aneurysmal subarachnoid hemorrhage.

Decompressive craniectomy in trauma: What you need to know.

Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.

Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma.

Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.

Effect of Decompressive Craniectomy on Intracranial Pressure Waveforms and Vascular Reactivity: A Systematic Scoping Review.

Decompressive craniectomy (DC) primarily aims at decreasing intracranial pressure (ICP) by allowing for the brain tissue to expand. However, it is uncertain to what extent DC impacts the transmission of vasogenic slow waves and thus the validity and utility of the pressure reactivity index (PRx). The purpose of this systematically performed scoping review is to assess the current knowledge of the impact of DC on ICP waveforms and measures of vascular reactivity. This scoping review considered studies including patients over 18 years old suffering from acute brain injuries (ABIs), who underwent secondary DC and had a perioperative (pre/post-DC) recording of ICP or waveform analysis. A search was conducted in EMBASE, PubMed, Web of Science, Scopus, and Medline from November 2023 till January 2024, yielding 787 studies. Duplicated studies were automatically removed, and two researchers independently screened the remaining studies. After examining 586 titles and abstracts, 38 full-text studies were assessed for eligibility, and 4 studies were included in the final review. The review suggests that cerebrovascular reactivity and slow waves are altered after DC, with positive PRx values and reduced slow power. One study suggested that the nature of slow waves and interactions is on the whole largely preserved. However, the findings should be interpreted with caution due to methodological limitations and the low number of studies.

Intracranial Haemorrhage After Decompressive Craniectomies for Trauma: Role of the Skull Clamp

Background: High Intracranial Pressure (ICP) is the most frequent cause of death and disability after severe Traumatic Brain Injury (TBI); in Europe, 33% of patients with TBI require neurosurgical intervention. Decompressive Craniectomy (DC) represents the extreme surgical treatment; although it is regarded as a relatively simple surgical procedure, it is often accompanied by many complications, including Extradural Hematoma (EDH) associated with an overlying fracture on the contralateral side. It presents an incidence of 5-12%, but Singh et al., analysing 2108 DC performed without the skull clump, estimate it to be about 0.48%. Any authors have indicated the relationship between EDH after DC for trauma in patients showing skull fractures and the use of this Head Immobilisation Device (HID). Materials and methods: We have retrospectively analysed all patients who underwent frontotemporoparietal DC and bifrontal DC after TBI at Venice Angel Hospital during a 5-year and six-month period (January 2017-June, 2022). All patients showed skull bone fractures at CT brain scan, associated with clinical and neuroradiological signs of increasing ICP. For each patient, we analysed: age and sex, neurological status: GCS at the moment of trauma and before surgery, pupillary size and form before and after surgery; neuroimaging evolution; the timing and DC. DORO© Mayfield skull clump was used in all cases. Results: Our surgical cohort counts 20 patients with M/F 3:2 and an average age of 47±17. 16 patients underwent urgent surgery (primary DC), and 4 were operated on after an overage of 50 hours of observation (secondary DC): 90% of patients experienced frontotemporoparietal DC and 10% bifrontal DC. Postoperative CT brain scan showed enlargement of brain contusion in 4 patients (20%); EDH in 4 patients: 2 in the side of skull fracture contralateral at DC, 1 contralateral at DC and skull fracture, 1 occipital in the side of fracture homolateral at DC; SDH in 2 cases, both homolateral at DC. For 3 patients, surgical treatment of EDH was necessary following DC. Conclusion: Our patients showed a higher probability of developing remote-site EDH; other typical complications presented the same or slightly higher frequency of occurrence. Considering the high risk-benefit ratio of skull bone application, we suggest adopting safer HID, such as surgical adhesive tape or a horseshoe headrest.

Is optic nerve sheath diameter a promising screening tool to predict neurological outcomes and the need for secondary decompressive craniectomy in moderate to severe head injury patients? A prospective monocentric observational pilot study.

Optic nerve sheath diameter (ONSD) has been shown to be a noninvasive and quick method to calculate intracranial pressure (ICP) and subsequent neurologic outcomes, although with variable cutoffs. ICP can be indirectly assessed by noninvasive methods such as transcranial Doppler, ONSD, tympanic membrane displacement, and fundoscopy. Knowledge regarding the diagnostic accuracy of ONSD for predicting unfavorable outcomes within 72 hours (h) of moderate and severe head injury is limited. The objective of this study was to measure ONSD measurements at 24-h intervals in moderate to severe head injury patients and to find its association with clinical outcomes in the target population. This prospective observational study was done on moderate to severe head injury patients. ONSD was measured twice at 24-h intervals over 48 h. The clinical outcome was divided into the favorable group (patients who were in conservative treatment with a stable Glasgow Coma Scale [GCS] score and discharged following treatment) and the unfavorable group (patients who had a drop in GCS motor score of one or more, or expired or underwent surgical intervention) within 72 h following traumatic brain injury. The Kruskal-Wallis test, Mann- Whitney test, and receiver operating characteristic curves were used to establish the association between ONSD and clinical outcomes. ONSD values measured at 24-h intervals >6.1 mm (P < 0.0146) and 6.2 mm (P < 0.0001) were found to be predictors of unfavorable outcomes (expired or underwent surgery), and hence the need for a secondary decompressive craniectomy (DC). ONSD is an efficient screening tool to assess neurological outcomes in severe head injury patients. It can reliably predict the need for secondary DC at an earlier stage before secondary brain damage ensues in these patients.

Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage

PurposeOur review of acute brain insult articles indicated that the patients’ individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented.MethodsWe retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.–45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death (n=25; 56%) or 3 years (n=20; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors).ResultsThe timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome.ConclusionsThe pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.

Decompressive Craniectomy in Severe Traumatic Brain Injury: The Intensivist’s Point of View

Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical-surgical consultation.

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).

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.

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.

Decompressive Craniectomy After Traumatic Brain Injury: Incorporating Patient Preferences into Decision-Making

Decompressive craniectomy (DC) is highly effective in relieving intracranial hypertension; however, patient selection, intracranial pressure threshold, timing, and long-term functional outcomes are all subject to controversy. Recently, recommendations were made to update the Brain Trauma Foundation guidelines in regards to the use of DC based on the DECRA (Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury) and RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) clinical trials. Neither the updated recommendations, nor the aforementioned trials, provide a method in incorporating individualized patient or surrogate decision-maker preferences into decision making. In this manuscript, we aimed to redress the gap of not incorporating patient preferences in such value-laden decision making as in the case of DC for refractory post-traumatic intracranial hypertension. We proposed a decision aid based on principles of Decision Theory, and specifically of Expected Utility Theory. We showed that 1) early secondary DC as studied in DECRA, and based on the 1-year outcome data, is associated with decreased expected utility for all possible preference rankings of outcomes; and 2) recommending a late secondary DC versus tier-3 medical therapy, as studied in RESCUEicp, should be informed by individualized patient preference rankings of outcomes as elicited via shared decision-making. The 1-year outcomes from DECRA and RESCUEicp have served as the basis for updated guidelines. However, unaided interpretation of trial data may not be adequate for individualized decision-making; we suggest that the latter can be significantly supported by decision aids such as the one described here and based on expected utility theory.

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.

Decompressive Craniectomy Following Traumatic Brain Injury; Does International Practice Align with Evidence? Harmonised, Multi-Centre Cohort Studies in Europe, the United Kingdom and Australia

Background: Clinical practice guidelines recommend both for and against use of decompressive craniectomy (DC) for treatment of intracranial hypertension following traumatic brain injury (TBI). The contemporary use of DC internationally, and the alignment of practice, evidence, and clinical practice guidelines, are unknown. Methods: We analysed the harmonised CENTER-TBI and OzENTER-TBI Core study datasets, which include patients of any age with TBI of any severity admitted to participating ICUs in Europe, the UK and Australia between 2015 and 2017. Patients were compared between different regions and by injury characteristics. Outcomes of interest were treatment with DC, and alignment with evidence and the Brain Trauma Foundation guidelines. Findings: 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 (used for treatment of measured intracranial hypertension) was used infrequently in patients whose characteristics matched the enrolment criteria of the two randomised clinical trials informing the guidelines: in 11/124 (8·9%) of those matching DECRA eligibility, and in 30/224 (13·4%) of those matching RESCUEicp eligibility. Of the 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 medical therapies prior to DC. Interpretation: Decompressive craniectomy remains in widespread use following TBI. Secondary DC was used infrequently in patients in whom it has been shown to be potentially harmful, indicating satisfactory alignment between evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefitted from DC remains unknown. Funding: European Commission 7th Framework programme, Australian National Health and Medical Research Council, and Victorian Transport Accident Commission. Declaration of Interest: AIRM declares consulting fees from PresSura Neuro, Integra Life Sciences, and NeuroTrauma Sciences. DJC is an Australian NHMRC Practitioner Fellow and reports grants from the NHMRC and consulting fees to Monash University from PresSura Neuro; additionally, he is the Chief Investigator for the DECRA trial. All other authors declare no competing interests. Ethical Approval: Human research ethics approvals were granted with waivers of consent by the ethics committees of all individual participating hospitals, and additionally of Monash University for OzENTER.

P0214 / #2052: DECOMPRESSIVE CRANIECTOMY (DC) IN THE MANAGEMENT OF INTRACRANIAL HYPERTENSION (ICHT) IN CHILDREN WITH SEVERE TRAUMA BRAIN INJURY (STBI).

Aims & Objectives: to show the impact of decompressive craniectomy in the management of intracranial hypertension in children with severe trauma brain injury. Methods: Study of 94 cases of children with STBI, hospitalized from January 1, 2015, to December 31, 2019, Préventive and/or secondary DC was performed in 16 patients. Results: Incidence:17%. Average age: 07 years old (Min:13 months – Max:15 years) Sex ratio: 1/2, male prédominance Mechanism of trauma: 12 falls, 04 road accident. initial pediatric Glasgow coma scale: 06/15. Primary intracranial lesions were: 07 Extra Dural hematoma, 06 sous Dural hematoma, 03 intra parenchymal hematoma. 12 Préventive decompressive craniectomy and 4 Secondary decompressive craniectomy. The site of DC: 04 fronto temporo parietal, 11 temporo parietal,01parieto occipital. Only 01 bilateral DC was performed. Average time to completion was 13 hours for Préventive craniectomy and 04 daysfor the Secondary one. post operative intra crânial hypertension has been registered in 11 patient. Mortality: 50%. Main Complications observed: 03 cérébral Hernia, 03 dura breach, 01 ventriculitis Conclusions: Despite the lack of benefit on the neurological prognosis, DC must be discussed on a case-by-case between anesthesiologist and neurosurgeons.

Use and impact of high intensity treatments in patients with traumatic brain injury across Europe: a CENTER-TBI analysis

PurposeTo study variation in, and clinical impact of high Therapy Intensity Level (TIL) treatments for elevated intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across European Intensive Care Units (ICUs).MethodsWe studied high TIL treatments (metabolic suppression, hypothermia (< 35 °C), intensive hyperventilation (PaCO2 < 4 kPa), and secondary decompressive craniectomy) in patients receiving ICP monitoring in the ICU stratum of the CENTER-TBI study. A random effect logistic regression model was used to determine between-centre variation in their use. A propensity score-matched model was used to study the impact on outcome (6-months Glasgow Outcome Score-extended (GOSE)), whilst adjusting for case-mix severity, signs of brain herniation on imaging, and ICP.Results313 of 758 patients from 52 European centres (41%) received at least one high TIL treatment with significant variation between centres (median odds ratio = 2.26). Patients often transiently received high TIL therapies without escalation from lower tier treatments. 38% of patients with high TIL treatment had favourable outcomes (GOSE ≥ 5). The use of high TIL treatment was not significantly associated with worse outcome (285 matched pairs, OR 1.4, 95% CI [1.0–2.0]). However, a sensitivity analysis excluding high TIL treatments at day 1 or use of metabolic suppression at any day did reveal a statistically significant association with worse outcome.ConclusionSubstantial between-centre variation in use of high TIL treatments for TBI was found and treatment escalation to higher TIL treatments were often not preceded by more conventional lower TIL treatments. The significant association between high TIL treatments after day 1 and worse outcomes may reflect aggressive use or unmeasured confounders or inappropriate escalation strategies.Take home messageSubstantial variation was found in the use of highly intensive ICP-lowering treatments across European ICUs and a stepwise escalation strategy from lower to higher intensity level therapy is often lacking. Further research is necessary to study the impact of high therapy intensity treatments.Trial registrationThe core study was registered with ClinicalTrials.gov, number NCT02210221, registered 08/06/2014, https://clinicaltrials.gov/ct2/show/NCT02210221?id=NCT02210221&draw=1&rank=1 and with Resource Identification Portal (RRID: SCR_015582).

Complications Following Decompressive Craniectomy.

Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications. We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed. DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome. The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.

Decompressive Craniectomy for Traumatic Intracranial Hypertension in Children.

Decompressive craniectomy (DC) for control of refractory intracranial pressure (ICP) elevations remains a controversial procedure because of its invasiveness and lack of clearly defined indications, the absence of an established surgical technique, the variability of its outcomes, and the significant risk of complications. The purpose of this study was to identify factors for unfavorable outcomes after DC in children with a severe traumatic brain injury (TBI). A longitudinal investigation of correlations was carried out in 64 children (mean age±4.8years) with severe TBI and a Glasgow Coma Scale (GCS) score of 6±2 on admission. The follow-up period was 6months. There was good recovery (with a Glasgow Outcome Scale (GOS) score of 4-5) in 45.3% of cases, severe disability in 31.0% of cases (with a GOS score of 3); and a GOS score of 1-2 in 23.4% of cases. Twelve patients (18.7%) died. Unfavorable prognostic signs were a GCS score < 5 (P = 0.0003); dilated, unreactive pupils (P < 0.05); and ICP >40 mmHg (P=0.0003; P<0.05). ICP characteristics appeared to be the most sensitive predictor of outcomes after secondary DC (P<0.05). DC may be effective in preventing dislocation syndrome but futile in cases of cerebral herniation. Outcomes after DC are determined by the severity of the primary and secondary brain injuries.