Decompressive craniectomy as a second/third-tier intervention in traumatic brain injury: A multicenter observational study

Objective To present our experiences on the treatment of severe traumatic brain injury on patients with herniation and discuss the indication for decompressive craniectomy (DC) and prognostic factors.Methods From May 2009 to Dec.2011,139 patients aged between 3 and 83 years with severe traumatic cerebral herniation were included.The patients' Glasgow Coma Scale score (GCS),pupil reaction,diagnosis,surgical treatment methods,and prognosis were analyzed retrospectively.Results 102patients underwent DC and 37 patients underwent non-decompressive craniectomy.Amongst 106 patients with GCS≤6,there were 85 patients undergoing DC (80.1％).Thirty-five patients with bilateral pupil dilation underwent DC (88％,35/40),and 67 (68％,67/99) patients with unilateral pupil dilation underwent DC(P ＜0.05).Based on the Glasgow Outcome Scale,42 patients were dead,31 in vegetative state,16 with severe disabilities,8 with moderate disabilities,and 42 had good recovery at the 3-month follow-up.Overall mortality was 30.2％.As for patients with GCS =3,the mortality was 63％ (19/30).Lower GCS was associated with worse outcomes.The mortality was 60％ in 40 patients with bilateral pupil dilation and 18％ in 99 patients with unilateral pupil dilation (P ＜ 0.05).The mortality was 5％ (2/37) in patients with epidural hematoma and 43％ (26/61) with subdural hematoma (P ＜ 0.05).The mortality was 74％ (14/19) when ICP 30 ～40 mm Hg,and the mortality was 100％ (8/8) when ICP ＞40 mm Hg.Conclusions Low GCS,bilateral pupil dilations,and ICP ≥ 30 mm Hg suggest higher mortality and unfavorable outcomes.GCS≤6,bilateral pupil dilations,and intraoperative brain swelling can be viewed as indications for DC in severe traumatic brain injury patients with herniation.Smart surgical technique is helpful for the treatment of herniation. Key words: Craniocerebral trauma; Encephalocele ; Decompressive craniectomy; Intracranial pressure; Prognosis

Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure

The treatment of severe traumatic brain injury (TBI) with brain herniation is challenging because outcomes are often associated with high mortality and morbidity. Our aim was to identity factors contributing to decompressive craniectomy (DC) and evaluate treatment outcomes in patients with severe TBI with brain herniation.In this retrospective study, we analyzed medical records of severe TBI with brain herniation from May 2009 to December 2013. We reviewed their demographic data, mechanism of injury, Glasgow Coma Scale (GCS) score, pupil status, computed tomography findings, surgical treatment methods, time interval between brain herniation and surgery, as well as outcomes. GCS and pupil status are clinical parameters for detecting increase intracranial pressure while brain parenchyma bulged above the inner plate of the skull during operation indicated brain swelling as well as increased intracranial pressure on which basis the decision to perform DC or craniotomy was determined intraoperatively.One hundred ninety-four patients were included in the study. We performed DC in 143 of the patients while 51 of them we performed craniotomy. There were no statistically significant differences in the age, gender, or injury mechanism between the 2 groups. GCS, pupillary dilation, midline shift, hematoma type and timing of surgery were associated with DC. Nevertheless, logistic regression analysis revealed that hematoma type and timing of surgery were significantly associated with favorable DC outcomes (P < .001 and P = .023). Subdural hematoma and timing of surgery >1 hour were both identified as risk factors for DC. Six months after TBI, 34.0% of patients exhibited favorable outcomes. Overall mortality rate was 30.4%. Age, GCS, pupil dilation, hematoma type, and timing of surgery were all associated with patient outcomes. Further logistic regression analysis revealed that, lower GCS, bilateral pupil dilation, timing of surgery >1 hour, and advanced age were independent risk factors for poor outcomes (P = .001, P = .037, P = .028, and P = .001, respectively).Our study revealed that, DC is not mandatory for all TBI patients with brain herniation. Nevertheless, DC decreases mortality rate in severe TBI patients with brain herniation. Subdural hematoma and timing of surgery >1 hour are key indicators for DC. Lower GCS, bilateral pupil dilation, delayed timing of surgery and advance age are indicators of poor outcomes.

Objective Traumatic brain injury (TBI) proves to be an obstacle for Bangladeshi patients due to the lack of facilities and specialist doctors in regional sections of the country. This study aimed to record different attributes of Bangladeshi TBI patients over a year i.e., their injury characteristics, treatments received and understand their impacts on the severity of TBI. Method This cross-sectional study was carried out among 280 TBI patients treated in a tertiary care hospital in Dhaka. The physicians determined TBI's severity and prognosis as per the Glasgow Coma Scale (GCS) and Glasgow Outcome Score (GOS) respectively. Results Most TBI patients were male (76.1%) and aged between 18 and 50 years (52.2%), as in previous studies in South Asian countries. However, the prevalence of TBI due to road traffic accidents (RTAs) was much higher (67.9%) than in the earlier studies in South Asia. Additionally, more patients suffered from severe TBI (29.3%) and moderate TBI (35.7%), and a higher percentage of patients went through surgery (56.8%) compared to previous studies. A significant association of demographic (residence) and clinical characteristics (consciousness after injury, CT scan findings and treatment type) with the severity of TBI was found in bivariate analysis. It also revealed the significant dependence of clinical characteristics (TBI etiology, post-injury consciousness, treatment type and TBI severity) on TBI prognosis. Multivariate analysis showed that patients who were unconscious after TBI and with evident brain injury observed in CT scans have a substantially higher risk of having moderate or severe TBI than mild TBI. Moreover, patients with TBI due to RTAs or falls, evident brain injury in CT scans, post-surgical seizure, and moderate or severe TBI have a significantly higher risk of getting a more unfavorable TBI prognosis than moderate disability. Conclusions In this study, RTAs were found to be the major cause of TBI. Additionally, some variables were identified as possible determinants of TBI severity and prognosis among Bangladeshi patients. The correlation of these variables with TBI should be further studied with the hopes that steps will be taken to reduce TBI incidents and improve its management to reduce the overall burden.

INTRODUCTION. Correlation between the optic nerve sheath diameter (ONSD) and the intracranial pressure (ICP) in the acute period of severe traumatic brain injury has been confirmed in numerous publications by foreign and Russian authors. Evaluation of ONSD in patients with cerebral edema and suspected intracranial hypertension (ICH) is possible using neuroimaging (CT, MRI) and ultrasound diagnostic methods (US). The use of ONSD data in patients with severe traumatic brain injury may be of diagnostic and prognostic value in the analysis of therapeutic and surgical methods effectiveness, including decompressive craniectomy (DCT).AIM. To evaluate changing in the ONSD on computed tomography (CT) in patients with severe traumatic brain injury after decompression craniotomy (DCT).MATERIALS AND METHODS. For the period from 2020 to 2022 on the basis of the N. N. Burdenko National Medical Research Center of Neurosurgery conducted a prospective single-center observational study included 31 patients (7 women and 24 men) with severe (GCS ≤ 8 points) traumatic brain injury (TBI) and invasive ICP monitoring. The final version of the study included 8 patients (3 women and 5 men) with a wide DCT during the first 3 days after the injury. The mean age in this group was 30 [26.3; 53.0]. All patients underwent invasive ICP monitoring and ICP-oriented therapy according to international and Russian recommendations. Analysis of the ONSD dynamics was carried out based on the comparison of the average, maximum, and minimum values of the ONSD before and after decompression.RESULTS. Significant differences were found in the ONSD in patients with severe TBI before and after decompressive trepanation: decrease in the maximum ONSD from 7.53 to 6.89 mm and decrease in the minimum ONSD from 7.20 to 6.54 mm (p=0.022 in both cases). These results allow us to conclude that changing in the ONSD parameter is affected by the fact of DCT – significantly lower ONSD values and also stabilization of ICP were noted after DCT in 75 % of the observations.CONCLUSION. The conductedstudy indicates the relationship between significant decrease in the ONSD parameter and the fact of DCT, accompanied by stabilization of ICP, in patients in the acute period of severe TBI.

Globally, severe traumatic brain injury (TBI) is a significant cause of death and disability, particularly among young adults in their productive years. The management of elevated intracranial pressure (ICP) following TBI remains one of the greatest challenges in neurotrauma care, with decompressive craniectomy (DC) being a prominent, albeit contentious, treatment option. DC, a surgical procedure that involves removing a portion of the skull to accommodate brain swelling, has emerged as a potential life-saving intervention in such scenarios. The rationale is that by reducing ICP and enhancing cerebral perfusion, DC may mitigate further neurological damage. However, while DC effectively reduces mortality, its association with a high prevalence of severe disability and poor long-term functional outcomes has led to ongoing debate regarding its clinical utility, ethical justification, and cost-effectiveness. From a health care economics standpoint, DC has been shown to be more cost-effective than alternatives like barbiturate coma, particularly in younger patients with less severe injuries. Yet, this advantage diminishes in older populations or those with profound neurological impairment, where survival often comes at the cost of substantial long-term care needs and significantly impaired quality of life. Additionally, the decision to perform DC often occurs under critical circumstances where inherent prognostic uncertainty of early outcome prediction and emotional stress further complicate the shared decision-making process. To aid in navigating these complex choices and to guide ethical resource allocation, prognostic models such as Corticosteroid Randomization After Significant Head injury (CRASH) and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) have been developed, offering evidence-based predictions of functional outcomes based on preoperative clinical and radiographic variables. Nevertheless, these models have limitations. This review synthesizes current evidence on the clinical effectiveness, cost utility, and ethical dimensions of DC in severe TBI. It also explores the role of predictive tools in facilitating evidence-informed and ethically responsible decisions. A literature review was conducted using major biomedical databases to identify and synthesize clinical, ethical, and economic evidence related to DC in severe TBI. We also sought the opinion of various experts and tried to provide a comprehensive, multidimensional understanding of DC in neurotrauma care to support clinicians in navigating the complexities of managing severe TBI patients.

Establishing neurological prognoses in traumatic brain injury (TBI) patients remains challenging. To help physicians in the early management of severe TBI, we have designed a visual score (ICEBERG score) including multimodal monitoring and treatment-related criteria. We evaluated the ICEBERG scores among patients with severe TBI to predict the 28-day mortality and long-term disability (Extended Glasgow Outcome Scale score at 3 years). In addition, we made a preliminary assessment of the nurses and doctors on the uptake and reception to the use of the ICEBERG visual tool. This study was part of a larger prospective cohort study of 207 patients with severe TBI in the Parisian region (PariS-TBI study). The ICEBERG score included six variables from multimodal monitoring and treatment-related criteria: cerebral perfusion pressure, intracranial pressure, body temperature, sedation depth, arterial partial pressure of CO 2 , and blood osmolarity. The primary outcome measures included the ICEBERG score and its relationship with hospital mortality and Extended Glasgow Outcome Score. The hospital mortality was 21% (45/207). The ICEBERG score baseline value and changes during the 72nd first hours were more strongly associated with TBI prognosis than the ICEBERG parameters measured individually. Interestingly, when the clinical and computed tomography parameters at admission were combined with the ICEBERG score at 48 hours using a multimodal approach, the predictive value was significantly increased (area under the curve = 0.92). Furthermore, comparing the ICEBERG visual representation with the traditional numerical readout revealed that changes in patient vitals were more promptly detected using ICEBERG representation ( p < 0.05). The ICEBERG score could represent a simple and effective method to describe severity in TBI patients, where a high score is associated with increased mortality and disability. In addition, ICEBERG representation could enhance the recognition of unmet therapeutic goals and dynamic evolution of the patient's condition. These preliminary results must be confirmed in a prospective manner. Diagnostic Tests or Criteria; Level III.

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).

Intensive insulin therapy on infection rate, days in NICU, in-hospital mortality and neurological outcome in severe traumatic brain injury patients: A randomized controlled trial

ObjectiveTo examine the clinical and neurological outcome of patients who sustained a severe non-penetrating traumatic brain injury (TBI) and underwent unilateral decompressive craniectomy (DC) for refractory intracranial hypertension.DesignSingle center, retrospective, observational.SettingLevel I Trauma Center in Portland, Maine.Patients31 patients aged 16–72 of either sex who sustained a severe, non-penetrating TBI and underwent a unilateral DC for evacuation of parenchymal or extra-axial hematoma or for failure of medical therapy to control intracranial pressure (ICP).InterventionsReview of the electronic medical record of patients undergoing DC for severe TBI and assessment of extended Glasgow Outcome Score (e-GOS) at 6-months following DC.Measurements and main resultsThe mean age was 39.3y ± 14.5. The initial GCS was 5.8 ± 3.2, and the ISS was 29.7 ± 6.3. Twenty-two patients underwent DC within the first 24 h, two within the next 24 h and seven between the 3rd and 7th day post injury. The pre-DC ICP was 30.7 ± 10.3 and the ICP was 12.1 ± 6.2 post-DC. Cranioplasty was performed in all surviving patients 1–4 months post-DC. Of the 29 survivors following DC, the e-GOS was 8 in seven patients, and 7 in ten patients. The e-GOS was 5–6 in 6 others. Of the 6 survivors with poor outcomes (e-GOS = 2–4), five were the initial patients in the series.ConclusionsIn patients with intractable cerebral hypertension following TBI, unilateral DC in concert with practice guideline directed brain resuscitation is associated with good functional outcome and acceptable-mortality.

High quality randomized controlled trials of standard large decompressive craniectomy for traumatic brain injury are rare, but have some defects. We compared two high quality randomized controlled trials of decompressive craniectomy for severe traumatic brain injury. To analyze the related factors in patients with severe traumatic brain injury, such as the homogeneity of the sample, the age and the grouping criterion of traumatic brain injury. Discuss its advantages and defects. The aim of this study is to provide a reference for the large sample, multi-center randomized controlled trial of large bone flap decompression in the future. Key words: Decompressive craniectomy; Traumatic brain injury; Randomizde controlled trial

Brain swelling after Traumatic Brain Injury (TBI) can elevate intracranial pressure, necessitating Decompressive Craniectomy (DC) as the preferred surgical intervention. This study aimed to analyze a large institutional database to identify clinical characteristics of patients requiring primary DC and their outcomes. We reviewed TBI patients admitted to our center from 2015 to 2021, utilizing a prospectively maintained registry. Data collected included demographics, injury mechanisms, admission findings, neuroimaging results, DC necessity, procedures during hospitalization, and functional outcomes at discharge and six-month follow-up. A total of 4,011 patients were analyzed, with 506 undergoing primary DC. Factors such as International Normalized Ratio, activated Partial Thromboplastin Time, subdural hematoma, midline shift, epidural hematoma, intracerebral hemorrhage, and the presence of compressed or absent basal cisterns were independently linked to the need for DC. Additionally, the requirement for DC correlated with an increased likelihood of tracheostomy. For patients requiring DC, older age, lower hemoglobin levels, higher Rotterdam scores, and the presence of compressed or absent basal cisterns were associated with unfavorable outcomes in mild to moderate TBI cases. In severe TBI patients, lower Glasgow Coma Scale scores and fixed pupils were linked to poor outcomes. This study represents one of the most comprehensive analyses of primary DC requirements and outcomes, revealing that the need for DC is associated with worse outcomes in TBI patients and identifying several independent predictors of outcomes across varying severity levels.

Objective: In the pediatric population, treatment of severely injured children presenting with low Glasgow Coma Score (GCS) and fixed and dilated pupils is controversial. The combination of barbiturate coma and decompressive craniectomy as an aggressive means of controlling intracranial pressure is limited to few studies. In the present series, we report our experience with aggressive combination therapy resulting in good outcomes in pediatric patients with severe traumatic brain injury (TBI). Patients and Methods: Six TBI patients, aged <18 years, either presented with or deteriorated to a GCS <5 with fixed and dilated pupils and CT evidence of surgical lesions with brain edema. Despite hyperventilation, anesthesia, and mannitol, intracranial pressures remained elevated and all patients underwent decompressive craniectomy and external ventricular drainage and were subsequently placed into barbiturate coma for 72 h. Results: One patient died and 1 patient remained vegetative. Two patients had excellent recoveries (GOS 5/Rankin 1 or 0, no cognitive deficits) and 2 patients had good recoveries (GOS 4/Rankin 1, mild cognitive deficits). Conclusions: Combination of barbiturate coma with decompressive craniectomy and external ventricular drainage led to good outcomes in a small group of pediatric patients with severe TBI. Based on this series we recommend further investigation into aggressive combination management.

Background:Traumatic brain injury (TBI) is a serious medical condition that often leads to significant morbidity and mortality. Decompressive craniectomy (DC) is now widely recognized as a primary or secondary treatment option for managing intracranial pressure (ICP) in patients with severe TBI. However, there is a lack of clarity in reviews regarding the impact of DC on TBI outcomes.Objectives:The aim of this study is to evaluate the effectiveness of DC in terms of overall mortality and long-term prognosis among patients with TBI.Materials and Methods:We conducted a systematic search of four common databases to include all parallel-arm randomized controlled trials (RCTs). We selected studies that reported outcomes for TBI cases, with DC as a treatment option. The outcomes examined included reduction in mortality, ICP levels, and the proportion of patients with a Glasgow Outcome Scale score >4.Results:Our review finally included eight RCTs [n = 1458, with 749 and 709 patients in the DC and control groups, respectively]. The weighted mean difference for ICP was estimated at -4.01 (95% Confidence interval [CI]: -5.31–-2.71), indicating a statistically significant reduction in ICP levels in the DC group compared to the control group. The pooled risk ratio was 0.67 (95% CI: 0.51–0.89), suggesting a statistically significant 31% decrease in mortality levels in the DC group. Subgroup and sensitivity analyzes were also conducted to address heterogeneity.Discussion and Conclusion:In conclusion, based on our meta-analysis, we find that DC can be considered a crucial surgical intervention for reducing mortality among patients with TBI when compared to control groups.

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.