scholarly journals Inadequate Decompressive Craniectomy Following a Wartime Traumatic Brain Injury – An Illustrative Case of Why Size Matters

2019 ◽  
Vol 184 (11-12) ◽  
pp. 929-933 ◽  
Author(s):  
Zachary C Janatpour ◽  
Nicholas S Szuflita ◽  
Joseph Spinelli ◽  
Daniel J Coughlin ◽  
Jeffrey V Rosenfeld ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Current Literature ◽  
Decompressive Craniectomy ◽  
Practice Patterns ◽  
Illustrative Case ◽  
Decompressive Hemicraniectomy ◽  
Penetrating Brain Injury ◽  
Current Guidelines

Abstract Traumatic brain injury has been called the “signature injury” of the wars in Iraq and Afghanistan, and the management of severe and penetrating brain injury has evolved considerably based on the experiences of military neurosurgeons. Current guidelines recommend that decompressive hemicraniectomy be performed with large, frontotemporoparietal bone flaps, but practice patterns vary markedly. The following case is illustrative of potential clinical courses, complications, and efforts to salvage inadequately-sized decompressive craniectomies performed for combat-related severe and penetrating brain injury. The authors follow this with a review of the current literature pertaining to decompressive craniectomy, and finally provide their recommendations for some of the technical nuances of performing decompressive hemicraniectomy after severe or penetrating brain injury.

scholarly journals Decision-making for decompressive craniectomy in traumatic brain injury aided by multimodality monitoring: illustrative case

2021 ◽  
Vol 1 (25) ◽  
Author(s):  
Myranda B. Robinson ◽  
Peter Shin ◽  
Robert Alunday ◽  
Chad Cole ◽  
Michel T. Torbey ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Decision Making ◽  
Brain Injury ◽  
Decompressive Craniectomy ◽  
Pupillary Response ◽  
Illustrative Case ◽  
Secondary Brain Injury ◽  
Brain Tissue Oxygenation ◽  
Multimodality Monitoring ◽  
Severe Tbi

BACKGROUND Severe traumatic brain injury (TBI) requires individualized, physiology-based management to avoid secondary brain injury. Recent improvements in quantitative assessments of metabolism, oxygenation, and subtle examination changes may potentially allow for more targeted, rational approaches beyond simple intracranial pressure (ICP)-based management. The authors present a case in which multimodality monitoring assisted in decision-making for decompressive craniectomy. OBSERVATIONS This patient sustained a severe TBI without mass lesion and was monitored with a multimodality approach. Although imaging did not seem grossly worrisome, ICP, pressure reactivity, brain tissue oxygenation, and pupillary response all began worsening, pushing toward decompressive craniectomy. All parameters normalized after decompression, and the patient had a satisfactory clinical outcome. LESSONS Given recent conflicting randomized trials on the utility of decompressive craniectomy in severe TBI, precision, physiology-based approaches may offer an improved strategy to determine who is most likely to benefit from aggressive treatment. Trials are underway to test components of these strategies.

scholarly journals Decompressive Craniectomy: Contralateral Lesions and Metabolic Abnormalities

2014 ◽  
Vol 41 (3) ◽  
pp. 350-356 ◽  
Author(s):  
F.A. Zeiler ◽  
M. West
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Head Injury ◽  
Decompressive Craniectomy ◽  
Metabolic Factors ◽  
Decompressive Hemicraniectomy ◽  
Time Period ◽  
Potential Association ◽  
Laboratory Results ◽  
Intracranial Lesions

Objective:To define the incidence of new contralateral intracranial lesions following decompressive hemicraniectomy for blunt traumatic brain injury, and explore the potential association with metabolic factors that contribute to coagulopathy.Methods:We retrospectively reviewed the records and imaging of all patients treated with hemicraniectomy for blunt traumatic brain injury at our institution from May 2007 up to and including January 2012.Results:Twenty patients were identified during the time period to have undergone decompressive craniectomy for blunt head injury. The average age and Glasgow Coma Scale on presentation was 44.1 years (range: 19 – 72 years) and 6.5 (range: 3 – 14) respectively. All but one patient presented with an extra-axial hematoma as their surgical indication for craniectomy. Seven patients (35.0%) developed new contralateral lesions post-craniectomy. The average peri-operative pH, bicarbonate (HCO3) and hematocrit (HCT) levels for those with new contralateral lesions were lower than those without new lesions. Five of the seven patients (71.4%) with new lesions had abnormalities on their laboratory results that have been know to be attributable to coagulopathy, with four (57.1%) having two or more abnormal results. Eight of 13 (61.5%) patients without new lesion had laboratory abnormalites, with five (38.5%) having two or more abnormalities identified.Conclusions:The incidence of new contralateral lesions post-craniectomy for blunt head injury is 35.0% in our experience. There is an association between the metabolic derangements linked to trauma related coagulopathy and the formation of new lesions.

Decompressive Craniectomy is Associated with Improved Quality of Life Up to Ten Years After Rehabilitation from Traumatic Brain Injury

2019 ◽  
Author(s):  
Katrin Rauen ◽  
Lara Reichelt ◽  
Philipp Probst ◽  
Barbara Schäpers ◽  
Friedemann Müller ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Decompressive Craniectomy

Early versus late decompressive craniectomy in traumatic brain injury: A retrospective comparative case study

Trauma ◽  
2020 ◽  
pp. 146040862093576
Author(s):  
Nida Fatima ◽  
Mujeeb-Ur-Rehman ◽  
Samia Shaukat ◽  
Ashfaq Shuaib ◽  
Ali Raza ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Regression Analysis ◽  
Brain Injury ◽  
Functional Outcome ◽  
Decompressive Craniectomy ◽  
Univariate Analysis ◽  
Timing Of Surgery ◽  
Comparative Case Study ◽  
Outcome Parameters ◽  
Good Functional Outcome

Objectives Decompressive craniectomy is a last-tier therapy in the treatment of raised intracranial pressure after traumatic brain injury. We report the association of demographic, radiographic, and injury characteristics with outcome parameters in early (<24 h) and late (≥24 h) decompressive craniectomy following traumatic brain injury. Methods We retrospectively identified 204 patients (158 (early decompressive craniectomy) and 46 (late decompressive craniectomy)), with a median age of 34 years (range 2–78 years) between 2015 and 2018. The primary endpoint was Glasgow Outcome Scale Extended (GOSE) at 60 days, while secondary endpoints included Glasgow Coma Score (GCS) at discharge, mortality at 30 days, and length of hospital stay. Regression analysis was used to assess the independent predictive variables of functional outcome. Results With a clinical follow-up of 60 days, the good functional outcome (GOSE = 5–8) was 73.5% versus 74.1% (p = 0.75) in early and late decompressive craniectomy, respectively. GCS ≥ 9 at discharge was 82.2% versus 91.3% (p = 0.21), mortality at 30 days was 10.8% versus 8.7% (p = 0.39), and length of stay in the hospital was 21 days versus 28 days (p = 0.20), respectively, in early and late decompressive craniectomy groups. Univariate analysis identified that GCS at admission (0.07 (0.32–0.18; < 0.05)) and indication for decompressive craniectomy (3.7 (1.3–11.01; 0.01)) are significantly associated with good functional outcome. Multivariate regression analysis revealed that GCS at admission (<9/≥9) (0.07 (0.03–0.16; <0.05)) and indication for decompressive craniectomy (extradural alone/ other hematoma) (1.75 (1.09–3.25; 0.02)) were significant independent predictors of good functional outcome irrespective of the timing of surgery. Conclusions Our results corroborate that the timing of surgery does not affect the outcome parameters. Furthermore, GCS ≥ 9 and/or extra dural hematoma are associated with relatively good clinical outcome after decompressive craniectomy.

scholarly journals Quantitative cerebral blood flow using xenon-enhanced CT after decompressive craniectomy in traumatic brain injury

2018 ◽  
Vol 129 (1) ◽  
pp. 241-246 ◽  
Author(s):  
Aditya Vedantam ◽  
Claudia S. Robertson ◽  
Shankar P. Gopinath
Keyword(s):  
Traumatic Brain Injury ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Brain Injury ◽  
Clinical Outcome ◽  
Decompressive Craniectomy ◽  
Decompressive Surgery ◽  
Hemodynamic Parameters ◽  
Enhanced Ct ◽  
The Mean

OBJECTIVEFew studies have reported on changes in quantitative cerebral blood flow (CBF) after decompressive craniectomy and the impact of these measures on clinical outcome. The aim of the present study was to evaluate global and regional CBF patterns in relation to cerebral hemodynamic parameters in patients after decompressive craniectomy for traumatic brain injury (TBI).METHODSThe authors studied clinical and imaging data of patients who underwent xenon-enhanced CT (XeCT) CBF studies after decompressive craniectomy for evacuation of a mass lesion and/or to relieve intractable intracranial hypertension. Cerebral hemodynamic parameters prior to decompressive craniectomy and at the time of the XeCT CBF study were recorded. Global and regional CBF after decompressive craniectomy was measured using XeCT. Regional cortical CBF was measured under the craniectomy defect as well as for each cerebral hemisphere. Associations between CBF, cerebral hemodynamics, and early clinical outcome were assessed.RESULTSTwenty-seven patients were included in this study. The majority of patients (88.9%) had an initial Glasgow Coma Scale score ≤ 8. The median time between injury and decompressive surgery was 9 hours. Primary decompressive surgery (within 24 hours) was performed in the majority of patients (n = 18, 66.7%). Six patients had died by the time of discharge. XeCT CBF studies were performed a median of 51 hours after decompressive surgery. The mean global CBF after decompressive craniectomy was 49.9 ± 21.3 ml/100 g/min. The mean cortical CBF under the craniectomy defect was 46.0 ± 21.7 ml/100 g/min. Patients who were dead at discharge had significantly lower postcraniectomy CBF under the craniectomy defect (30.1 ± 22.9 vs 50.6 ± 19.6 ml/100 g/min; p = 0.039). These patients also had lower global CBF (36.7 ± 23.4 vs 53.7 ± 19.7 ml/100 g/min; p = 0.09), as well as lower CBF for the ipsilateral (33.3 ± 27.2 vs 51.8 ± 19.7 ml/100 g/min; p = 0.07) and contralateral (36.7 ± 19.2 vs 55.2 ± 21.9 ml/100 g/min; p = 0.08) hemispheres, but these differences were not statistically significant. The patients who died also had significantly lower cerebral perfusion pressure (52 ± 17.4 vs 75.3 ± 10.9 mm Hg; p = 0.001).CONCLUSIONSIn the presence of global hypoperfusion, regional cerebral hypoperfusion under the craniectomy defect is associated with early mortality in patients with TBI. Further study is needed to determine the value of incorporating CBF studies into clinical decision making for severe traumatic brain injury.

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