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.

Long-Term Effects of Decompressive Craniectomy on Functional Outcomes after Traumatic Brain Injury: A Multicenter Study

2018 ◽  
Vol 84 (8) ◽  
pp. 1314-1318 ◽  
Author(s):  
Eliza Moskowitz ◽  
Claudia I. Melendez ◽  
Julie Dunn ◽  
Abid D. Khan ◽  
Richard Gonzalez ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Confidence Interval ◽  
Functional Outcome ◽  
Decompressive Craniectomy ◽  
Functional Outcomes ◽  
Structured Interview ◽  
Good Functional Outcome

Decompressive craniectomy (DC) is a surgical modality sometimes used in the management of elevated intracranial pressure. Questions remain as to its long-term benefits in traumatic brain injury patients. The extended Glasgow Outcome Scale (eGOS) is a scoring system based on a structured interview that allows for consistent and reproducible measurement of long-term functional outcomes. The purpose of this study was to determine the eGOS score of post-craniectomy patients after discharge and stratify survivors based on outcome. A multicenter review of patients who underwent DC was performed. Survivors underwent a phone survey at which time the eGOS was calculated. Patients with an eGOS ≥ 5 were considered to have a good functional outcome. Fifty-four patients underwent DC. Age (OR 1.038; confidence interval 1.003–1.074) and Glasgow Coma Scale (OR 0677; confidence interval 0.527–0.870) were predictors of mortality. Patients who were available for follow-up (n = 13) had poor functional outcomes at discharge (eGOS = 3); however, this improved at the time of follow-up survey (eGOS = 5; P = 0.005). DC is a controversial operation with high mortality and uncertain benefit. Among our cohort, the eGOS score was significantly higher at follow-up survey than it was at discharge. Although the mortality was high, if patients survived to discharge, most had a good functional outcome at follow-up survey.

Timing of Surgery After Multisystem Injury With Traumatic Brain Injury: Effect on Neuropsychological and Functional Outcome

2007 ◽  
Vol 62 (5) ◽  
pp. 1250-1258 ◽  
Author(s):  
Marjorie C. Wang ◽  
Nancy R. Temkin ◽  
Richard A. Deyo ◽  
Gregory J. Jurkovich ◽  
Jason Barber ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Functional Outcome ◽  
Timing Of Surgery

Impact of Decompressive Craniectomy on Functional Outcome After Severe Traumatic Brain Injury

2009 ◽  
Vol 66 (6) ◽  
pp. 1570-1576 ◽  
Author(s):  
Regan F. Williams ◽  
Louis J. Magnotti ◽  
Martin A. Croce ◽  
Brinson B. Hargraves ◽  
Peter E. Fischer ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Functional Outcome ◽  
Decompressive Craniectomy ◽  
Severe Traumatic Brain Injury

scholarly journals Role of Cisternal Drainage in Patients with Traumatic Brain Injury Undergoing Decompressive Craniectomy

2019 ◽  
Vol 15 (3) ◽  
pp. 14-20
Author(s):  
Amit Thapa ◽  
Rupendra Bahadur Adhikari ◽  
Bidur KC ◽  
Bikram Shakya
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Functional Outcome ◽  
Decompressive Craniectomy ◽  
Brain Injuries ◽  
Injury Severity ◽  
Absolute Risk ◽  
Group 2 ◽  
Cisternal Drainage ◽  
Group 1

The effect of decompressive craniectomy (DC) on survival and functional outcome in traumatic brain injuries (TBI) is far from satisfactory. Additional modalities including cisternal drainage (CD) that provides good control of refractory intracranial pressure (ICP) intraoperatively need careful scrutiny. Two centre retrospective superiority study with one centre offering only standard decompressive craniectomy (DC) i.e. Group 1 and the other centre supplementing cisternal drainage (CD) to standard DC i.e. Group 2 was conducted. Consecutive patients with traumatic brain injury with signs of brain herniation or CT scan showing mass lesion or diffuse brain edema or midline shift or with GCS less than 9 or rapid fall in GCS over 2 points with persistently raised ICP of 25 mmHg over 15 minutes between August 2012 and July 2017 were included. The primary outcome was rating on Glasgow Outcome Scale (GOS) at 6 months post operatively, with GOS (1-3) categorized as ‘Unfavorable’ and GOS (4,5) as ‘Favorable’. Patients either received DC alone (Group 1=73 patients, 48.7%) or DC with CD (Group 2=77 patients, 51.3%). 107 (71.3%) severe, 36 (24%) moderate, and 7 (4.7%) mild head injuries cases received 72 unilateral and 78 bilateral DC. GOS 1 was observed in 32 DC only group (43.8%) and 22 DC plus CD group (28.6%) (p=0.052), an absolute risk reduction of 15.2% was found. Outcome (favorable sun favorable) against all strata of head injury severity, predominant radiological feature, laterality of surgery, and patient characteristics across the two groups were statistically not significant, however the groups were statistically significantly different on age and GCS at presentation (p=0.016 & 0.034 consecutively). Distinct survival benefit in patients with traumatic brain injury receiving cisternal drainage during decompressive craniectomy did not translate to better functional outcome.

scholarly journals Outcome in Patients with Isolated Moderate to Severe Traumatic Brain Injury

2018 ◽  
Vol 2018 ◽  
pp. 1-7 ◽  
Author(s):  
D. Jochems ◽  
K. J. P. van Wessem ◽  
R. M. Houwert ◽  
H. B. Brouwers ◽  
J. W. Dankbaar ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Functional Outcome ◽  
Cause Of Death ◽  
Outcome Data ◽  
Unresponsive Wakefulness Syndrome ◽  
Exclusion Criteria ◽  
Good Functional Outcome ◽  
Cord Injury ◽  
Life Sustaining Treatment

Introduction. Traumatic brain injury (TBI) remains a major cause of death. Withdrawal of life-sustaining treatment (WLST) can be initiated if there is little anticipated chance of recovery to an acceptable quality of life. The aim of this study was firstly to investigate WLST rates in patients with moderate to severe isolated TBI and secondly to assess outcome data in the survivor group. Material and Methods. A retrospective cohort study was performed. Patients aged ≥ 18 years with moderate or severe isolated TBI admitted to the ICU of a single academic hospital between 2011 and 2015 were included. Exclusion criteria were isolated spinal cord injury and referrals to and from other hospitals. Gathered data included demographics, mortality, cause of death, WLST, and Glasgow Outcome Scale (GOS) score after three months. Good functional outcome was defined as GOS > 3. Results. Of 367 patients, 179 patients were included after applying inclusion and exclusion criteria. 55 died during admission (33%), of whom 45 (82%) after WLST. Patients undergoing WLST were older, had worse neurological performance at presentation, and had more radiological abnormalities than patients without WLST. The decision to withdraw life-sustaining treatment was made on the day of admission in 40% of patients. In 33% of these patients, this decision was made while the patient was in the Emergency Department. 71% of survivors had a good functional outcome after three months. No patient left hospital with an unresponsive wakefulness syndrome (UWS) or suffered from UWS after three months. One patient died within three months of discharge. Conclusion. In-hospital mortality in isolated brain injured patients was 33%. The vast majority died after a decision to withdraw life-sustaining treatment. None of the patients were discharged with an unresponsive wakefulness syndrome.

scholarly journals Effect of preoperative antiplatelet or anticoagulation therapy on hemorrhagic complications in patients with traumatic brain injury undergoing craniotomy or craniectomy

2019 ◽  
Vol 47 (5) ◽  
pp. E3 ◽  
Author(s):  
Ladina Greuter ◽  
Muriel Ullmann ◽  
Luigi Mariani ◽  
Raphael Guzman ◽  
Jehuda Soleman
Keyword(s):  
Traumatic Brain Injury ◽  
Regression Analysis ◽  
Brain Injury ◽  
Univariate Analysis ◽  
Postoperative Bleeding ◽  
Acute Subdural Hematoma ◽  
Control Group ◽  
Bleeding Events ◽  
Cox Regression Analysis ◽  
Significant Difference

OBJECTIVETraumatic brain injury (TBI) is common among the elderly, often treated with antiplatelet (AP) or anticoagulation (AC) therapy, creating new challenges in neurosurgery. In contrast to elective craniotomy, in which AP/AC therapy is mostly discontinued, in TBI usually no delay in treatment can be afforded. The aim of this study was to analyze the effect of AP/AC therapy on postoperative bleeding after craniotomy/craniectomy in TBI.METHODSPostoperative bleeding rates in patients treated with AP/AC therapy (blood thinner group) and in those without AP/AC therapy (control group) were retrospectively compared. Furthermore, univariate and multivariate analyses were conducted to identify risk factors for postoperative bleeding. Lastly, a proportional Cox regression analysis comparing postoperative bleeding events within 14 days in both groups was performed.RESULTSOf 143 consecutive patients undergoing craniotomy/craniectomy for TBI between 2012 and 2017, 47 (32.9%) were under AP/AC treatment. No significant difference for bleeding events was observed in univariate (40.4% blood thinner group vs 36.5% control group; p = 0.71) or Cox proportional regression analysis (log rank χ2 = 0.29, p = 0.59). Patients with postoperative bleeding showed a significantly higher mortality rate (p = 0.035). In the univariate analysis, hemispheric lesion, acute subdural hematoma, hematological disease, greater extent of midline shift, and pupillary difference were significantly associated with a higher risk of postoperative bleeding. However, in the multivariate regression analysis none of these factors showed a significant association with postoperative bleeding.CONCLUSIONSPatients treated with AP/AC therapy undergoing craniotomy/craniectomy due to TBI do not appear to have increased rates of postoperative bleeding. Once postoperative bleeding occurs, mortality rates rise significantly.

scholarly journals Decompressive Craniectomy for Traumatic Brain Injury: In-hospital Mortality-Associated Factors

2020 ◽  
Vol 11 (04) ◽  
pp. 601-608
Author(s):  
Fernando Celi ◽  
Giancarlo Saal-Zapata
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Hospital Mortality ◽  
Decompressive Craniectomy ◽  
Univariate Analysis ◽  
Midline Shift ◽  
Tomographic Images ◽  
Radiological Criteria ◽  
The Mean ◽  
Gcs Score

Abstract Objective Determine predictors of in-hospital mortality in patients with severe traumatic brain injury (TBI) who underwent decompressive craniectomy. Materials and Methods This retrospective study reviewed consecutive patients who underwent a decompressive craniectomy between March 2017 and March 2020 at our institution, and analyzed clinical characteristics, brain tomographic images, surgical details and morbimortality associated with this procedure. Results Thirty-three (30 unilateral and 3 bifrontal) decompressive craniectomies were performed, of which 27 patients were male (81.8%). The mean age was 52.18 years, the mean Glasgow coma scale (GCS) score at admission was 9, and 24 patients had anisocoria (72.7%). Falls were the principal cause of the trauma (51.5%), the mean anterior–posterior diameter (APD) of the bone flap in unilateral cases was 106.81 mm (standard deviation [SD] 20.42) and 16 patients (53.3%) underwent a right-sided hemicraniectomy. The temporal bone enlargement was done in 20 cases (66.7%), the mean time of surgery was 2 hours and 27 minutes, the skull flap was preserved in the subcutaneous layer in 29 cases (87.8%), the mean of blood loss was 636.36 mL,and in-hospital mortality was 12%. Univariate analysis found differences between the APD diameter (120.3 mm vs. 85.3 mm; p = 0.003) and the presence of midline shift > 5 mm (p = 0.033). Conclusion The size of the skull flap and the presence of midline shift > 5 mm were predictors of mortality. In the absence of intercranial pressure (ICP) monitoring, clinical and radiological criteria are mandatory to perform a decompressive craniectomy.

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