Decompressive craniectomy in a neurologically devastated pregnant woman to maintain fetal viability

2012 ◽  
Vol 116 (3) ◽  
pp. 487-490 ◽  
Author(s):  
Nathaniel Whitney ◽  
Ahmed M. Raslan ◽  
Brian T. Ragel
Keyword(s):  
Traumatic Brain Injury ◽  
Pregnant Woman ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Glasgow Coma Scale ◽  
Decompressive Craniectomy ◽  
Aggressive Management ◽  
Severe Tbi ◽  
Aggressive Medical Management ◽  
In Utero Development

Severe traumatic brain injury (TBI) in pregnant women can result in devastating outcomes for both the mother and the fetus. Historically, there has been concern regarding the issues involved when the fetus is not yet viable outside the womb. Currently, the ability to treat severe TBI with aggressive management of intracranial pressure (ICP) has led to the possibility of sustaining maternal life until the fetus is of a viable age and can be delivered. The authors present the case of a young woman 21 weeks pregnant with a severe TBI (Glasgow Coma Scale Score 3) in whom safe medical ICP management became ineffective. A decompressive craniectomy was performed to obviate the need for aggressive medical management of elevated ICP using fetal-toxic medications, and thus providing the fetus the best chance of continued in utero development until a viable gestational age was reached.

scholarly journals Decompressive Craniectomy for Elevated Intracranial Pressure and Its Effect on the Cumulative Ischemic Burden and Therapeutic Intensity Levels After Severe Traumatic Brain Injury

Neurosurgery ◽  
2010 ◽  
Vol 66 (6) ◽  
pp. 1111-1119 ◽  
Author(s):  
Gregory M. Weiner ◽  
Michelle R. Lacey ◽  
Larami Mackenzie ◽  
Darshak P. Shah ◽  
Suzanne G. Frangos ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Decompressive Craniectomy ◽  
Severe Traumatic Brain Injury ◽  
Intensity Level ◽  
Before And After ◽  
Severe Tbi ◽  
Therapeutic Intensity ◽  
The Brain

Abstract BACKGROUND Increased intracranial pressure (ICP) can cause brain ischemia and compromised brain oxygen (PbtO2 ≤ 20 mm Hg) after severe traumatic brain injury (TBI). OBJECTIVE We examined whether decompressive craniectomy (DC) to treat elevated ICP reduces the cumulative ischemic burden (CIB) of the brain and therapeutic intensity level (TIL). METHODS Ten severe TBI patients (mean age, 31.4 ± 14.2 years) who had continuous PbtO2 monitoring before and after delayed DC were retrospectively identified. Patients were managed according to the guidelines for the management of severe TBI. The CIB was measured as the total time spent between a PbtO2 of 15 to 20, 10 to 15, and 0 to 10 mm Hg. The TIL was calculated every 12 hours. Mixed-effects models were used to estimate changes associated with DC. RESULTS DC was performed on average 2.8 days after admission. DC was found to immediately reduce ICP (mean [SEM] decrease was 7.86 mm Hg [2.4 mm Hg]; P = .005). TIL, which was positively correlated with ICP (r = 0.46, P ≤ .001), was reduced within 12 hours after surgery and continued to improve within the postsurgical monitoring period (P ≤ .001). The duration and severity of CIB were significantly reduced as an effect of DC in this group. The overall mortality rate in the group of 10 patients was lower than predicted at the time of admission (P = .015). CONCLUSION These results suggest that a DC for increased ICP can reduce the CIB of the brain after severe TBI. We suggest that DC be considered early in a patient's clinical course, particularly when the TIL and ICP are increased.

Pressure autoregulation, intracranial pressure, and brain tissue oxygenation in children with severe traumatic brain injury

2009 ◽  
Vol 4 (5) ◽  
pp. 420-428 ◽  
Author(s):  
Anthony A. Figaji ◽  
Eugene Zwane ◽  
A. Graham Fieggen ◽  
Andrew C. Argent ◽  
Peter D. Le Roux ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Blood Flow ◽  
Brain Injury ◽  
Mean Arterial Pressure ◽  
Intracranial Pressure ◽  
Glasgow Coma Scale ◽  
Arterial Pressure ◽  
Clinical Factors ◽  
Severe Tbi ◽  
Pressure Autoregulation

Object Cerebral pressure autoregulation is an important neuroprotective mechanism that stabilizes cerebral blood flow when blood pressure (BP) changes. In this study the authors examined the association between autoregulation and clinical factors, BP, intracranial pressure (ICP), brain tissue oxygen tension (PbtO2), and outcome after pediatric severe traumatic brain injury (TBI). In particular we examined how the status of autoregulation influenced the effect of BP changes on ICP and PbtO2. Methods In this prospective observational study, 52 autoregulation tests were performed in 24 patients with severe TBI. The patients had a mean age of 6.3 ± 3.2 years, and a postresuscitation Glasgow Coma Scale score of 6 (range 3–8). All patients underwent continuous ICP and PbtO2 monitoring, and transcranial Doppler ultrasonography was used to examine the autoregulatory index (ARI) based on blood flow velocity of the middle cerebral artery after increasing mean arterial pressure by 20% of the baseline value. Impaired autoregulation was defined as an ARI < 0.4 and intact autoregulation as an ARI ≥ 0.4. The relationships between autoregulation (measured as both a continuous and dichotomous variable), outcome, and clinical and physiological variables were examined using multiple logistic regression analysis. Results Autoregulation was impaired (ARI < 0.4) in 29% of patients (7 patients). The initial Glasgow Coma Scale score was significantly associated with the ARI (p = 0.02, r = 0.32) but no other clinical factors were associated with autoregulation status. Baseline values at the time of testing for ICP, PbtO2, the ratio of PbtO2/PaO2, mean arterial pressure, and middle cerebral artery blood flow velocity were similar in the patients with impaired or intact autoregulation. There was an inverse relationship between ARI (continuous and dichotomous) with a change in ICP (continuous ARI, p = 0.005; dichotomous ARI, p = 0.02); that is, ICP increased with the BP increase when ARI was low (weak autoregulation). The ARI (continuous and dichotomous) was also inversely associated with a change in PbtO2 (continuous ARI, p = 0.002; dichotomous ARI, p = 0.02). The PbtO2 increased when BP was increased in most patients, even when the ARI was relatively high (stronger autoregulation), but the magnitude of this response was still associated with the ARI. There was no relationship between the ARI and outcome. Conclusions These data demonstrate the influence of the strength of autoregulation on the response of ICP and PbtO2 to BP changes and the variability of this response between individuals. The findings suggest that autoregulation testing may assist clinical decision-making in pediatric severe TBI and help better define optimal BP or cerebral perfusion pressure targets for individual patients.

ICP MONITOR PLACEMENT STEPWISE EARLY DECOMPRESSIVE CRANIECTOMY FOR THE MANAGEMENT OF SEVERE TBI PATIENTS: A CASE REPORT

2018 ◽  
pp. 35-40
Author(s):  
Dirga Rachmad Aprianto ◽  
Achmad Kurniawan ◽  
Andhika Tomy Permana ◽  
Fadillah Putri Rusdi ◽  
Akbar Wido ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Case Report ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Intracranial Hemorrhage ◽  
Decompressive Craniectomy ◽  
Pressure Monitor ◽  
Severe Tbi ◽  
Gradual Release ◽  
Increased Icp

Introduction. Increased intracranial pressure (ICP) is a secondary event that mostly occurs following traumatic brain injury (TBI) and it correlates with poor outcome of the patients. Several studies have suggested that early decompressive craniectomy (DC; within 48 hours after injury) is recommended for severe TBI patients requiring removal of intracranial hemorrhage and early DC was able to reduce the complications of TBI caused by increased ICP. However, even early DC has been performed, increased ICP may still progress due to massive brain edema. Methods. We herein report a case report of patient admitted with severe TBI and intracranial hemorrhage. The patients were underwent DC and ICP monitor placement after the removal of the intracranial hemorrhage. During postoperative observation in ICU, the CSF of the patients was gradually drained if the ICP was over 15mmHg. Results. The ICP right after performed early DC was 30 cmH2O (22 mmHg). One day after surgery, the hemodynamic of the patient was stable and the GCS was 2X5 with the ICP of the patient was about 18 cmH2O. On day 2-5, patient was hemodynamically stable with improved GCS (3X5) and decreased of ICP (around 13-15 cmH2O). On day 6, the ICP monitor was removed and the patient discharged on day 19 after fully recovered. Conclusion. The placement of ICP monitor and the application of gradual release of CSF after DC might be helpful to reduce increased ICP in severe TBI patients, and thus reducing the morbidity and mortality.   Keywords: Traumatic brain injury, intracranial pressure monitor, decompressive craniectomy

scholarly journals Modulated Neuroprotection in Unresponsive Wakefulness Syndrome after Severe Traumatic Brain Injury

2021 ◽  
Vol 11 (8) ◽  
pp. 1044
Author(s):  
Cristina Daia ◽  
Cristian Scheau ◽  
Aura Spinu ◽  
Ioana Andone ◽  
Cristina Popescu ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Severe Traumatic Brain Injury ◽  
Functional Independence ◽  
Unresponsive Wakefulness Syndrome ◽  
Coma Scale ◽  
Severe Tbi ◽  
Neuroprotective Treatment ◽  
Gcs Score

Background: We aimed to assess the effects of modulated neuroprotection with intermittent administration in patients with unresponsive wakefulness syndrome (UWS) after severe traumatic brain injury (TBI). Methods: Retrospective analysis of 60 patients divided into two groups, with and without neuroprotective treatment with Actovegin, Cerebrolysin, pyritinol, L-phosphothreonine, L-glutamine, hydroxocobalamin, alpha-lipoic acid, carotene, DL-α-tocopherol, ascorbic acid, thiamine, pyridoxine, cyanocobalamin, Q 10 coenzyme, and L-carnitine alongside standard treatment. Main outcome measures: Glasgow Coma Scale (GCS) after TBI, Extended Glasgow Coma Scale (GOS E), Disability Rankin Scale (DRS), Functional Independence Measurement (FIM), and Montreal Cognitive Assessment (MOCA), all assessed at 1, 3, 6, 12, and 24 months after TBI. Results: Patients receiving neuroprotective treatment recovered more rapidly from UWS than controls (p = 0.007) passing through a state of minimal consciousness and gradually progressing until the final evaluation (p = 0.000), towards a high cognitive level MOCA = 22 ± 6 points, upper moderate disability GOS-E = 6 ± 1, DRS = 6 ± 4, and an assisted gait, FIM =101 ± 25. The improvement in cognitive and physical functioning was strongly correlated with lower UWS duration (−0.8532) and higher GCS score (0.9803). Conclusion: Modulated long-term neuroprotection may be the therapeutic key for patients to overcome UWS after severe TBI.

Trauma: Traumatic Brain Injury

2018 ◽  
pp. 95-100
Author(s):  
Ruchir Gupta
Keyword(s):  
Traumatic Brain Injury ◽  
Substance Abuse ◽  
Acute Respiratory Distress Syndrome ◽  
Cervical Spine ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Glasgow Coma Scale ◽  
Elevated Intracranial Pressure ◽  
Intraoperative Management ◽  
History Of

In this chapter the essential aspects of anesthesia for traumatic brain injury are discussed. Subtopics include manifestations and treatment of elevated intracranial pressure (ICP), Glasgow Coma Scale (GCS), drugs used to lower ICP, and patient monitoring. The case presented is an emergent craniotomy. The chapter is divided into preoperative, intraoperative, and postoperative sections with important subtopics related to the main topic in each section. Preoperative topics discussed are evaluation of trauma, use of the GCS in this case, assessing intracranial hypertension, history of substance abuse, and clearing the cervical spine. Issues related to intraoperative management in this case include induction and use of blood products. Postoperative concerns addressed include polyuria and acute respiratory distress syndrome.

scholarly journals High Serum Caspase-Cleaved Cytokeratin-18 Levels and Mortality of Traumatic Brain Injury Patients

2019 ◽  
Vol 9 (10) ◽  
pp. 269 ◽  
Author(s):  
Leonardo Lorente ◽  
María M. Martín ◽  
Agustín F. González-Rivero ◽  
Antonia Pérez-Cejas ◽  
Mónica Argueso ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Area Under The Curve ◽  
High Serum ◽  
Early Mortality ◽  
Cytokeratin 18 ◽  
New Findings ◽  
Severe Tbi ◽  
Time Of Admission

Objective: Apoptosis increases in traumatic brain injury (TBI). Caspase-cleaved cytokeratin (CCCK)-18 in blood during apoptosis could appear. At the time of admission due to TBI, higher blood CCCK-18 levels were found in non-surviving than in surviving patients. Therefore, the objective of our study was to analyze whether serum CCCK-18 levels determined during the first week after TBI could predict early mortality (at 30 days). Methods: Severe TBI patients were included (considering severe when Glasgow Coma Scale < 9) in this observational and multicentre study. Serum CCCK-18 levels were determined at day 1 of TBI, and at days 4 and 8 after TBI. Results: Serum CCCK-18 levels at day 1 of TBI, and in the days 4 and 8 after TBI were higher (p < 0.001) in non-surviving than in surviving patients (34 and 90 patients, respectively) and could predict early mortality (p < 0.001 in the area under the curve). Conclusions: The new findings from our study were that serum CCCK-18 levels at any moment of the first week of TBI were higher in non-surviving patients and were able to predict early mortality.

Do long-term results justify decompressive craniectomy after severe traumatic brain injury?

2008 ◽  
Vol 109 (4) ◽  
pp. 685-690 ◽  
Author(s):  
Matthias H. Morgalla ◽  
Bernd E. Will ◽  
Florian Roser ◽  
Marcos Tatagiba
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Decompressive Craniectomy ◽  
Severe Traumatic Brain Injury ◽  
Barthel Index ◽  
Case Series ◽  
Clinical Results ◽  
Long Term Results

Object A decompressive craniectomy can be a life-saving procedure to relieve critically increased intracranial pressure. The survival of a patient is important as well as the subsequent and long-term quality of life. In this paper the authors' goal was to investigate whether long-term clinical results justify the use of a decompressive craniectomy. Methods Thirty-three patients (20 males and 13 females) with a mean age of 36.3 years (range 13–60 years) with severe traumatic brain injury (Grades III and IV) and subsequent massive brain swelling were examined. For postoperative assessment the Barthel Index was used. A surgical intervention was based on the following criteria: 1) The intracranial pressure could not be controlled by conservative treatment and constantly exceeded 30 mm Hg (cerebral perfusion pressure < 50 mm Hg). 2) Transcranial Doppler ultrasonography revealed only a systolic flow pattern or systolic peaks. 3) There were no other major injuries. 4) The patient was not older than 60 years. Results One-fifth of all patients died and one-fifth remained in a vegetative state. Mild deficits were seen in 6 of 33 patients. A full rehabilitation (Barthel Index 90–100) was achieved in 13 patients (39.4%). Five patients could resume their former occupation, and another 4 had to change jobs. Conclusions Age remains to be one of the most important exclusion factors. Decompressive craniectomy provided good clinical results in nearly 40% of patients who were otherwise most likely to die. Therefore, long-term results justify the use of decompressive craniectomy in this case series.

scholarly journals Outcome of children with severe traumatic brain injury who are treated with decompressive craniectomy

2015 ◽  
Vol 16 (5) ◽  
pp. 508-514 ◽  
Author(s):  
Maroun J. Mhanna ◽  
Wael EI Mallah ◽  
Margaret Verrees ◽  
Rajiv Shah ◽  
Dennis M. Super
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Decompressive Craniectomy ◽  
Cerebral Edema ◽  
Severe Traumatic Brain Injury ◽  
Medical Records ◽  
Case Control Study ◽  
Case Control ◽  
Severe Tbi ◽  
Control Study

OBJECT Decompressive craniectomy (DC) for the management of severe traumatic brain injury (TBI) is controversial. The authors sought to determine if DC improves the outcome of children with severe TBI. METHODS In a retrospective, case-control study, medical records of all patients admitted to the pediatric ICU between May 1998 and May 2008 with severe TBI and treated with DC were identified and matched to patients who were treated medically without DC. Medical records were reviewed for patients’ demographic data and baseline characteristics. RESULTS During the study period, 17 patients with severe TBI treated with DC at a median of 2 hours (interquartile range [IQR] 1–14 hours) after admission were identified and matched to 17 contemporary controls. On admission, there were no differences between DC and control patients regarding age (10.2 ± 5.9 years vs 12.4 ± 5.4 years, respectively [mean ± SD]), sex, weight, Glasgow Coma Scale score (median 5 [IQR 3–7] vs 4 [IQR 3–6], respectively; p = 0.14), or the highest intracranial pressure (median 42 [IQR 22–54] vs 30 [IQR 21–36], respectively; p = 0.77). However, CT findings were significant for a higher rate of herniation and cerebral edema among patients with DC versus controls (7/17 vs 2/17, respectively, had herniation [p = 0.05] and 14/17 vs 6/17, respectively, had cerebral edema [p = 0.006]). Overall there were no significant differences in survival between patients with DC and controls (71% [12/17] vs 82% [14/17], respectively; p = 0.34). However, among survivors, at 4 years (IQR 1–6 years) after the TBI, 42% (5/12) of the DC patients had mild disability or a Glasgow Outcome Scale score of 5 vs none (0/14) of the controls (p = 0.012). CONCLUSIONS In this retrospective, small case-control study, the authors have shown that early DC in pediatric patients with severe TBI improves outcome in survivors. Future prospective randomized controlled studies are needed to confirm these findings.

scholarly journals Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

2012 ◽  
Vol 117 (4) ◽  
pp. 729-734 ◽  
Author(s):  
Arash Farahvar ◽  
Linda M. Gerber ◽  
Ya-Lin Chiu ◽  
Nancy Carney ◽  
Roger Härtl ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Intracranial Hypertension ◽  
Severe Traumatic Brain Injury ◽  
Lower Mortality ◽  
Icp Monitoring ◽  
Improvement Program ◽  
Severe Tbi ◽  
Gcs Score

Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor. Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension. Results Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality. Conclusions In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.

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