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 Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care—Indicative Observations and Future Perspectives

2021 ◽  
Vol 12 ◽  
Author(s):  
Teodor M. Svedung Wettervik ◽  
Anders Lewén ◽  
Per Enblad
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Fine Tuning ◽  
Neurointensive Care ◽  
Secondary Brain Injury ◽  
Brain Tissue Oxygenation ◽  
Treatment Protocols ◽  
Injury Mechanisms ◽  
Severe Tbi ◽  
Type Of Injury

Neurointensive care (NIC) has contributed to great improvements in clinical outcomes for patients with severe traumatic brain injury (TBI) by preventing, detecting, and treating secondary insults and thereby reducing secondary brain injury. Traditional NIC management has mainly focused on generally applicable escalated treatment protocols to avoid high intracranial pressure (ICP) and to keep the cerebral perfusion pressure (CPP) at sufficiently high levels. However, TBI is a very heterogeneous disease regarding the type of injury, age, comorbidity, secondary injury mechanisms, etc. In recent years, the introduction of multimodality monitoring, including, e.g., pressure autoregulation, brain tissue oxygenation, and cerebral energy metabolism, in addition to ICP and CPP, has increased the understanding of the complex pathophysiology and the physiological effects of treatments in this condition. In this article, we will present some potential future approaches for more individualized patient management and fine-tuning of NIC, taking advantage of multimodal monitoring to further improve outcome after severe TBI.

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 Predictors of recovery in moderate to severe traumatic brain injury

2019 ◽  
Vol 131 (5) ◽  
pp. 1648-1657
Author(s):  
Kadhaya David Muballe ◽  
Constance R. Sewani-Rusike ◽  
Benjamin Longo-Mbenza ◽  
Jehu Iputo
Keyword(s):  
Oxidative Stress ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Clinical Outcomes ◽  
Secondary Brain Injury ◽  
Coma Scale ◽  
Severity Of Injury ◽  
Severe Tbi

OBJECTIVETraumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide. Clinical outcomes in TBI are determined by the severity of injury, which is dependent on the primary and secondary brain injury processes. Whereas primary brain injury lesions are related to the site of impact, secondary brain injury results from physiological changes caused by oxidative stress and inflammatory responses that occur after the primary insult. The aim of this study was to identify important clinical and biomarker profiles that were predictive of recovery after moderate to severe TBI. A good functional outcome was defined as a Glasgow Outcome Scale (GOS) score of ≥ 4.METHODSThis was a prospective study of patients with moderate to severe TBI managed at the Nelson Mandela Academic Hospital during the period between March 2014 and March 2016. Following admission and initial management, the patient demographic data (sex, age) and admission Glasgow Coma Scale score were recorded. Oxidative stress and inflammatory biomarkers in blood and CSF were sampled on days 1–7. On day 14, only blood was sampled for the same biomarkers. The primary outcome was the GOS score—due to its simplicity, the GOS was used to assess clinical outcomes at day 90. Because of difficulty in performing regular follow-up due to the vastness of the region, difficult terrain, and long travel distances, a 3-month follow-up period was used to avoid default.RESULTSSixty-four patients with Glasgow Coma Scale scores of ≤ 12 were seen and managed. Among the 56 patients who survived, 42 showed significant recovery (GOS score ≥ 4) at 3 months. Important predictors of recovery included antioxidant activity in the CSF (superoxide dismutase and total antioxidant capacity).CONCLUSIONSRecovery after TBI was dependent on the resolution of oxidative stress imbalance.

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.

scholarly journals Rescue Decompressive Craniectomy in Children with Severe Traumatic Brain Injury

2017 ◽  
Vol 07 (01) ◽  
pp. 033-038
Author(s):  
Panagiotis Poulos ◽  
Maria Kazantzi ◽  
Panagiotis Kalampalikis ◽  
Dimitrios Rallis
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Decompressive Craniectomy ◽  
Neurological Outcome ◽  
Rescue Therapy ◽  
Increased Intracranial Pressure ◽  
Poor Neurological Outcome ◽  
Severe Tbi ◽  
The Impact

AbstractDecompressive craniectomy (DC) is considered a rescue therapy in patients with traumatic brain injury (TBI) with increased intracranial pressure (ICP). In this retrospective study, we examined the impact of craniectomy on ICP in children with severe TBI and their neurological outcome. A total of 14 patients were enrolled. Peak ICP was significantly lower (31 ± 2.9 to 19 ± 4.6, p < 0.001) and minimum cerebral perfusion pressure (CPP) higher (41 ± 10.5 to 58 ± 11.4, p < 0.001) postcraniectomy. The survival rate was 71%. However, 57% of our cohort had a poor neurological outcome at 6 months postinjury. In conclusion, although rescue DC was effective in controlling ICP and CPP, the long-term neurological outcome remained poor.

scholarly journals Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations

Neurosurgery ◽  
2020 ◽  
Vol 87 (3) ◽  
pp. 427-434 ◽  
Author(s):  
Gregory W J Hawryluk ◽  
Andres M Rubiano ◽  
Annette M Totten ◽  
Cindy O’Reilly ◽  
Jamie S Ullman ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Decompressive Craniectomy ◽  
Severe Traumatic Brain Injury ◽  
Controlled Trial ◽  
Outcome Data ◽  
The Body ◽  
Severe Tbi ◽  
Key Issues ◽  
New Evidence

Abstract When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of “living guidelines,” whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at: https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/.

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.

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