Surgical Outcome Following Early Decompressive Hemicraniectomy in Patients of Severe Traumatic Brain Injury: A Retrospective Study

Introduction: Traumatic Brain Injury (TBI) has become an epidemic and remains the leading cause of death and disability in people of 2nd to 4th decade. Road Traffic Accidents (RTA) are responsible for the majority of cases. Primary brain injury sustained on impact and secondary brain injury that develops in following hours and days contribute together to overall injury and decides ultimate outcome. The goal of management in any TBI patient aims to prevent secondary brain injury. Understanding the importance of Intracranial Pressure (ICP) is key to minimise secondary injury. Decompressive hemicraniectomy is a novel technique of reducing ICP in patients of severe brain injury. It’s judicious and timely performance not only saves life but also prevents the dreaded consequences of raised ICP. Aim: To evaluate the role of early decompressive hemicraniectomy in improving the survival rate among patients of severe TBI and analysing the important factors (glasgow coma scale, airway status, timing of surgery) affecting the surgical outcome. Materials and Methods: It was a retrospective study conducted at the Department of Neurosurgery, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India between September 2016 to March 2020. Case records of 60 patients of TBI who had undergone unilateral Decompressive Craniectomy (DECRA) were analysed. The decision for decompressive hemicraniectomy was purely based upon Glasgow Coma Scale GCS) and Computed Topography (CT) findings. The presence of an evacuable mass lesion, diffuse oedema and obliteration of basal cistern in CT was considered to be the most important criteria for the early decompressive procedure. Patients were assessed until their discharge from ward. Statistical analysis was performed by statistical package for science version 12. Results: A total of 60 patients with severe TBI, who underwent DECRA were analysed. Road Traffic Accident (RTA) was the predominant mechanism of injury. All had presence of a surgically evacuable mass lesion along with compression/obliteration of the basal cistern. The majority of mass lesions (n=42) were frontotemporal contusions (70%). Forty patients of total achieved good surgical outcome (66.67%) and rest 20 patients (33.33%) had poor outcomes. Overall incidence of complications was around 40%. The most important factors associated with good outcomes were GCS of 7 and and above, patent airway, and early surgery. Conclusion: Decompressive hemicraniectomy is a novel technique of reducing ICP which acts by directly breaking the rigid box phenomenon of Monro-Kellie doctrine. However patient selection, prompt decision, earliest intervention, adoption of standard technique of DECRA and post operative critical care management are important aspects behind the successful outcome.

Download Full-text

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

Frontiers in Neurology ◽

10.3389/fneur.2021.638132 ◽

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.

Download Full-text

Immediate Outcomes of Traumatic Brain Injury at a Tertiary Care Hospital Of Pakistan- A Retrospective Study

10.21203/rs.3.rs-84330/v2 ◽

2021 ◽

Author(s):

Maria Khan ◽

Uzair Yaqoob ◽

Zair Hassan ◽

Muhammad Muizz Uddin

Keyword(s):

Traumatic Brain Injury ◽

Retrospective Study ◽

Brain Injury ◽

Road Traffic ◽

Tertiary Care ◽

Initial Assessment ◽

Care Hospital ◽

Hospital Data ◽

Epidemiological Characteristics ◽

The Impact

Abstract Background: Traumatic Brain Injury (TBI) is the leading cause of morbidity and mortality all over the world and the impact is much worse in Pakistan. The objective here is to describe the epidemiological characteristics of patients with TBI in our country and to determine the immediate outcomes of patients with TBI after the presentation.Method: This retrospective study was conducted at the Lady Reading Hospital. Data were extracted from the medical record room from January 1st to December 31st, 2019. The severity of TBI was based on Glasgow Coma Scale (GCS) and was divided into mild (GCS 13-15), moderate (GCS 9-12), and severe TBI (GCS <8) based on the GCS. SPSS v.23 was used for data analysis. Results: Out of 5047 patients, 3689 (73.1%) males and 1358 (26.9%) females. The most commonly affected age group was 0-10 years (25.6%) and 21-30 years (20.1%). Road Traffic accident was the predominant cause of injury (38.8%, n=1960) followed by fall (32.7%, n=1649). Most (93.6%, n=4710) of the TBIs were mild. After the full initial assessment and workup, and completing all first-aid management, the immediate outcome was divided into four, most frequent (67.2%, n=3393) of which was “disposed (discharged)”, and 9.3% (n=470) were admitted for further management.Conclusion: Our study represents a relatively conclusive picture of epidemiological data on the burden of TBI in Pakistan. Although a large proportion of patients had a mild TBI, they may likely be under-diagnosed. This warrants further investigation of MTBI in population-based studies across the globe.

Download Full-text

Predictors of In-Hospital Mortality for Road Traffic Accident-Related Severe Traumatic Brain Injury

Journal of Personalized Medicine ◽

10.3390/jpm11121339 ◽

2021 ◽

Vol 11 (12) ◽

pp. 1339

Author(s):

Chien-Hung Chen ◽

Yu-Wei Hsieh ◽

Jen-Fu Huang ◽

Chih-Po Hsu ◽

Chia-Ying Chung ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Mortality Rate ◽

Hospital Mortality ◽

Prothrombin Time ◽

High Mortality ◽

Clinical Characteristics ◽

Road Traffic ◽

Road User ◽

Severe Tbi

(1) Background: Road traffic accidents (RTAs) are the leading cause of pediatric traumatic brain injury (TBI) and are associated with high mortality. Few studies have focused on RTA-related pediatric TBI. We conducted this study to analyze the clinical characteristics of RTA-related TBI in children and to identify early predictors of in-hospital mortality in children with severe TBI. (2) Methods: In this 15-year observational cohort study, a total of 618 children with RTA-related TBI were enrolled. We collected the patients’ clinical characteristics at the initial presentations in the emergency department (ED), including gender, age, types of road user, the motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and the intracranial computed tomography (CT) Rotterdam score, as potential mortality predictors. (3) Results: Compared with children exhibiting mild/moderate RTA-related TBI, those with severe RTA-related TBI were older and had a higher mortality rate (p < 0.001). The in-hospital mortality rate for severe RTA-related TBI children was 15.6%. Compared to children who survived, those who died in hospital had a higher incidence of presenting with hypothermia (p = 0.011), a lower mGCS score (p < 0.001), a longer initial prothrombin time (p < 0.013), hyperglycemia (p = 0.017), and a higher Rotterdam CT score (p < 0.001). Multivariate analyses showed that the mGCS score (adjusted odds ratio (OR): 2.00, 95% CI: 1.28–3.14, p = 0.002) and the Rotterdam CT score (adjusted OR: 2.58, 95% CI: 1.31–5.06, p = 0.006) were independent predictors of in-hospital mortality. (4) Conclusions: Children with RTA-related severe TBI had a high mortality rate. Patients who initially presented with hypothermia, a lower mGCS score, a prolonged prothrombin time, hyperglycemia, and a higher Rotterdam CT score in brain CT analyses were associated with in-hospital mortality. The mGCS and the Rotterdam CT scores were predictive of in-hospital mortality independently.

Download Full-text

Incidence, causes and consequences of moderate and severe traumatic brain injury as determined by Abbreviated Injury Score in the Netherlands

Scientific Reports ◽

10.1038/s41598-021-99484-6 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Denise Jochems ◽

Eveline van Rein ◽

Menco Niemeijer ◽

Mark van Heijl ◽

Michael A. van Es ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

The Netherlands ◽

Traffic Accidents ◽

Road Traffic ◽

The Elderly ◽

National Database ◽

Target Prevention ◽

Severe Tbi ◽

Polytrauma Patients

AbstractTraumatic brain injury (TBI) is a leading cause of death and disability. Epidemiology seems to be changing. TBIs are increasingly caused by falls amongst elderly, whilst we see less polytrauma due to road traffic accidents (RTA). Data on epidemiology is essential to target prevention strategies. A nationwide retrospective cohort study was conducted. The Dutch National Trauma Database was used to identify all patients over 17 years old who were admitted to a hospital with moderate and severe TBI (AIS ≥ 3) in the Netherlands from January 2015 until December 2017. Subgroup analyses were done for the elderly and polytrauma patients. 12,295 patients were included in this study. The incidence of moderate and severe TBI was 30/100.000 person-years, 13% of whom died. Median age was 65 years and falls were the most common trauma mechanism, followed by RTAs. Amongst elderly, RTAs consisted mostly of bicycle accidents. Mortality rates were higher for elderly (18%) and polytrauma patients (24%). In this national database more elderly patients who most often sustained the injury due to a fall or an RTA were seen. Bicycle accidents were very frequent, suggesting prevention could be an important aspect in order to decrease morbidity and mortality.

Download Full-text

Predictors of recovery in moderate to severe traumatic brain injury

Journal of Neurosurgery ◽

10.3171/2018.4.jns172185 ◽

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.

Download Full-text

Early decompressing craniectomy in patients with traumatic brain injury and cerebral edema

Asian Biomedicine ◽

10.5372/1905-7415.0801.261 ◽

2014 ◽

Vol 8 (1) ◽

pp. 53-59 ◽

Cited By ~ 2

Author(s):

Jiang-Biao Gong ◽

Liang Wen ◽

Ren-Ya Zhan ◽

Heng-Jun Zhou ◽

Fang Wang ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Prognostic Factors ◽

Retrospective Study ◽

Brain Injury ◽

Cerebral Edema ◽

Severe Traumatic Brain Injury ◽

Midline Shift ◽

Important Method ◽

Severe Tbi ◽

Gcs Score

Abstract Background: Decompressing craniectomy (DC) is an important method for the management of severe traumatic brain injury (TBI). Objective: To analyze the effect of prophylactic DC within 24 hours after head trauma TBI. Methods: Seventy-two patients undergoing prophylactic DC for severe TBI were included in this retrospective study. Both of the early and late outcomes were studied and the prognostic factors were analyzed. Results: In this series, cumulative death in the first 30 days after DC was 26%, and 28 (53%) of 53 survivors in the first month had a good outcomes. The factors including Glasgow Coma Score (GCS) score at admission, whether the patient had an abnormal pupil response and whether the midline shift was greater than 5 mm were most important prognostic factors for the prediction of death in the first 30 days and the final outcome at 6 months after DC. Conclusion: Prophylactic DC plays an important role in the management of highly elevated ICP, especially when other methods of reduction of ICP are unavailable.

Download Full-text

Co-Expression Network Analysis of MicroRNAs and Proteins in Severe Traumatic Brain Injury: A Systematic Review

Cells ◽

10.3390/cells10092425 ◽

2021 ◽

Vol 10 (9) ◽

pp. 2425

Author(s):

Claire Osgood ◽

Zubair Ahmed ◽

Valentina Di Pietro

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Therapeutic Potential ◽

Psychosocial Problems ◽

Bioinformatic Analysis ◽

Healthcare Services ◽

Secondary Brain Injury ◽

Mortality And Morbidity ◽

Severe Tbi ◽

Novel Target

Traumatic brain injury (TBI) represents one of the leading causes of mortality and morbidity worldwide, placing an enormous socioeconomic burden on healthcare services and communities around the world. Survivors of TBI can experience complications ranging from temporary neurological and psychosocial problems to long-term, severe disability and neurodegenerative disease. The current lack of therapeutic agents able to mitigate the effects of secondary brain injury highlights the urgent need for novel target discovery. This study comprises two independent systematic reviews, investigating both microRNA (miRNA) and proteomic expression in rat models of severe TBI (sTBI). The results were combined to perform integrated miRNA-protein co-expression analyses with the aim of uncovering the potential roles of miRNAs in sTBI and to ultimately identify new targets for therapy. Thirty-four studies were included in total. Bioinformatic analysis was performed to identify any miRNA–protein associations. Endocytosis and TNF signalling pathways were highlighted as common pathways involving both miRNAs and proteins found to be differentially expressed in rat brain tissue following sTBI, suggesting efforts to find novel therapeutic targets that should be focused here. Further high-quality investigations are required to ascertain the involvement of these pathways and their miRNAs in the pathogenesis of TBI and other CNS diseases and to therefore uncover those targets with the greatest therapeutic potential.

Download Full-text

Management and Challenges of Severe Traumatic Brain Injury

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0040-1716493 ◽

2020 ◽

Author(s):

Shayan Rakhit ◽

Mina F. Nordness ◽

Sarah R. Lombardo ◽

Madison Cook ◽

Laney Smith ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Great Promise ◽

Secondary Brain Injury ◽

Trauma Patients ◽

Barbiturate Coma ◽

High Quality Research ◽

Paroxysmal Sympathetic Hyperactivity ◽

Vte Prophylaxis ◽

Severe Tbi

AbstractTraumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro–Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.

Download Full-text

Hyperglycemia in severe traumatic brain injury patients and its association with thirty-day mortality: a prospective observational cohort study in Uganda

PeerJ ◽

10.7717/peerj.10589 ◽

2021 ◽

Vol 9 ◽

pp. e10589

Author(s):

Paul Matovu ◽

Musa Kirya ◽

Moses Galukande ◽

Joel Kiryabwire ◽

John Mukisa ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Acute Stress ◽

Road Traffic ◽

Glucose Monitoring ◽

Serum Glucose ◽

Health Concern ◽

Predictors Of Mortality ◽

Glucose Levels ◽

Severe Tbi

Background Traumatic brain injury (TBI) is a growing public health concern that can be complicated with an acute stress response. This response may be assessed by monitoring blood glucose levels but this is not routine in remote settings. There is a paucity of data on the prevalence of hyperglycemia and variables associated with mortality after severe TBI in Uganda. Objective We aimed to determine the prevalence of hyperglycemia in patients with severe TBI and variables associated with 30-day mortality at Mulago National Referral Hospital in Uganda. Methods We consecutively enrolled a cohort 99 patients patients with severe TBI. Serum glucose levels were measured at admission and after 24 h. Other study variables included: mechanism of injury, CT findings, location and size of hematoma, and socio-demographics. The main outcome was mortality after 30 days of management and this was compared in patients with hyperglycemia more than 11.1 mmol/L to those without. Results Most patients (92.9%) were male aged 18–30 years (47%). Road Traffic Collisions were the most common cause of severe TBI (64.7%) followed by assault (17.1%) and falls (8.1%). Nearly one in six patients were admitted with hyperglycemia more than 11.1 mmol/L. The mortality rate in severe TBI patients with hyperglycemia was 68.8% (OR 1.47; 95% CI [0.236–9.153]; P = 0.063) against 43.7% in those without hyperglycemia. The presence of hypothermia (OR 10.17; 95% CI [1.574–65.669]; P = 0.015) and convulsions (OR 5.64; 95% CI [1.541–19.554]; P = 0.009) were significant predictors of mortality. Conclusion Hypothermia and convulsions at admission were major predictors of mortality in severe TBI. Early hyperglycemia following severe TBI appears to occur with a tendency towards high mortality. These findings justify routine glucose monitoring and could form the basis for establishing a blood sugar control protocol for such patients in remote settings.

Download Full-text

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

Journal of Neurosurgery: Case Lessons ◽

10.3171/case2197 ◽

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.

Download Full-text