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

Abstract

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.

Multi-Mechanistic Approaches to the Treatment of Traumatic Brain Injury: A Review

“…TBI treatment based on MMM-derived optimal cerebral perfusion has demonstrated improved clinical outcomes, especially in older patients who may have reduced autoregulatory capacity [ 114 ]. PRx allows for real-time measurement of cerebrovascular autoregulation [ 121 ] and may help to predict the need for surgical intervention in severe TBI [ 112 , 122 , 123 ]. Measurement of brain oxygenation parameters, such as P bt O 2 , allows for rapid implementation of therapeutic interventions to correct cerebral hypoxia [ 109 , 121 ], and measurement of P bt O 2 and ICP in the BOOST-II trial was suggested to improve secondary injury after TBI demonstrating the potential effect of such early interventions [ 116 ].…”

“…Invasive MMM is generally considered safe [ 210 ], however, noninvasive approaches to MMM could expand its use to the mTBI population. Noninvasive measurements of ICP, including optic nerve sheath diameter, have been shown to correlate with invasive ICP measurement techniques and help guide surgical management of TBI [ 112 , 211 ], and thus may allow MMM to guide treatment in mTBI without insertion of invasive monitoring devices. However, noninvasive techniques have significant variation in inter-user reliability [ 212 ], and have not demonstrated an ability to monitor changes in ICP over time [ 213 ], which significantly limits their ability to guide treatment.…”

Multi-mechanistic Approaches to the Treatment of Traumatic Brain Injury: A Review

“…TBI treatment based on MMM-derived optimal cerebral perfusion has demonstrated improved clinical outcomes, especially in older patients who may have reduced autoregulatory capacity [81]. PRx allows for real-time measurement of cerebrovascular autoregulation [82] and may help to predict the need for surgical intervention in severe TBI [83][84][85]. Measurement of brain oxygenation parameters such as PbtO2 allows for rapid implementation of theraputic interventions to correct cerebral hypoxia [82,86], and measurement of PbtO2 and ICP in the BOOST-II trial was suggested to improve secondary injury after TBI demonstrating the potential effect of such early interventions [87].…”

“…Invasive MMM is generally considered safe [175], however noninvasive approaches to MMM could expand its use to the mTBI population. Noninvasive measurements of ICP including optic nerve sheath diameter have been shown to correlate with invasive ICP measurement techniques and help guide surgical management of TBI [83,176], and thus may allow MMM to guide treatment in mTBI without insertion of invasive monitoring devices. However noninvasive techniques have significant variation in inter-user reliability [177], and have not desmonstrated an ability to monitor changes in ICP over time [178], which significantly limits their ability to guide treatment.…”