Decompressive craniectomy in traumatic brain injury: usage and clinical outcome in a single centre

Wettervik, Teodor Svedung; Lenell, Samuel; Nyholm, Lena; Howells, Tim; Lewén, Anders; Enblad, Per

doi:10.1007/s00701-017-3418-3

Cited by 47 publications

(32 citation statements)

References 19 publications

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“…Decompressive craniectomy [ 42 ] is used when Step 1B is insufficient to reduce ICP or when adverse effects of the thiopental treatment are observed. Bi-fronto-temporal craniectomies are done, sparing the bone ridge in the midline when there are no mass lesions.…”

Section: Methodsmentioning

confidence: 99%

Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care

et al. 2019

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Background The probability of favorable outcome after traumatic brain injury (TBI) decreases with age. Elderly, ≥ 60 years, are an increasing part of our population. Recent studies have shown an increase of favorable outcome in elderly over time. However, the optimal patient selection and neurointensive care (NIC) treatments may differ in the elderly and the young. The aims of this study were to examine outcome in a larger group of elderly TBI patients receiving NIC and to identify demographic and treatment related prognostic factors. Methods Patients with TBI ≥ 60 years receiving NIC at our department between 2008 and 2014 were included. Demographics, co-morbidity, admission characteristics, and type of treatments were collected. Clinical outcome at around 6 months was assessed. Potential prognostic factors were included in univariate and multivariate regression analysis with favorable outcome as dependent variable. Results Two hundred twenty patients with mean age 70 years (median 69; range 60–87) were studied. Overall, favorable outcome was 46% (Extended Glasgow Outcome Scale (GOSE) 5–8), unfavorable outcome 27% (GOSE 2–4), and mortality 27% (GOSE 1). Significant independent negative prognostic variables were high age ( p < 0.05), multiple injuries ( p < 0.05), GCS M ≤ 3 on admission ( p < 0.05), and mechanical ventilation ( p < 0.001). Conclusions Overall, the elderly TBI patients > 60 years receiving modern NIC in this study had a fair chance of favorable outcome without large risks for severe deficits and vegetative state, also in patients over 75 years of age. High age, multiple injuries, GCS M ≤ 3 on admission, and mechanical ventilation proved to be independent negative prognostic factors. The results underline that a selected group of elderly with TBI should have access to NIC.

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Section: Methodsmentioning

confidence: 99%

Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care

et al. 2019

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“…All patients were treated in accordance with a standardized ICP-oriented treatment protocol to avoid secondary insults [8,9]. Treatment goals were ICP ≤ 20 mmHg, CPP ≥ 60 mmHg, systolic blood pressure > 100 mmHg, central venous pressure 0-5 mmHg, pO 2 > 12 kPa, blood glucose 5-10 mmol/L, electrolytes within normal ranges together with normovolemia and body temperature < 38 °C.…”

Section: Treatment Protocolmentioning

confidence: 99%

Intracranial pressure variability: relation to clinical outcome, intracranial pressure–volume index, cerebrovascular reactivity and blood pressure variability

Wettervik

Howells

Enblad

et al. 2019

J Clin Monit Comput

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It was recently found in traumatic brain injury (TBI) that ICP variability (ICPV) predicted favorable outcome. We hypothesized that ICPV may depend on intracranial compliance, unstable blood pressure and cerebral vasomotion. In this study, we aimed to further investigate the explanatory variables for ICPV and its relation to outcome. Data from 362 TBI patients were retrospectively analyzed day 2 to 5 post-injury. ICPV was evaluated in three ways. First, variability in the sub-minute time interval (similar to B waves) was calculated as the amplitude of the ICP slow waves using a bandpass filter, limiting the analysis to oscillations of 55 to 15 s (ICP AMP 55-15). The second and third ICPV measures were calculated as the deviation from the mean ICP averaged over 30 min (ICPV-30m) and 4 h (ICPV-4h), respectively. All ICPV measures were associated with a reduced intracranial pressure/volume state (high ICP and RAP) and high blood pressure variability in multiple linear regression analyses. Higher ICPV was associated with better pressure reactivity in the univariate, but not the multiple analyses. All ICPV measures were associated with favorable outcome in univariate analysis, but only ICP AMP 55-15 and ICPV-30m did so in the multiple logistic regression analysis. Higher ICPV can be explained by a reduced intracranial compliance and variations in cerebral blood volume due to the vessel response to unstable blood pressure. As ICP AMP 55-15 and ICPV-30m independently predicted favorable outcome, it may represent general cerebral vessel activity, associated with better cerebral blood flow regulation and less secondary insults.

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“…While many studies have shown the efficacy of DC in reducing ICP and improving mortality from severe TBI, others have questioned on its usefulness. [ 3 4 6 14 15 16 17 ] A meta-analysis was published by Zhang et al . in 2017, analyzing four RCTs, five retrospective studies, and one prospective study in the role of DC in TBI.…”

Section: Discussionmentioning

confidence: 99%

Protocol-based early decompressive craniectomy in a resource-constrained environment: A tertiary care hospital experience

Pattankar

Misra

2020

Asian J Neurosurg

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Objectives: Decompressive craniectomy (DC) is an emergency life-saving procedure used to treat refractory intracranial hypertension (RICH). The authors aim to analyze their experience with protocol-based early DC (<24 h) in RICH cases diagnosed based on clinical and radiological evidence, without preoperative intracranial pressure monitoring done over 10 years. Materials and Methods: This is a retrospective, observational study which includes 58 consecutive patients who underwent protocol-based early DC by the senior author at a single institution between 2007 and 2017. Background variables and outcome in the form of Glasgow Outcome Score-Extended (GOS-E) at 6 months and 1 year were analyzed. Results: Fourteen patients had traumatic brain injury (TBI), 17 had intracranial hemorrhage (ICH), 14 had malignant cerebral infarcts (MCI), and the reminder 13 patients had other causes. At 6 months, the mortality rate was 22.4%. Good recovery, moderate disability, and severe disability were seen in 13.8%, 17.2%, and 43.1% of patients, respectively. Two patients were in vegetative state. The cutoff for favorable/unfavorable outcome was defined as GOS-E 4–8/1–3. By this application, 63.8% of patients had favorable outcome at 6 months. The favorable outcome in patients of TBI, ICH, and MCI was 57.1%, 58.8%, and 85.7%, respectively. Conclusions: DC helps in obtaining a favorable outcome in selected patients with a defined pathology. The diagnosis of RICH based on clinical and radiological parameters, and protocol-based early DC, is reasonably justified as the way forward for resource-constrained environments. The risk of vegetative state is small.

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Decompressive craniectomy in traumatic brain injury: usage and clinical outcome in a single centre

Cited by 47 publications

References 19 publications

Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care

Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care

Intracranial pressure variability: relation to clinical outcome, intracranial pressure–volume index, cerebrovascular reactivity and blood pressure variability

Protocol-based early decompressive craniectomy in a resource-constrained environment: A tertiary care hospital experience

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