Early decompressive craniectomy for severe penetrating and closed head injury during wartime

Abstract

Object Decompressive craniectomy has defined this era of damage-control wartime neurosurgery. Injuries that in previous conflicts were treated in an expectant manner are now aggressively decompressed at the far-forward Combat Support Hospital and transferred to Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center (NNMC) in Bethesda for definitive care. The purpose of this paper is to examine the baseline characteristics of those injured warriors who received decompressive craniectomies. The importance of this procedure will be emphasized and guidance provided to current and future neurosurgeons deployed in theater. Methods The authors retrospectively searched a database for all soldiers injured in Operations Iraqi Freedom and Enduring Freedom between April 2003 and October 2008 at WRAMC and NNMC. Criteria for inclusion in this study included either a closed or penetrating head injury suffered during combat operations in either Iraq or Afghanistan with subsequent neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all cases in which primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow Coma Scale (GCS) score and injury severity score (ISS) at admission, and Glasgow Outcome Scale (GOS) score at discharge, 6 months, and 1–2 years. Results Four hundred eight patients presented with head injury during the study period. In this population, a total of 188 decompressive craniectomies were performed (154 for penetrating head injury, 22 for closed head injury, and 12 for unknown injury mechanism). Patients who underwent decompressive craniectomies in the combat theater had significantly lower initial GCS scores (7.7 ± 4.2 vs 10.8 ± 4.0, p < 0.05) and higher ISSs (32.5 ± 9.4 vs 26.8 ± 11.8, p < 0.05) than those who did not. When comparing the GOS scores at hospital discharge, 6 months, and 1–2 years after discharge, those receiving decompressive craniectomies had significantly lower scores (3.0 ± 0.9 vs 3.7 ± 0.9, 3.5 ± 1.2 vs 4.0 ± 1.0, and 3.7 ± 1.2 vs 4.4 ± 0.9, respectively) than those who did not undergo decompressive craniectomies. That said, intragroup analysis indicated consistent improvement for those with craniectomy with time, allowing them, on average, to participate in and improve from rehabilitation (p < 0.05). Overall, 83% of those for whom follow-up data are available achieved a 1-year GOS score of greater than 3. Conclusions This study of the provision of early decompressive craniectomy in a military population that sustained severe penetrating and closed head injuries represents one of the largest to date in both the civilian and military literature. The findings suggest that patients who undergo decompressive craniectomy had worse injuries than those receiving craniotomy and, while not achieving the same outcomes as those with a lesser injury, did improve with time. The authors recommend hemicraniectomy for damage control to protect patients from the effects of brain swelling during the long overseas transport to their definitive care, and it should be conducted with foresight concerning future complications and reconstructive surgical procedures.

Safe management of paediatric penetrating head injury without a CT scanner: A strategy for humanitarian surgeons based on experience in southern Afghanistan

“…[1][2][3][4][5] The use of imaging is an integral part of decision-making in the management of these patients, and the information provided by computed tomography (CT) remains the 'gold standard'. [6][7][8][9] In an area of conflict, it may be impossible to establish the exact timing and circumstances of a head injury, and the results of clinical assessments and nature of any medical interventions (such as the administration of drugs) 'en route' to the surgical facility may be unknown.…”

Decompressive craniotomy in patients with intracranial aneurysmal hemorrhage

“…Применение ДТЧ в лечении больных с тяжелыми аневризматическими кровоизлияниями основано на по-ложительном опыте использования этой операции при ВЧГ у больных с черепно-мозговой травмой и у пациентов с ишемическим инсультом, который по патогенезу наи-более близок к таким осложнениям аневризматического кровоизлияния, как ангиоспазм и его последствия [29][30][31][32][33][34][35][36]. Положительный эффект ДТЧ при церебральной ише-мии обусловлен существенным снижением ВЧД, увеличе-нием оксигенации мозговой ткани и улучшением показа-телей цереброваскулярной реактивности [13].…”

Traumatic brain injury

“…(a) Decompressive craniectomy There is an increasing clinical recognition that victims of penetrating ballistic injury and closed blast injury often suffer early and severe oedema of both extraand intracranial tissue, and that such oedema can lead to early and life-threatening ICP elevation [77,78]. This is coupled with a need to safely transfer soldiers away from the theatre of war on long aeromedical transfers (sometimes without ICP monitoring); and local civilians to indigenous hospitals where facilities are limited, and ongoing specialist critical care for ICP management is unavailable.…”