Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury: a clinical study

Picetti, Edoardo; Caspani, Maria Luisa; Iaccarino, Corrado; Pastorello, Giulia; Salsi, Pierpaolo; Viaroli, Edoardo; Servadei, Franco

doi:10.1007/s00701-017-3118-z

Cited by 35 publications

(26 citation statements)

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“…Leitgeb et al described a large series of patients who had surgery as a primary procedure for sTBI with an early mortality rate of 46.7% and only 32.2% of the patients experienced a favorable outcome. Moreover, the results in terms of ICP control in our cohort were remarkable, noting that primary DC has been associated with a persistent intracranial hypertension in a high percentage of patients, as described by the group of Servadei [29]. In their study, despite primary DC, a further interventional treatment was necessary in a high rate of patients (barbiturate coma 20.6%, external ventricular drainage 11.8%, and DC diameter widening 2.9%).…”

Section: Discussionsupporting

confidence: 56%

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

Giammattei¹,

Starnoni²,

Maduri³

et al. 2020

Acta Neurochir

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Objective To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI). Methods A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, "primary procedure" and "secondary procedure", was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO 2) values as well as the need for additional osmotherapy and CSF drainage. Results Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average postsurgical ICP values, higher PbO 2 values and required less osmotic treatments as compared with those treated with DC alone. Conclusion Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.

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Section: Discussionsupporting

confidence: 56%

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

Giammattei¹,

Starnoni²,

Maduri³

et al. 2020

Acta Neurochir

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“…They reported that neurological outcomes did not differ between the patient groups with ICP monitoring and without ICP monitoring. On the contrary, in a retrospective study by Picetti et al, [25] authors evaluated the clinical follow-up in 34 patients after primary DC following emergency hematoma evacuation. They noted that the knowledge of ICP values might be helpful in guiding therapy after primary DC.…”

Section: Discussionmentioning

confidence: 99%

Factors Associated with Mortality in Acute Subdural Hematoma: Is Decompressive Craniectomy Effective?

Yılmaz

Ertem

Kılıç

et al. 2018

Ulus Travma Acil Cerrahi Derg

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BACKGROUND: Despite rapid diagnosis and aggressive neurosurgical intervention, acute subdural hematoma (ASDH) is a severe type of head injury that can result in high morbidity and mortality. Although surgical procedures, such as craniotomy and decompressive craniectomy (DC), can be effective, the preferred approach for treating an ASDH remains controversial. The aim of this report was to evaluate factors associated with mortality in patients with ASDH and determinants of outcome in those with ASDH who underwent DC. METHODS: The demographic details and clinical and radiological characteristics of a total of 93 patients with ASDH who underwent DC during a 60-month period from 2012 to 2017 were evaluated to determine the effect on mortality and any association with the Glasgow Coma Scale (GCS) score recorded on arrival. RESULTS: Sixty-five male and 28 female subjects with a mean age of 59.82±19.49 years (range: 16-88 years) were included in the study. Sixteen patients (17.2%) died following the surgery. Older age (p=0.007) and lower GCS scores (p=0.022) were statistically significantly associated with the mortality rate. The mean hematoma thickness was 15.46±5.73 mm, and the mean midline shift was 9.90±4.84 mm. The mortality rate was positively correlated with an excessive midline shift (p=0.011; r=0.262) and age (p=0.022; r=0.237) in patients with ADSH. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm was significantly associated with mortality (p=0.014; p=0.039). The etiology of the trauma; comorbidities of subarachnoid, epidural, or intracranial hemorrhage; compression fractures; or contusions were not significantly correlated. CONCLUSION: The results indicated that there was a higher mortality rate among older patients and those with a GCS score of <6 on arrival. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm were significantly related to mortality. Our study supports the conclusion that DC may help prevent further midline shift and be associated with a lower mortality rate compared with a craniotomy.

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“…As many as three consensus conferences have tried to address this and other controversies and uncertainties [2,3,8]. One of the recommendations was that BICP monitoring is generally recommended following a secondary decompressive craniectomy (DC) in order to assess the effectiveness of DC, in terms of ICP control, and guide further therapy^ [8].Indeed there exists plentiful information from recent trials (DECRA and RESCUEicp) about situations where DC was employed to control rising ICP refractory to maximal medical therapy [4,6]; this being secondary DC.One of the gaps in our knowledge, and the main objective of the featured study by Picetti et al [7], was to explore the role of ICP monitoring in traumatic brain injury (TBI) patients after primary decompressive craniectomy. BPrimary^in this context refers to DC during evacuation of an intracranial lesion in the acute phase.…”

mentioning

confidence: 99%

“…One of the gaps in our knowledge, and the main objective of the featured study by Picetti et al [7], was to explore the role of ICP monitoring in traumatic brain injury (TBI) patients after primary decompressive craniectomy. BPrimary^in this context refers to DC during evacuation of an intracranial lesion in the acute phase.…”

mentioning

confidence: 99%

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Intracranial pressure monitoring after primary decompressive craniectomy: is it useful?

Demetriades

2017

Acta Neurochir

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Intracranial hypertension is an important secondary insult after traumatic brain injury, and its control is considered to be of benefit to our patients. Intracranial pressure (ICP) monitoring is considered standard practice, at least in the developed world, in the modern neurosurgical management of traumatic brain injury. ICP waveform analysis and understanding has improved tremendously over the last few decades. However, there is still a lack of Bclass I^evidence in support of superiority of treatment based on intracranial-pressure monitoring over treatment guided by neurological testing and serial computed tomography imaging in improving short-term or longterm recovery in the general population of patients with severe traumatic brain injury [1].In settings such as the developing world, where ICP monitoring may come with equipoise, controversies exist, including the use of postoperative ICP monitoring. As many as three consensus conferences have tried to address this and other controversies and uncertainties [2,3,8]. One of the recommendations was that BICP monitoring is generally recommended following a secondary decompressive craniectomy (DC) in order to assess the effectiveness of DC, in terms of ICP control, and guide further therapy^ [8].Indeed there exists plentiful information from recent trials (DECRA and RESCUEicp) about situations where DC was employed to control rising ICP refractory to maximal medical therapy [4,6]; this being secondary DC.One of the gaps in our knowledge, and the main objective of the featured study by Picetti et al. [7], was to explore the role of ICP monitoring in traumatic brain injury (TBI) patients after primary decompressive craniectomy. BPrimary^in this context refers to DC during evacuation of an intracranial lesion in the acute phase.Worded differently, there has been controversy as to whether ICP monitoring is futile after such primary DC.Recent data on this topic suggest that ICP monitoring after primary DC for head-injured patients significantly decreases in-hospital mortality and should be implemented in neurocritical care to ensure the highest chances of surviving TBI [5].Picetti et al. [7] provide further useful information on this topic. They selected and analysed data from 34 patients, out of a database of 880. The vast majority (26/34; 77%) were cases of acute subdural haematoma. The authors report that despite decompressive craniectomy, ICP may still rise to dangerous levels in most cases; furthermore, one-third of ICP monitoring days revealed at least one episode of intracranial hypertension. Intracranial hypertension was high enough to affect a reduction in cerebral perfusion pressure (CPP) of less than 60 mmHg in 1-6 days monitored. Despite decompressive craniectomy, patients needed ICP-and CPP-driven escalation therapy and monitoring assistance in taking decisions.This study is one of the first to specifically address the clinical utility of ICP monitoring after primary decompressive craniectomy.The message is clear:-Intracranial hypertension associated with ...

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Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury: a clinical study

Abstract: Intracranial hypertension and/or low CPP occurs frequently after primary DC; their occurence is associated with an unfavorable neurological outcome. ICP monitoring appears useful in guiding therapy after primary DC.

Cited by 35 publications

References 33 publications

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

Factors Associated with Mortality in Acute Subdural Hematoma: Is Decompressive Craniectomy Effective?

Intracranial pressure monitoring after primary decompressive craniectomy: is it useful?

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