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Acta Neurochirurgica

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Open Access 01-02-2018 | Original Article - Brain Injury

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

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

Published in: Acta Neurochirurgica | Issue 2/2018

Abstract

Background

Two randomised controlled trials (RCTs) of decompressive craniectomy (DC) in traumatic brain injury (TBI) have shown poor outcome, but there are considerations of how these protocols relate to real practice. The aims of this study were to evaluate usage and outcome of DC and thiopental in a single centre.

Method

The study included all TBI patients treated at the neurointensive care unit, Akademiska sjukhuset, Uppsala, Sweden, between 2008 and 2014. Of 609 patients aged 16 years or older, 35 treated with DC and 23 treated with thiopental only were studied in particular. Background variables, intracranial pressure (ICP) measures and global outcome were analysed.

Results

Of 35 DC patients, 9 were treated stepwise with thiopental before DC, 9 were treated stepwise with no thiopental before DC and 17 were treated primarily with DC. Six patients received thiopental after DC. For 23 patients, no DC was needed after thiopental. Eighty-eight percent of our DC patients would have qualified for the DECRA study and 38% for the Rescue-ICP trial. Favourable outcome was 44% in patients treated with thiopental before DC, 56% in patients treated with DC without prior thiopental, 29% in patients treated primarily with DC and 52% in patients treated with thiopental with no DC.

Conclusions

The place for DC in TBI management must be evaluated better, and we believe it is important that future RCTs should have clearer and less permissive ICP criteria regarding when thiopental should be followed by DC and DC followed by thiopental.

Compagnone C, Murray GD, Teasdale GM, Maas AI, Esposito D, Princi P et al (2005) The management of patients with intradural post-traumatic mass lesions: a multicenter survey of current approaches to surgical management in 729 patients coordinated by the European brain injury consortium. Neurosurgery 57:1183–1192CrossRefPubMed

Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P et al (2011) Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:1493–1502CrossRefPubMed

Coplin WM, Cullen NK, Policherla PN, Vinas FC, Wilseck JM, Zafonte RD et al (2001) Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury. J Trauma 50:1050–1059CrossRefPubMed

Cushing H (1908) I. Subtemporal decompressive operations for the intracranial complications associated with bursting fractures of the skull. Ann Surg 47:641–644 641CrossRefPubMedPubMedCentral

Fischerström A, Nyholm L, Lewén A, Enblad P (2014) Acute neurosurgery for traumatic brain injury by general surgeons in Swedish county hospitals: a regional study. Acta Neurochir 156:177–185CrossRefPubMed

Howells T, Elf K, Jones PA, Ronne-Engström E, Piper I, Nilsson P et al (2005) Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg 102:311–317CrossRefPubMed

Hutchinson P, Kolias A. Protocol 14PRT/6944: randomised evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural haematoma (RESCUE-ASDH)—ISRCTN87370545. Lancet (http://www.thelancet.com/protocol-reviews/14PRT-6944). Accessed 10 October 2017

Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J et al (2016) Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 375:1119–1130CrossRefPubMed

Kocher T (1901) Die Therapie des Hirndruckes. A Hölder, Vienna

10.

Kramer AH, Deis N, Ruddell S, Couillard P, Zygun DA, Doig CJ et al (2016) Decompressive craniectomy in patients with traumatic brain injury: are the usual indications congruent with those evaluated in clinical trials? Neurocrit Care 25:10–19CrossRefPubMed

11.

Miller JD, Piper I, Dearden N (1993) Management of intracranial hypertension in head injury: matching treatment with cause. Acta Neurochir Suppl 57:152–159

12.

Nyholm L, Howells T, Enblad P, Lewén A (2013) Introduction of the Uppsala traumatic brain injury register for regular surveillance of patient characteristics and neurointensive care management including secondary insult quantification and clinical outcome. Ups J Medical Sci 118:169–180CrossRef

13.

Olivecrona M, Rodling-Wahlström M, Naredi S, Koskinen L-OD (2007) Effective ICP reduction by decompressive craniectomy in patients with severe traumatic brain injury treated by an ICP-targeted therapy. J Neurotrauma 24:927–935CrossRefPubMed

14.

Peeters W, van den Brande R, Polinder S, Brazinova A, Steyerberg EW, Lingsma HF et al (2015) Epidemiology of traumatic brain injury in Europe. Acta Neurochir 157:1683–1696CrossRefPubMedPubMedCentral

15.

Rosner MJ, Rosner SD, Johnson AH (1995) Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 83:949–962CrossRefPubMed

16.

Skoglund TS, Eriksson-Ritzén C, Jensen C, Rydenhag B (2006) Aspects on decompressive craniectomy in patients with traumatic head injuries. J Neurotrauma 23:1502–1509CrossRefPubMed

17.

Teasdale GM, Pettigrew LE, Wilson JL, Murray G, Jennett B (1998) Analyzing outcome of treatment of severe head injury: a review and update on advancing the use of the Glasgow outcome scale. J Neurotrauma 15:587–597

18.

Timofeev I, Hutchinson P (2006) Outcome after surgical decompression of severe traumatic brain injury. Injury 37:1125–1132CrossRefPubMed

19.

Whitfield P, Patel H, Hutchinson P, Czosnyka M, Parry D, Menon D et al (2001) Bifrontal decompressive craniectomy in the management of posttraumatic intracranial hypertension. Br J Neurosurg 15:500–507CrossRefPubMed

20.

Wilson JL, Pettigrew LE, Teasdale GM (1998) Structured interviews for the Glasgow outcome scale and the extended Glasgow outcome scale: guidelines for their use. J Neurotrauma 15:573–585CrossRefPubMed

21.

Yang X, Wen L, Shen F, Li G, Lou R, Liu W et al (2008) Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir 150:1241CrossRefPubMed

Title: Decompressive craniectomy in traumatic brain injury: usage and clinical outcome in a single centre
Authors: Teodor Svedung Wettervik
Samuel Lenell
Lena Nyholm
Tim Howells
Anders Lewén
Per Enblad
Publication date: 01-02-2018
Publisher: Springer Vienna
Published in: Acta Neurochirurgica / Issue 2/2018
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI: https://doi.org/10.1007/s00701-017-3418-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

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

Abstract

Background

Method

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Method

Results

Conclusions

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