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      Effects of unilateral decompressive craniectomy on patients with unilateral acute post-traumatic brain swelling after severe traumatic brain injury

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          Abstract

          Introduction

          Acute post-traumatic brain swelling (BS) is one of the pathological forms that need emergent treatment following traumatic brain injury. There is controversy about the effects of craniotomy on acute post-traumatic BS. The aim of the present clinical study was to assess the efficacy of unilateral decompressive craniectomy (DC) or unilateral routine temporoparietal craniectomy on patients with unilateral acute post-traumatic BS.

          Methods

          Seventy-four patients of unilateral acute post-traumatic BS with midline shifting more than 5 mm were divided randomly into two groups: unilateral DC group (n = 37) and unilateral routine temporoparietal craniectomy group (control group, n = 37). The vital signs, the intracranial pressure (ICP), the Glasgow outcome scale (GOS), the mortality rate and the complications were prospectively analysed.

          Results

          The mean ICP values of patients in the unilateral DC group at hour 24, hour 48, hour 72 and hour 96 after injury were much lower than those of the control group (15.19 +/- 2.18 mmHg, 16.53 +/- 1.53 mmHg, 15.98 +/- 2.24 mmHg and 13.518 +/- 2.33 mmHg versus 19.95 +/- 2.24 mmHg, 18.32 +/- 1.77 mmHg, 21.05 +/- 2.23 mmHg and 17.68 +/- 1.40 mmHg, respectively). The mortality rates at 1 month after treatment were 27% in the unilateral DC group and 57% in the control group (p = 0.010). Good neurological outcome (GOS Score of 4 to 5) rates 1 year after injury for the groups were 56.8% and 32.4%, respectively (p = 0.035). The incidences of delayed intracranial hematoma and subdural effusion were 21.6% and 10.8% versus 5.4% and 0, respectively (p = 0.041 and 0.040).

          Conclusions

          Our data suggest that unilateral DC has superiority in lowering ICP, reducing the mortality rate and improving neurological outcomes over unilateral routine temporoparietal craniectomy. However, it increases the incidence of delayed intracranial hematomas and subdural effusion, some of which need secondary surgical intervention. These results provide information important for further large and multicenter clinical trials on the effects of DC in patients with acute post-traumatic BS.

          Trial registration

          ISRCTN14110527

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          Induced hypothermia and fever control for prevention and treatment of neurological injuries.

          Kees H Polderman (2008)
          Increasing evidence suggests that induction of mild hypothermia (32-35 degrees C) in the first hours after an ischaemic event can prevent or mitigate permanent injuries. This effect has been shown most clearly for postanoxic brain injury, but could also apply to other organs such as the heart and kidneys. Hypothermia has also been used as a treatment for traumatic brain injury, stroke, hepatic encephalopathy, myocardial infarction, and other indications. Hypothermia is a highly promising treatment in neurocritical care; thus, physicians caring for patients with neurological injuries, both in and outside the intensive care unit, are likely to be confronted with questions about temperature management more frequently. This Review discusses the available evidence for use of controlled hypothermia, and also deals with fever control. Besides discussing the evidence, the aim is to provide information to help guide treatments more effectively with regard to timing, depth, duration, and effective management of side-effects. In particular, the rate of rewarming seems to be an important factor in establishing successful use of hypothermia in the treatment of neurological injuries.
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            Surgical decompression for traumatic brain swelling: indications and results.

            Patrícia Fritsch, R-M Gaab, W Kleist-Welch Guerra … (1999)
            Decompressive craniectomy has been performed since 1977 in patients with traumatic brain injury. The authors assess the efficacy of this treatment and the indications for its use. The clinical status of the 57 patients, their computerized tomography (CT) scans, and intracranial pressure (ICP) levels were documented prospectively in a standard protocol. At the beginning of the study, all patients older than 30 years were excluded. As of 1989 patients older than 40 years were excluded until 1991; since that time patients older than 50 years have been excluded. Primary brain or brainstem injury with fully developed bulbar brain syndrome, loss of auditory evoked potentials (AEPs), and/or oscillation flow in a transcranial Doppler ultrasound examination were contraindications to decompressive craniectomy. A positive indication for decompression was given in the case of progressive therapy-resistant intracranial hypertension in correlation with clinical (Glasgow Coma Scale [GCS] score, decerebrate posturing, dilating of pupils) and electrophysiological (electroencephalography, somatosensory evoked potentials, and AEPs) parameters and with findings on CT scans. Unilateral decompressive craniectomy was performed in 31 patients and bilateral craniectomy in 26 patients. In all cases, a wide frontotemporoparietal craniectomy was followed by a dura enlargement covered with temporal muscle fascia. The outcomes of the treatment were surprisingly good. Only 11 patients (19%) died, three of whom died of acute respiratory disease syndrome. Five patients (9%) survived, but remained in a persistent vegetative state; six patients (11%) survived with a severe permanent neurological deficit, and 33 patients (58%) attained social rehabilitation. Two patients (3.5%) did not have a follow-up examination. The GCS score on the 1st day posttrauma and the mean ICP turned out to be the best predictors for a good prognosis. The results demonstrate the importance of decompressive craniectomy in the treatment of traumatic brain swelling. Surgical decompression should be routinely performed when indicated before irreversible ischemic brain damage occurs.
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              Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management.

              Kern Guppy, Paul T Akins (2007)
              Decompressive craniectomy is reclaiming a role in neurocritical care. The altered pathophysiology found in a cranium converted from a 'closed' box to an 'open' box' carries benefits and risks. In some craniectomy patients, the forces of atmospheric pressure and gravity overwhelm intracranial pressures, and the brain appears sunken. This can lead to paradoxical herniation and the sinking skin flap syndrome, also called the syndrome of the trephined. At the other polar extreme, external brain tamponade occurs when subgaleal fluid accumulates under pressure and 'pushes' on the brain across the craniectomy defect. The neuro-intensive care team should be prepared to diagnose and treat a spectrum of decompressive craniectomy complications including: cerebral contusions, infections, seizures, intra- and extra-axial hemorrhages and fluid collections, sinking skin flap syndrome or syndrome of the trephined, paradoxical herniation, and external brain tamponade. The treating physicians must set aside the Monro-Kellie doctrine and recognize the new pathophysiologic state of these 'open box' patients.
              Article 0 comments Cited 32 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Crit Care
                Journal ID (iso-abbrev): Crit Care
                Title: Critical Care
                Publisher: BioMed Central
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Print): 2009
                Publication date (Electronic): 23 November 2009
                Volume: 13
                Issue: 6
                Page: R185
                Affiliations
                [1 ]Department of Neurosurgery, Hangzhou Second Hospital, College of Medicine, Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310015, China
                [2 ]Brain Medicine Research Institute, College of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
                [3 ]Department of Neurosurgery, Second Affiliated Hospital, College of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
                Article
                Publisher ID: cc8178
                DOI: 10.1186/cc8178
                PMC ID: 2811943
                PubMed ID: 19930556
                SO-VID: e42efab7-205b-4856-aa2c-7a14f3b1e11b
                Copyright © Copyright ©2009 Qiu et al; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 6 April 2009
                Date revision requested : 3 June 2009
                Date revision received : 21 August 2009
                Date accepted : 23 November 2009
                Categories
                Subject: Research

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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