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      Outcome of Decompressive Craniectomy for Traumatic Brain Injury: Ways to Better Evaluate Functional Outcome

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          Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension.

          Background The effect of decompressive craniectomy on clinical outcomes in patients with refractory traumatic intracranial hypertension remains unclear. Methods From 2004 through 2014, we randomly assigned 408 patients, 10 to 65 years of age, with traumatic brain injury and refractory elevated intracranial pressure (>25 mm Hg) to undergo decompressive craniectomy or receive ongoing medical care. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOS-E) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 6 months. The primary-outcome measure was analyzed with an ordinal method based on the proportional-odds model. If the model was rejected, that would indicate a significant difference in the GOS-E distribution, and results would be reported descriptively. Results The GOS-E distribution differed between the two groups (P<0.001). The proportional-odds assumption was rejected, and therefore results are reported descriptively. At 6 months, the GOS-E distributions were as follows: death, 26.9% among 201 patients in the surgical group versus 48.9% among 188 patients in the medical group; vegetative state, 8.5% versus 2.1%; lower severe disability (dependent on others for care), 21.9% versus 14.4%; upper severe disability (independent at home), 15.4% versus 8.0%; moderate disability, 23.4% versus 19.7%; and good recovery, 4.0% versus 6.9%. At 12 months, the GOS-E distributions were as follows: death, 30.4% among 194 surgical patients versus 52.0% among 179 medical patients; vegetative state, 6.2% versus 1.7%; lower severe disability, 18.0% versus 14.0%; upper severe disability, 13.4% versus 3.9%; moderate disability, 22.2% versus 20.1%; and good recovery, 9.8% versus 8.4%. Surgical patients had fewer hours than medical patients with intracranial pressure above 25 mm Hg after randomization (median, 5.0 vs. 17.0 hours; P<0.001) but had a higher rate of adverse events (16.3% vs. 9.2%, P=0.03). Conclusions At 6 months, decompressive craniectomy in patients with traumatic brain injury and refractory intracranial hypertension resulted in lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability than medical care. The rates of moderate disability and good recovery were similar in the two groups. (Funded by the Medical Research Council and others; RESCUEicp Current Controlled Trials number, ISRCTN66202560 .).
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            Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use.

            The Glasgow Outcome Scale (GOS) is the most widely used outcome measure after traumatic brain injury, but it is increasingly recognized to have important limitations. It is proposed that shortcomings of the GOS can be addressed by adopting a standard format for the interview used to assign outcome. A set of guidelines are outlined that are directed at the main problems encountered in applying the GOS. The guidelines cover the general principles underlying the use of the GOS and common practical problems of applying the scale. Structured interview schedules are described for both the five-point GOS and an extended eight-point GOS (GOSE). An interrater reliability study of the structured interviews for the GOS and GOSE yielded weighted kappa values of 0.89 and 0.85, respectively. It is concluded that assessment of the GOS using a standard format with a written protocol is practical and reliable.
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              Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury

              Background Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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                Author and article information

                Journal
                Asian J Neurosurg
                Asian J Neurosurg
                10.1055/s-00053244
                Asian Journal of Neurosurgery
                Thieme Medical and Scientific Publishers Pvt. Ltd. (A-12, 2nd Floor, Sector 2, Noida-201301 UP, India )
                1793-5482
                2248-9614
                24 August 2022
                June 2022
                1 August 2022
                : 17
                : 2
                : 394-395
                Affiliations
                [1 ]Department of General Medicine, Sengkang General Hospital, Singapore
                [2 ]Department of Rehabilitation Medicine, Singapore General Hospital, Singapore
                Author notes
                Address for correspondence Ng Kuan Geok, MD, MRCP, MMed Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886Singapore ng.kuan.geok@ 123456singhealth.com.sg
                Article
                36521
                10.1055/s-0042-1750810
                9473814
                f66bb7e8-ba07-4802-91b8-fe20888d4d16
                Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ )

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

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                Surgery
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