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Controlled Cortical Impact Model for Traumatic Brain Injury
Published on: August 5, 2014
Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year
Jacques Albanèse1, Marc Leone, Jean-Roch Alliez
1Department of Intensive Care and Trauma Center, Marseilles University Hospital System, Marseilles School of Medicine, France.
Insights
Decompressive craniectomy for severe head trauma with high intracranial pressure showed varied outcomes. Early surgery had higher mortality, while late surgery offered better chances for social rehabilitation in select patients.
Area of Science:
- Neurosurgery
- Trauma Surgery
- Critical Care Medicine
Background:
- Severe head trauma frequently leads to intractable cerebral hypertension.
- Decompressive craniectomy is a potential intervention for managing elevated intracranial pressure.
- Timing of decompressive craniectomy may influence patient outcomes.
Purpose of the Study:
- To evaluate the impact of early (within 24 hours) versus late (after 24 hours) decompressive craniectomy on patient outcomes.
- To assess the effectiveness of decompressive craniectomy in severely head-injured patients with refractory intracranial hypertension.
Main Methods:
- Retrospective cohort study involving 40 patients with severe head trauma (Glasgow Coma Scale ≤8).
- Patients were divided into early (<24 hours) and late (>24 hours) decompressive craniectomy groups based on clinical and radiological criteria.
- Outcomes assessed at 1 year included social rehabilitation, persistent vegetative state, severe disability, and mortality.
Main Results:
- Early decompressive craniectomy (n=27) resulted in good recovery for 19%, severe disability/vegetative state for 30%, and mortality for 52%.
- Late decompressive craniectomy (n=13) showed social rehabilitation in 38%, severe disability/vegetative state in 38%, and mortality in 23%.
- Complications like meningitis or abscess occurred in 6 patients but were successfully treated.
Conclusions:
- Decompressive craniectomy in high-risk patients with intractable intracranial hypertension achieved social rehabilitation in 25% at 1 year.
- The timing of decompressive craniectomy may influence outcomes, with late surgery showing a trend towards better functional recovery in this cohort.
- Further research is warranted to optimize the timing and selection criteria for decompressive craniectomy.
Objective:
To assess the effect on outcome (1 yr) of decompressive craniectomy performed within or after the first 24 hrs post-trauma in severely head-injured trauma patients with intractable cerebral hypertension.
Design:
Retrospective cohort study.
Settings:
Intensive care unit of a university hospital.
Patients:
Among 816 patients with severe head trauma (Glasgow Coma Scale < or =8), 40 underwent decompressive craniectomy. After data collection, patients were divided into two groups: early and late decompressive craniectomy. An early decompressive craniectomy was performed within the first 24 hrs in patients according to the following criteria: a Glasgow Coma Scale score <6 and the existence of clinical signs of cerebral herniation (absence of pupillary reflexes), correlated with abnormalities in computed tomography scan including hematoma, appearance of diffuse or unilateral brain swelling, and/or cerebral herniation. The intracranial pressure in these patients was not measured before the decompressive craniectomy was performed. A late decompressive craniectomy (>24 hrs) was performed according to following criteria: an intractable intracranial hypertension with intracranial pressure >35 mm Hg, a unilateral or bilateral absence of pupillary reflexes, and the same abnormalities in computed tomography scan as previously described.
Intervention:
Twenty-seven patients with signs of cerebral herniation required the procedure at the time of initial evacuation of a mass lesion. In 13 patients, decompressive craniectomy was performed because of elevated intracranial pressure refractory to medical treatment consisting of cerebrospinal fluid derivation, deep sedation, osmotherapy, hyperventilation, and nesdonal or propofol.
Measurements And Main Results:
Five patients (19%) in whom an early decompressive craniectomy was performed had good recoveries (social rehabilitation), eight patients (30%) remained in a persistent vegetative state or with a severe disability, and 14 died (52%). On the other hand, the performance of late decompressive craniectomy in case of medical treatment failure was followed by social rehabilitation in five patients (38%) and death in three patients (23%). A persistent vegetative state or a severe disability was observed in five patients (38%). Meningitis or cerebral abscess occurred in six patients after decompressive craniectomy and were easily cured by antibiotic treatment.
Conclusions:
In 40 patients with intractable intracranial hypertension and at very high risk of brain death, decompressive craniectomy allowed 25% of patients to attain social rehabilitation at 1 yr.
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