Decompressive Bifrontal Craniectomy in the Treatment of Severe Refractory Posttraumatic Cerebral Edema

Polin, Richard S.; Shaffrey, Mark E.; Bogaev, Christopher A.; Tisdale, Nancy; Germanson, Teresa P.; Bocchicchio, Ben; Jane, John A.

doi:10.1097/00006123-199707000-00018

Cited by 484 publications

(342 citation statements)

References 12 publications

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“…In this series, there were no beds in the ICU for 24 patients (27%) after surgery, and they remained in the post-anesthesia recovery room, without ICP monitoring. But of all these factors, the only one that was statistically related (p<0.05) to bad prognosis was GCS upon admittance, in agreement with other authors 3,4,11,14 .It is worth emphasizing characteristics of the hospital where the study was carried out (Hospital Pronto Socorro João XXIII), which is a reference center for trauma in Minas Gerais. Although is has a large number of ICU beds, there is always a larger number of patients in the polytrauma room.…”

Section: Discussionsupporting

confidence: 85%

“…Among infection cases, four were meningitis, and the others were superficial. Polin et al reported 28.5% of hydrocephalus 11 . Guerra et al found subdural effusions in 26%, hydrocephalus in 14%, and infection in 2% 4 .…”

Section: Discussionmentioning

confidence: 98%

“…Cerebral contusion was an associated finding in 46.9% of tomographies. Over the past two decades, there was a revival of DC to treat ICH, with results that proved superior to the previous series [2][3][4]11 . But what has changed?…”

Section: Postoperative Datamentioning

confidence: 99%

“…This fact is confirmed in Seelig et al, where a considerable reduction of death is shown when patients with ASDH were operated on before 4 hours after admittance to hospital 13 . Therefore one of the main differences in new practices is early DC, that often replaces clinical procedures such as hyperventilation, hypothermia or barbiturate coma 4,11,14 . But when we look closely at the series considered in this study, we notice that DC was performed very early (<6 h) in 22.7% of the patients, early (6-24 h) in 36.4% and late (>24 h) in 40.9%.…”

Section: Postoperative Datamentioning

confidence: 99%

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Decompressive craniotomy: prognostic factors and complications in 89 patients

Faleiro

Caetano

et al. 2008

Arq. Neuro-Psiquiatr.

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-Decompressive craniotomy (DC) is applied to treat post-traumatic intracranial hypertension (ICH).The purpose of this study is to identify prognostic factors and complications of unilateral DC. Eighty-nine patients submited to unilateral DC were retrospectively analyzed over a period of 30 months. Qui square independent test and Fisher test were used to identify prognostic factors. The majority of patients were male (87%). Traffic accidents had occurred in 47% of the cases. 64% of the patients had suffered severe head injury, while pupillary abnormalities were already present in 34%. Brain swelling plus acute subdural hematoma were the most common tomographic findings (64%). Complications occurred in 34.8% of the patients: subdural effusions in 10 (11.2%), hydrocephalus in 7 (7.9%) and infection in 14 (15.7%). The admittance Glasgow coma scale was a statistically significant predictor of outcome ( p=0.0309).KEY WORDS: head injury, intracranial hypertension, decompressive craniotomy. Craniotomia descompressiva: análise de fatores prognósticos e complicações em 89 pacientesResumo -A craniotomia descompressiva (CD) é técnica utilizada para tratamento da hipertensão intracraniana (HIC) pós-traumática. O objetivo do estudo foi determinar fatores prognósticos e complicações nos pacientes submetidos a esta técnica. Realizou-se estudo retrospectivo de 89 pacientes submetidos à CD unilateral para tratamento da HIC pós-traumática durante 30 meses. Utilizou-se testes do Qui-quadrado de independência e teste exato de Fisher para análise de fatores independentes de prognóstico. A maioria dos pacientes era do sexo masculino (87%). A causa mais comum foi o acidente de trânsito (47%). A maioria apresentava traumatismo cranioencefálico grave (64%), 34% já apresentavam anisocoria. O achado tomográfico mais comum foi a associação entre tumefação cerebral e hematoma subdural agudo (64%). Em 34,8% dos pacientes houve complicações inerentes à técnica: coleção subdural (11,2%), hidrocefalia (7,9%) e infecção (15,7%). A escala de coma de Glasgow à admissão correlacionou-se estatisticamente como fator prognóstico (p=0,0309). Decompressive craniotomy (DC) is a surgical method performed to immediately reduce intracranial pressure (ICP). It is usually indicated in cases of brain swelling (BS) and acute subdural hematoma (ASDH), or even for nontraumautic lesions in order to accommodate the swollen brain 1 . It consists of a unilateral craniotomy and dural augmentation. The bone can be temporarily stored in the abdominal subcutaneous tissue or can be disposed in case of a subsequent cranioplasty (with methylmethacrylate or titanium plate, among other materials). PALAVRAS-CHAVERecent studies have been evaluating DC efficacy when performed early in patients with severe traumatic brain injury (TBI) and with intracranial hypertension (ICH), yielding a superior result as compared to late performance or to specific clinical procedures (barbiturate coma and hypothermia) [2][3][4][5][6] . The purpose of this study was to evaluate prognostic...

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Section: Discussionsupporting

confidence: 85%

Section: Discussionmentioning

confidence: 98%

Section: Postoperative Datamentioning

confidence: 99%

Section: Postoperative Datamentioning

confidence: 99%

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Decompressive craniotomy: prognostic factors and complications in 89 patients

Faleiro

Caetano

et al. 2008

Arq. Neuro-Psiquiatr.

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“…Once the decision has been made to perform a decompressive craniectomy, Polin et al suggest doing so within 48 h of injury onset and report an advantage among pediatric patients when compared to matched controls taken from the Trauma Coma Data Bank [9]. Additionally, Aarabi et al found that patients with an admission GCS greater than 6 make them good candidates for decompressive craniectomy [10].…”

mentioning

confidence: 99%

State of the Art in Cerebral Trauma: A Neurosurgeon’s Perspective

Hsu

Keen

2011

Transl. Stroke Res.

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CommentaryNeurosurgery has always played an integral role in the management of cerebral trauma but, historically, treatments were limited and mortality and morbidity high. While cerebral trauma remains a leading cause of death worldwide, advancements in basic science injury models, pharmacology, and prevention strategies over the past several decades have resulted in a better understanding of injury mechanisms and have lead to improved outcomes in certain groups. The elucidation of the pathophysiology of secondary brain injury has lead to more targeted therapies; and the establishment of evidence-based guidelines has systematized the management of cerebral trauma, spawning the growth of neurocritical care, multimodal neuromonitoring, and the resurgence of surgical management.Cerebral trauma consists of a heterogeneous group of primary injuries with different causes, presentations, severity, and outcomes, but the final common pathway that leads to the most deleterious effects is that of secondary injury, which involves complex biomechanical and biochemical-triggered cascades that lead to cerebral ischemia, metabolic derangements, inflammation, edema, and cell death. Once cerebral blood flow, and therefore oxygenation, is diminished, neurons depolarize and release excitatory neurotransmitters, such as glutamate, that act at NMDA and AMPA receptors to permit massive influxes of sodium and calcium. The influx of calcium, in particular, activates multiple self-digesting mechanisms that lead to membrane damage, DNA degradation, and ultimately cell death [1]. These processes will often propagate until diffuse ischemia, inflammation, and edema lead to brain herniation and death, unless there is prompt intervention.The goal of neurocritical care is to anticipate the evolution of secondary injury and intervene early. Traditionally, this has been accomplished by measuring intracranial pressure (ICP) with external ventricular drains and parenchymal monitors to derive cerebral perfusion pressure (CPP) by subtracting ICP from mean arterial pressure. The goal has been to keep CPP above an acceptable threshold to ensure adequate cerebral perfusion and oxygenation. While consensus exists for treating ICP greater than 20 mmHg, CPP management has been less straightforward. Some studies have demonstrated improved outcomes with CPP >70 mmHg, whereas several others have not and revealed high rates of pulmonary complications [2]. Currently, the recommended threshold below which CPP should not fall is 50 mmHg, but artificially driving CPP higher than 70 mmHg has fallen out of favor [3]. The difficulty with an ICP and CPP management strategy is that some individuals may benefit from higher or lower CPP values depending upon the nature of their injury. Another complicating factor is that focal injury causing regional metabolic derangements may not be detected by more globally oriented monitoring techniques, such as intracranial pressure monitoring, whereas focal monitoring may not detect the presence of larger areas of injury if the devi...

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Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury

Sahuquillo

2006

Cochrane Database of Systematic Reviews

252

127

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There is no evidence to support the routine use of secondary DC to reduce unfavourable outcome in adults with severe TBI and refractory high ICP. In the pediatric population DC reduces the risk of death and unfavourable outcome. Despite the wide confidence intervals for death and the small sample size of the only study identified, this treatment maybe justified in patients below the age of 18 when maximal medical treatment has failed to control ICP. To date, there are no results from randomised trials to confirm or refute the effectiveness of DC in adults. However, the results of non-randomized trials and controlled trials with historical controls involving adults, suggest that DC may be a useful option when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of DC (Rescue ICP and DECRAN) that may allow further conclusions on the efficacy of this procedure in adults.

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Decompressive Bifrontal Craniectomy in the Treatment of Severe Refractory Posttraumatic Cerebral Edema

Cited by 484 publications

References 12 publications

Decompressive craniotomy: prognostic factors and complications in 89 patients

Decompressive craniotomy: prognostic factors and complications in 89 patients

State of the Art in Cerebral Trauma: A Neurosurgeon’s Perspective

Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury

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