Is the recommended target of 4 hours from head injury to emergency craniotomy achievable?

Sergides, Ioannis G.; Whiting, Gemma; Howarth, Simon; Hutchinson, Peter J.

doi:10.1080/02688690600999976

Cited by 21 publications

(12 citation statements)

References 18 publications

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“…18 In particular, the delay to neurosurgery in previous studies has included various combinations of prehospital time, interfacility transfer time, and in-hospital time after reaching a place with neurosurgical capability. The time point used to calculate delays to neurosurgery has been variously defined as the injury occurrence time, 3,7,11,17,19,[21][22][23]25,29,30,32,33,[37][38][39][40][41][42][43][44][45] time of the call received by the emergency response system, 6 time of patients' ED arrival, 3,15,26,37,38 onset of the loss of consciousness, 13,28 and onset of traumatic decerebration. 12 Although all patients in the present study were treated with decompressive craniectomy, it remains controversial whether this procedure, when done specifically for elevated ICP, improves outcomes.…”

Section: Discussionmentioning

confidence: 99%

Association of time to craniectomy with survival in patients with severe combat-related brain injury

Shackelford

Junco

Reade³

et al. 2018

Neurosurgical Focus

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OBJECTIVEIn combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.METHODSPatients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2–5, quintiles 1–2 vs 3–5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.RESULTSOf 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30–152 minutes); 7% for quintile 2 (n = 42, 154–210 minutes); 7% for quintile 3 (n = 43, 212–320 minutes); 19% for quintile 4 (n = 42, 325–639 minutes); and 14% for quintile 5 (n = 43, 665–3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1–3) relative to longer delays (quintiles 4–5), with an adjusted hazard ratio of 0.28, 95% CI 0.10–0.76 (p = 0.012).CONCLUSIONSPostoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.

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Section: Discussionmentioning

confidence: 99%

Association of time to craniectomy with survival in patients with severe combat-related brain injury

Shackelford

Junco

Reade³

et al. 2018

Neurosurgical Focus

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“…In the multivariate analysis, the time between the injury and the surgery was placed among the factors which were significantly associated with the outcome after 6 months (p = 0.03). Therefore, it is reasonable to perform a surgery as soon as possible [42][43][44][45].…”

Section: Time Injury-operationmentioning

confidence: 99%

The Initial Factors with Strong Predictive Value in Relation to Six-Month Outcome among Patients Operated due to Extra-Axial Hematomas

et al. 2020

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Introduction: Traumatic brain injuries (TBI) are a real social problem, with an upward trend worldwide. The most frequent consequence of a traumatic brain injury is extra-axial hemorrhage, i.e., an acute subdural (SDH) and epidural hematoma (EDH). Most of the factors affecting the prognosis have been analyzed on a wide group of traumatic brain injuries. Nonetheless, there are few studies analyzing factors influencing the prognosis regarding patients undergoing surgery due to acute subdural and epidural hematoma. The aim of this study was to identify the factors which have the strongest prognostic value in relation to the 6-month outcome of the patients undergoing surgery for SDH and EDH. Patients and methods: The study included a group of 128 patients with isolated craniocerebral injuries. Twenty eight patients were operated upon due to EDH, and a group of 100 patients were operated upon due to SDH. The following factors from the groups were analyzed: demographic data, physiological factors, laboratory factors, computed tomography scan characteristics, and time between the trauma and the surgery. All of these factors were correlated in a multivariate analysis with the six-month outcome in the Glasgow outcome scale. Results: The factors with the strongest prognostic value are GCS score, respiration rate, saturation, glycaemia and systolic blood pressure. Conclusion: Initial GCS score, respiratory rate, saturation, glycaemia and systolic blood pressure were the factors with the strongest prognostic value.

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“…This study has provided a detailed picture of the treatment of traumatic intracranial haematomas in a typical region of the United Kingdom. Although treatment times are better than in other studies [4], only 32% of patients had their haematoma decompressed within 4 h. This answers our first question -there continues to be a problem in treating these patients in a timely fashion. Determining which phase of treatment is responsible is more complicated.…”

Section: Discussionmentioning

confidence: 61%

“…In the UK the perception is that these targets are not being achieved. Some units report that as few as one in 24 patients are decompressed within 4 h [4]. Due to the large number of services involved in the management of the severely head injured patient and the difficulty in collecting data in these emergency situations, there is little information on why these targets are not met and where delays occur.…”

mentioning

confidence: 99%

“…The mean age of the patients was 44.5 years (range 19-75); 19 were male and eight female. The median Glasgow Coma Score (GCS) at the time of intubation (or at the time of referral if not intubated) was 7 (range[3][4][5][6][7][8][9][10][11][12]. Eight patients had one fixed and dilated pupil and two had bilaterally fixed and dilated pupils.The median (IQR) time to surgical decompression was 5.0 h (4.1-6.6).…”

mentioning

confidence: 99%

See 1 more Smart Citation

A prospective study of the time to evacuate acute subdural and extradural haematomas*

Bulters¹,

Belli

2009

Anaesthesia

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Summary We performed a prospective, single‐centre study of times to treatment of patients with life‐threatening, traumatic, extra‐ and subdural haematomas requiring surgical evacuation between May 2006 and May 2007. The mean time to surgical decompression was 5.0 h and 32% were performed within 4 h. Patients who initially presented to a district hospital and required transfer for neurosurgery were decompressed in 5.4 h vs 3.7 h for those admitted directly. The current standard of surgical evacuation of all haematomas within 4 h is not being met. Delays were identified in every stage in the management of these patients and no single step was identified as the major cause. Initial treatment in district hospitals led to delays greater than the added driving time. There may be time savings from carrying out treatment steps in parallel instead of in series.

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Is the recommended target of 4 hours from head injury to emergency craniotomy achievable?

Cited by 21 publications

References 18 publications

Association of time to craniectomy with survival in patients with severe combat-related brain injury

Association of time to craniectomy with survival in patients with severe combat-related brain injury

The Initial Factors with Strong Predictive Value in Relation to Six-Month Outcome among Patients Operated due to Extra-Axial Hematomas

A prospective study of the time to evacuate acute subdural and extradural haematomas*

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