The Retrospective Application of a Prediction Model to Patients Who Have Had a Decompressive Craniectomy for Trauma

Abstract

There is currently a resurgence of interest in the use of decompressive craniectomy. As the procedure is used more frequently, there may be an increasing number of patients surviving a severe traumatic brain injury with severe neurological impairment. The aim of this study was to determine if we could predict those cases that fall into this category. We used the web-based prediction model prepared by the CRASH collaborators and applied it to a cohort of patients who had a decompressive craniectomy in 2006 and 2007 at the two major trauma hospitals in Western Australia. All clinical and radiological data were reviewed and entered into the model, and predicted outcome and actual outcome were compared. Our analysis indicated that a significant cut-off point appeared at which the model predicted a 75% risk of an unfavorable outcome at 6 months; 19 of 27 patients with CRASH scores <75% returned to work, whereas none of the 14 patients with higher scores achieved this degree of rehabilitation at 18 months. Statistical analysis of the outcomes in our cohort confirmed that the CRASH model reliably predicted unfavorable outcome. This study demonstrated that our ability to predict poor outcome has improved.

Prognostic significance of blood-brain barrier disruption in patients with severe nonpenetrating traumatic brain injury requiring decompressive craniectomy

“…The management strategies and outcomes of patients who had severe TBI requiring decompressive craniectomy before 2011 are described in our previous publications. 15,16 In this study, we defined BBB disruption as a total CSF protein concentration to total plasma protein concentration ratio greater than 0.007, which correlates well with the traditional biochemical marker of BBB disruption (CSF-plasma albumin quotient [correlation coefficient 0.97]). 34 Because the BBB can be disrupted across a continuum of severity, we also assessed the prognostic significance of BBB disruption by analyzing the ratio of the total CSF protein concentrations to total plasma protein concentrations as a continuous variable.…”

“…[15][16][17] In terms of developing secondary brain injury, for many years intracranial pressure (ICP) has been used as a means of assessment with little doubt of its prognostic value. 3,20,21 However, use of ICP as a measure has some limitations as it becomes increasingly apparent that it is essentially a measure of end organ injury, demonstrated by the failure of many ICP-lowering therapies to improve outcome.…”

Validation of the CRASH model in the prediction of 18-month mortality and unfavorable outcome in severe traumatic brain injury requiring decompressive craniectomy

“…The data from two previous studies were combined with data that have been collected prospectively since 2009. 11,13 This study has included all patients who had undergone a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia between 2004 and 2012 and in whom 18-month follow-up data were available. These two major trauma hospitals are the only neurosurgical centers that provide adult neurotrauma services in Western Australia, and there is a vast geographical separation from other state capital cities.…”

“…17 Previous studies have demonstrated that the predicted risk of an unfavorable outcome can be used as a surrogate index of injury severity, which can allow patients to be stratified accordingly. 11,13 Comparing the predicted outcome with the observed long-term outcome provides an objective assessment of the outcome following surgical intervention relative to the severity of injury and the expected outcome. In this study, we aimed to assess the predictive validity of the CRASH model in patients with severe TBI requiring decompressive craniectomy.…”

Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction

“…The model provides a percentagepredicted risk of unfavorable outcome at 6 months (defined by the Glasgow Outcome Scale as dead, persistent vegetative state, or severely disabled), and those predictions can be used as a surrogate index of injury severity that can be useful as a means to stratify patients according to injury severity. 23,24 Comparing the percentage-predicted risk of an unfavorable outcome with the observed long-term outcome provides an objective assessment of the most likely long-term outcome in patients who require life-saving decompressive surgery (Figure 2). No such models currently exist for stroke patients; however, given the amount of data now available, it would be feasible to develop a similar model based on prognostically important factors, such as age, presenting Glasgow Coma Scale, pupillary function, infarct size and location, and comorbidities.…”