Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury - A Meta-Analysis of Randomized Controlled Trials
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SUBMITTER: Zhang Q
PROVIDER: S-EPMC10789412 | biostudies-literature | 2023 Jan
REPOSITORIES: biostudies-literature
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Project description:In the context of traumatic brain injury (TBI), decompressive craniectomy (DC) is used as part of tiered therapeutic protocols for patients with intracranial hypertension (secondary or protocol-driven DC). In addition, the bone flap can be left out when evacuating a mass lesion, usually an acute subdural haematoma (ASDH), in the acute phase (primary DC). Even though, the principle of "opening the skull" in order to control brain oedema and raised intracranial pressure has been practised since the beginning of the 20th century, the last 20 years have been marked by efforts to develop the evidence base with the conduct of randomised trials. This article discusses the merits and challenges of this approach and provides an overview of randomised trials of DC following TBI. An update on the RESCUEicp study, a randomised trial of DC versus advanced medical management (including barbiturates) for severe and refractory post-traumatic intracranial hypertension is provided. In addition, the rationale for the RESCUE-ASDH study, the first randomised trial of primary DC versus craniotomy for adult head-injured patients with an ASDH, is presented.
| S-EPMC4841020 | biostudies-literature
Project description:We aim to perform a systematic review and meta-analysis to examine the prognostic value of decompressive craniectomy (DC) in patients with traumatic intracranial hypertension. PubMed, EMBASE, Cochrane Controlled Trials Register, Web of Science, http://clinicaltrials.gov/ were searched for eligible studies. Ten studies were included in the systematic review, with four randomized controlled trials involved in the meta-analysis, where compared with medical therapies, DC could significantly reduce mortality rate [risk ratio (RR), 0.59; 95% confidence interval (CI), 0.47-0.74, P < 0.001], lower intracranial pressure (ICP) [mean difference (MD), -2.12 mmHg; 95% CI, -2.81 to -1.43, P < 0.001], decrease the length of ICU stay (MD, -4.63 days; 95% CI, -6.62 to -2.65, P < 0.001) and hospital stay (MD, -14.39 days; 95% CI, -26.00 to -2.78, P = 0.02), but increase complications rate (RR, 1.94; 95% CI, 1.31-2.87, P < 0.001). No significant difference was detected for Glasgow Outcome Scale at six months (RR, 0.85; 95% CI, 0.61-1.18, P = 0.33), while in subgroup analysis, early DC would possibly result in improved prognosis (P = 0.04). Results from observational studies supported pooled results except prolonged length of ICU and hospital stay. Conclusively, DC seemed to effectively lower ICP, reduce mortality rate but increase complications rate, while its benefit on functional outcomes was not statistically significant.
| S-EPMC5562822 | biostudies-literature
Project description:When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of "living guidelines," whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at: https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/.
| S-EPMC7426189 | biostudies-literature
Project description:Traumatic brain injury (TBI) causes brain edema that induces increased intracranial pressure and decreased cerebral perfusion. Decompressive craniectomy has been recommended as a surgical procedure for the management of swollen brain and intracranial hypertension. Proper location and size of a decompressive craniectomy, however, remain controversial and no clinical guidelines are available. Mathematical and computational (in silico) models can predict the optimum geometric conditions and provide insights for the brain mechanical response following a decompressive craniectomy. In this work, we present a finite element model of post-traumatic brain injury and decompressive craniectomy that incorporates a biphasic, nonlinear biomechanical model of the brain. A homogenous pressure is applied in the brain to represent the intracranial pressure loading caused by the tissue swelling and the models calculate the deformations and stresses in the brain as well as the herniated volume of the brain tissue that exits the skull following craniectomy. Simulations for different craniectomy geometries (unilateral, bifrontal and bifrontal with midline bar) and sizes are employed to identify optimal clinical conditions of decompressive craniectomy. The reported results for the herniated volume of the brain tissue as a function of the intracranial pressure loading under a specific geometry and size of craniectomy are exceptionally relevant for decompressive craniectomy planning.
| S-EPMC7596483 | biostudies-literature
Project description: Not available
| S-EPMC6953357 | biostudies-literature
Project description:BackgroundDecompressive craniectomy is an important surgical treatment for patients with severe traumatic brain injury (TBI). Several reports have been published on the efficacy of non-watertight sutures in duraplasty performed in decompressive craniectomy. This study sought to determine the safety and feasibility of the non-suture dural closure technique in decompressive craniectomy.MethodsA total of 106 patients were enrolled at a single trauma center between January 2017 and December 2018. We retrospectively collected data and classified the patients into non-suture and suture duraplasty craniectomy groups. We compared the characteristics of patients and their intra/postoperative findings such as operative time, blood loss, imaging findings, complications, and Glasgow Outcome Scale scores.ResultsThere were 37 and 69 patients in the non-suture and suture duraplasty groups, respectively. There were no significant differences between the two groups concerning general characteristics. The operative time was significantly lower in the non-suture duraplasty group than in the suture duraplasty group (150 min vs. 205 min; p = 0.002). Furthermore, blood loss was significantly less severe in the non-suture duraplasty group than in the suture duraplasty group (1000 mL vs. 1500 mL; p = 0.028). There were no other significant differences.ConclusionNon-suture duraplasty involved shorter operative times and less severe blood losses than suture duraplasty. Other complications and prognoses were similar across groups. Therefore, the non-suture duraplasty in decompressive craniectomy is a safe and feasible surgical technique.
| S-EPMC7544056 | biostudies-literature
Project description:ObjectiveMany patients with severe traumatic brain injury (TBI) require a tracheostomy after decompressive craniectomy. Determining which patients will require tracheostomy is often challenging. The existing methods for predicting which patients will require tracheostomy are more applicable to stroke and spontaneous intracranial hemorrhage. The aim of this study was to investigate whether the Glasgow Coma Scale (GCS) motor score can be used as a screening method for predicting which patients who undergo decompressive craniectomy for severe TBI are likely to require tracheostomy.MethodsThe neurosurgery census at the University of Kansas Medical Center was retrospectively reviewed to identify adult patients aged over 18 years who underwent decompressive craniectomy for TBI. Eighty patients met the inclusion criteria for the study. There were no exclusion criteria. The primary outcome of interest was the need for tracheostomy. The secondary outcome was the comparison of the total length of stay (LOS) and intensive care unit LOS between the early and late tracheostomy patient groups.ResultsAll patients (100%) with a GCS motor score of 4 or less on post operative (POD) 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending tracheostomy resulted in 86.7% sensitivity, 91.7% specificity, and 90.5% positive predictive value, with an area under the receiver operator curve of 0.9101.ConclusionGCS motor score of 5 or less on POD 5 of decompressive craniectomy is a useful screening threshold for selecting patients who may benefit from tracheostomy, or may be potential candidates for extubation.
| S-EPMC10782100 | biostudies-literature
Project description:Decompressive craniectomy (DC) in traumatic brain injury (TBI) has been suggested to influence cerebrovascular reactivity. We aimed to determine if the statistical properties of vascular reactivity metrics and slow-wave relationships were impacted after DC, as such information would allow us to comment on whether vascular reactivity monitoring remains reliable after craniectomy. Using the CENTER-TBI High Resolution Intensive Care Unit (ICU) Sub-Study cohort, we selected those secondary DC patients with high-frequency physiological data for both at least 24 h pre-DC, and more than 48 h post-DC. Data for all physiology measures were separated into the 24 h pre-DC, the first 48 h post-DC, and beyond 48 h post-DC. We produced slow-wave data sheets for intracranial pressure (ICP) and mean arterial pressure (MAP) per patient. We also derived a Pressure Reactivity Index (PRx) as a continuous cerebrovascular reactivity metric updated every minute. The time-series behavior of the PRx was modeled for each time period per patient. Finally, the relationship between ICP and MAP during these three time periods was assessed using time-series vector autoregressive integrative moving average (VARIMA) models, impulse response function (IRF) plots, and Granger causality testing. Ten patients were included in this study. Mean PRx and proportion of time above PRx thresholds were not affected by craniectomy. Similarly, PRx time-series structure was not affected by DC, when assessed in each individual patient. This was confirmed with Granger causality testing, and VARIMA IRF plotting for the MAP/ICP slow-wave relationship. PRx metrics and statistical time-series behavior appear not to be substantially influenced by DC. Similarly, there is little change in the relationship between slow waves of ICP and MAP before and after DC. This may suggest that cerebrovascular reactivity monitoring in the setting of DC may still provide valuable information regarding autoregulation.
| S-EPMC7249464 | biostudies-literature
Project description:Decompressive craniectomy (DC) is often performed as an empirical lifesaving measure to protect the injured brain from the damaging effects of propagating oedema and intracranial hypertension. However, there are no clearly defined indications or specified guidelines for patient selection for the procedure.To evaluate outcome determinants and factors important in patient selection for the procedure.We reviewed the literature on DC, including single case reports and reported case series, to identify factors affecting outcome following the procedure, as well as its pitfalls and associated complications.Glasgow coma score of 8 and above, age less than 50 years and early intervention were found to be among the most significant determinants of prognosis.Improving patient selection for DC may be expected to further improve the outcome following the procedure in severely brain-injured patients.
| S-EPMC3066780 | biostudies-other
Project description:Hyperelastic finite element models, with either an idealized cylindrical geometry or with realistic craniectomy geometries, were used to explore clinical issues relating to decompressive craniectomy. The potential damage in the brain tissue was estimated by calculating the volume of material exceeding a critical shear strain. Results from the idealized model showed how the potentially damaged volume of brain tissue increased with an increasing volume of brain tissue herniating from the skull cavity and with a reduction in craniectomy area. For a given herniated volume, there was a critical craniectomy diameter where the volume exceeding a critical shear strain fell to zero. The effects of details at the craniectomy edge, specifically a fillet radius and a chamfer on the bone margin, were found to be relatively slight, assuming that the dura is retained to provide effective protection. The location in the brain associated with volume expansion and details of the material modeling were found to have a relatively modest effect on the predicted damage volume. The volume of highly sheared material in the realistic models of the craniectomy varied roughly in line with differences in the craniectomy area.
| S-EPMC5112297 | biostudies-literature