Indication of Decompressive Craniectomy in Traumatic Brain Injury


Authors: V. Juráň 1;  M. Smrčka 1;  K. Svoboda 1;  P. Fadrus 1;  A. Šprláková 2;  R. Gál 3
Authors‘ workplace: Neurochirurgická klinika LF MU a FN Brno, 2Radiodi agnostická klinika LF MU a FN Brno, 3Klinika anesteziologi e, resuscitace a intenzivní medicíny LF MU a FN Brno 1
Published in: Cesk Slov Neurol N 2009; 72/105(5): 439-445
Category: Original Paper

Overview

Backgrounds:
Decompressive craniectomy (DC) is a type of neurosurgical operation performed for the purpose of radical reduction of intracranial pressure, which enables sufficient cerebral perfusion and prevents from brain ischaemia. In severe traumatic brain injuries (Glasgow Coma Scale 3–8), the indication depends on the clinical status of the patient, findings of CT scans, on intracranial and perfusion pressure and on perioperativefindings.

Aim:
To identify the group of patients which most benefit from DC. To evaluate the significance of intracranial monitoring and level of decrease of intracranial pressure after DC. To summarize the main operation diagnoses and review the area of the performed DC.

Patient group and methods:

The study is based on three-year prospective monitoring of 81 patients undergoing DC after severe brain injury in 2003–2005. Control group was formed by 68 retrospectively analyzed patients who had undergone DC in the years 1996–1998. In both groups we analyzed age, sex, anamnesis, operative diagnosis, performed monitoring, timing of the operation, localization and the area of DC, GCS at the time of indication of DC and GOS 12 months after injury.

Results:
The group of patients younger than 50 years of age had good recovery (GOS 4–5) in 45% of cases and if these patients had even ICP monitoring, good recovery was present in 70% of cases, which was statistically significant (α < 0.05). After DC there was a statistically significant reduction in intracranial pressure from a mean of 31.8 mmHg to 9.2 mmHg 2 hours after the operation, and 11.0 mmHg 24 hours after the operation (p < 0.01), respectively. Most frequent operative diagnoses were: acute subdural haematoma in 56% of cases, and cerebral contusion in 25% of cases. Mean area of performed DC was 157 cm2.

Conclusion:
Good recovery in patients with severe traumatic brain injury is conditioned by early indication of DC according to ICP monitoring, by age under 50 years, and by performing sufficiently large decompression.

Key words:
decompressive craniectomy –  traumatic brain injury –  indicati on –  monitoring


Sources

1. Bre asted JH. The Edwin Smith Surgical Papyrus. Chicago: Chicago University Press 1930.

2. Kocher T. Di e Therapi e des Hirndruckes. In: Hölder A (ed). Hirnerschütterung, Hirndruck und chirurgische Eingriffe bei Hirnkrankheiten. Wi en: Hölder 1901: 262– 266.

3. Cushing H. The establishment of cerebral herni a as a decompressive me asure for inaccessible brain tumor, with the descripti on of intramuscular methods of making the bone defect in temporal and occipital regi ons. Surg Gynecol Obstet 1905; 1: 297– 314.

4. Clark K, Nash TM, Hutchison GC. The failure of circumferenti al crani otomy in acute tra umatic cerebral swelling. J Ne urosurg 1968; 29(4): 367– 371.

5. Mraček Z. Význam veliké dekompresivní krani ektomi e při edému mozku u těžkých krani ocerebrálních poranění. Rozhl Chir 1977; 56(9): 597– 605.

6. Smrčka M et al. Patofyzi ologi e poranění mozku. Edice kontinu álního vzdělávání. Brno: LF a MU v Brně 2002.

7. French BN, Dublin AB. The value of computerized tomography in the management of 1000 consecutive he ad injuri es. Surg Ne urol 1977; 7(4): 171– 183.

8. Te asdale G, Jennett B. Assessment of Coma and Impaired Consci o usness. A Practical Scale. Lancet 1974; 2(7872): 81– 84.

9. Marshall LF, Marshall SB, Kla uber M, Braakman R. A new Classificati on he ad injury based on computerized tomography. J Ne urosurg 1991; 75 (Suppl): S14– S20.

10. Compagnone C, Murray GD, Te asdale GM, Maas AIR, Esposito D, Princi P et al. The management of pati ents with intradural post‑tra umatic mass lesi ons: a multicenter survey of current appro aches to surgical management in 729 pati ents co ordinated by the EBIC. Ne urosurgery 2005; 57(6): 1183– 1192.

11. Gál R, Čundre I, Zimová I. Řízená hypotermi e u paci entů s těžkým poraněním mozku. Anest Ne odkl Péče 2000; 11: 174– 175.

12. Smrčka M, Otevřel F, Kuchtičková Š, Horký M, Juráň V, Duba M et al. Experimental Model of Reversible Focal Ischemi a in the Rat. Scripta Medica 2001; 74(6): 391– 398.

13. Weiwei H, Yu Y, Weiguo L. Decompressive cra­ni ectomy as tre atment for a rat model of “malignant” middle cerebral artery infarcti on. Cesk Slov Ne urol N 2007; 70/ 103(4): 388– 391.

14. Hutchinson PJ, Corteen E, Czosnyka M, Mendelow AD, Menon DK, Mitchell P et al. Decompressive crani ectomy in tra umatic brain injury: the randomized multicenter RESCUEicp study (www.RESCUEicp.com). Acta Ne urochir Suppl 2006; 96: 17– 20.

15. Co oper DJ. The DECRA tri al: e arly decompressive crani ectomy in pati ents with severe tra umatic brain injury (Clinical Tri al Feeds website). Available at: http:/ / clinicaltri alsfeeds.org/ clinical- tri als/ show/ NCT00155987.

16. Ji ang JY, Xu W, Li WP, Xu WH, Zhang J, Bao YH et al. Efficacy of standard tra uma crani ectomy for refractory intracrani al hypertensi on with severe tra umatic brain injury: a multicentre, prospective, randomized controlled study. J Ne urotra uma 2005; 22(6): 623– 628.

17. Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfi eld M,Lewis E et al. A randomized tri al of very e arly decompressive crani ectomy in children with tra umatic brain injury and sustained intracrani al hypertensi on. Childs Nerv Syst 2001; 17(3): 154– 162.

18. Polin RS, Shaffrey ME, Bogaev CA, Tisdale N, Germanson T, Bocchicchi B et al. Decompressive bifrontal crani ectomy in the tre atment of severe refractory posttra umatic cerebral edema. Ne urosurgery 1997; 41(1): 84– 94.

19. Chesnut RM, Marshall SB, Pi ek J, Blunt BA, Kla uber MR, Marshall LF. Early and late systemic hypotensi on as a frequent and fundamental so urce of cerebral ischemi a following severe he ad injury in the Tra uma Coma Data Bank. Acta Ne urochir Suppl (Wi en) 1993; 59: 121– 125.

20. Valadka AB, Robertson CS. Surgery of cerebral tra uma and associ ated critical care. Ne urosurgery 2007; 61 (Suppl 1): 203– 221.

21. Mraček J, Choc M, Mraček Z. Oste oplastická dekompresivní krani otomi e. Cesk Slov Ne urol N 2007; 70/ 103(3): 290– 293.

22. Albanèse J, Le one M, Alli ez J, Kaya J, Antonini F, Alli ez B, Martin C. Decompressive crani ectomy for severe tra umatic brain injury: Evalu ati on of the effects at one ye ar. Crit Care Med 2003; 31(10): 2535– 2538.

23. Co oper PR, Hagler H, Clark WK, Barnett P. Enhancement of experimental cerebral edema after decompressive crani ectomy: Implicati ons for the management of severe he ad injuri es. Ne urosurgery 1979; 4(4): 296– 300.

24. Juráň V, Smrčka M, Vidlák M. Programy kvality a standardy léčebných postupů, Chirurgi e/ 11. Poranění mozku. Praha: Verlag Dashöfer 2004.

25. Skoglund TS, Eriksson- Ritzén C, Jensen C, Rydenhag B. Aspects on decompressive crani ectomy in pati ents with tra umatic he ad injuri es. J Ne urotra uma 2006; 23(10): 1502– 1509.

26. Münch E, Horn P, Schürer L, Pi epgras A, Pa ul T, Schmidec P. Management of severe tra umatic brain injury by decompressive crani ectomy. Ne urosurgery 2000; 47(2): 315– 323.

27. Pi ek J. Decompressive surgery in the tre atment of tra umatic brain injury. Curr Opin Crit Care 2002; 8(2): 134– 138.

28. Mei er U, Gräwe A. The importance of decompressive crani ectomy for the management of severe he ad injuri es. Acta Ne urochir (Suppl) 2003; 86: 367– 371.

29. Jennett B, Bond M. Assessment of o utcome after severe brain damage. Lancet 1975; 1(7905): 480– 484.

30. Navrátil L. Dekompresivní krani otomi e u krani ocerebrálních poranění –  hodnocení přežití a jeho kvality po jednom roce od úrazu. Cesk Slov Ne urol N 2007; 70/ 103(3): 294– 301.

Labels
Paediatric neurology Neurosurgery Neurology
Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account