The influence of decompressive craniectomy on intracranial pressure in patients with severe traumatic brain injury
Keywords:traumatic brain injury, diffuse brain injury, decompressive craniectomy, intracranial pressure, intracranial hypertension, surgical decompression
A prospective study of decompressive craniectomy (DC) influence on intracranial pressure (ICP) in patients with severe traumatic brain injury (TBI) has been performed using intraoperative and postoperative monitoring.
Purpose. To study quantitative indicators of DC influence on ICP in patients with severe TBI through continuous intraoperative and postoperative monitoring.
Materials and methods. A total of 75 patients (14 women and 61 men) with severe TBI (the GCS score at admission was 8 or less) who underwent DC and dura mater opening with further duraplasty were included in the study. A unilateral wide fronto-temporo-parietal decompression was performed. Primary DC was performed in 64 patients. Secondary DC was performed in 11 patients. ICP measurements were carried out using parenchymal sensors on the REF HDM 26.1/FV500 Brain Pressure Monitor (Spiegelberg,Hamburg,Germany). ICP sensor was installed during the first surgery stage. In each case, a decompressive effect of each surgery stage and the entire surgery was assessed.
Results. High ICP was diagnosed in 86.7 % of patients preoperatively and in 24 % of patients (P < 0.05) postoperatively. The mean post-DC ICP decreased from 39 mmHg (preoperative) to 15.8 mmHg (postoperative), the average decrease was 59.5 % from the baseline. The largest decrease in ICP by 42.6 % was detected after bone flap removal. Dura mater opening resulted to additional decrease in ICP by 24.7 %.
Conclusions. A unilateral wide fronto-temporo-parietal craniectomy is an effective method for sustainable ICP reduction. DC reduces the percentage of patients with intracranial hypertension. Decompressive effect of a surgery does not significantly depend on DC, brain injury type or traumatic compression substrate.
Tang, A., Pandit, V., Fenkell, V., Jones, T., Joseph, B., O'Keeffe, T., et al. (2015) Intracranial pressure monitoring in patients with traumatic brain injury. Journal of surgical research, 194(2), 565–570. doi: 10.1016/j.jss.2014.11.017
Adams, H., Donnelly, J., Czosnyka, M., Kolias, A. G., Helmy, A., Menon, D. K., et al. (2017) Temporal profile of intracranial pressure and cerebrovascular reactivity in severe traumatic brain injury and association with fatal outcome: An observational study. PLoS Med, 14(7), e1002353. doi: 10.1371/journal.pmed.1002353
Tsai, T. H., Huang, T. Y., Kung, S. S., Su, Y. F., Hwang, S. L., & Lieu A. S. (2013) Intraoperative intracranial pressure and cerebral perfusion pressure for predicting surgical outcome in severe traumatic brain injury. Kaohsiung Journal of Medical Sciences, 29(10), 540–546. doi: 10.1016/j.kjms.2013.01.010
Bor-Seng-Shu, E., Figueiredo, E. G., Amorim, R. L. O., Teixeira, M. J., Valbuza, J. S., De Oliveira, M. M., et al. (2012) Decompressive craniectomy: a meta-analysis of influences on intracranial pressure and cerebral perfusion pressure in the treatment of traumatic brain injury. J. Neurosurg, 117(3), 589–596. doi: 10.3171/2012.6.JNS101400
Bor-Seng-Shu, E., Figueiredo, E. G., Fonoff, E. T., Fujimoto, Y., Panerai, R. B., & Teixeira, M. J. (2013) Decompressive craniectomy and head injury: brain morphometry, ICP, cerebral hemodynamics, cerebral microvascular reactivity, and neurochemistry. Neurosurg. Rev, 36(3), 361–370. doi: 10.1007/s10143-013-0453-2
Zhang, D., Xue, Q, Chen, J, Dong, Y, Hou, L., Jiang, Y., & Wang J. (2017) Decompressive craniectomy in the management of intracranial hypertension after traumatic brain injury: a systematic review and meta-analysis. Scientific Reports, 7(1), 8800. doi: 10.1038/s41598-017-08959-y
Olivecrona, M., Rodling-Wahlstrom, M., Naredi, S., & Koskineni, L.D. (2007) Effective ICP reduction by decompressive craniectomy in patients with severe traumatic brain injury treated by an ICP-targeted therapy. Journal of neurotrauma, 24(6), 927–935. doi: 10.1089/neu.2005.356E
Cooper, D. J., Rosenfeld, J. V., Murray, L., Arabi, Y. M., Davies, A. R., D’Urso, P., et al (2011) Decompressive craniectomy in diffuse traumatic brain injury. N. Engl. J. Med., 364(16), 1493–1502. doi: 10.1056/NEJMoa1102077
Carney, N., Totten, A. M., O’Reilly, C., Ullman, J. S., Hawryluk, G. W. J., Bell, M. B., et al. (2016) Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery, 80(1), 6–15. doi: 10.1227/NEU.0000000000001432
Hutchinson, P. (2005) Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of intracranial pressure. doi: 10.1186/ISRCTN66202560
Sauvigny, T., Göttsche, J., Czorlich, P., Vettorazzi, E., Westphal, M., & Regelsberger, J. (2017) Intracranial pressure in patients undergoing decompressive craniectomy: new perspective on thresholds. J. Neurosurg., 128(3), 819–827. doi: 10.3171/2016.11.JNS162263
Pedachenko, Ye. A., Dziak, L. A., Sirko, A. A. (patentee) (2010) Pat. 54368 Ukraina, MPK A61V17/00. Sposib dekompresyvnoi trepanatsii cherepa pry patolohii holovnoho mozku, shcho suprovodzhuietsia pidvyshchenniam vnutrishnocherepnoho tysku [Patent 54368 Ukraine, MPK A61V17/00. Method of decompressive trepanation of the skull with pathology of the brain, accompanied by an increase in intracranial pressure]. Biul., 20. [in Ukrainain]
Pedachenko, Ye. A., Dziak, L. A., Sirko, A. A., Suk, V. M., (patentee) (2010) Pat. 54363 Ukraina, MPK A61V17/00. Sposib vyznachennia dekompresyvnoho efektu operatsii pry tiazhkii cherepnomozkovii travmi [Patent 54363 Ukraine, MPK A61V17/00. A method for determining the decompression effect of surgery in severe brain injury]. Biul., 21. [in Ukrainain]
Abraham, P., Rennert, R. C., Gabel, B. C., Sack J. A., Karanjia N., Warnke P., et al. (2017) ICP management in patients suffering from traumatic brain injury: a systematic review of randomized controlled trials. Acta Neurochir, 159(12), 2279–2287. doi: 10.1007/s00701-017-3363-1
Shen, L., Wang, Z., Su, Z., Qiu, S., Xu, J., Zhou, Y., et al. (2016) Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis. PLoS ONE, 11(12), e0168901. doi:10.1371/journal.pone.0168901
Han, J., Yang, S., Zhang, C., Zhao, M., & Li, A. (2016) Impact of intracranial pressure monitoring on prognosis of patients with severe traumatic brain injury: A PRISMA systematic review and meta-analysis. Medicine, 95(7), e2827. doi: 10.1097/MD.0000000000002827
Bao, Y. H., Liang, Y. M., Gao, G. Y., Pan, Y. H., Luo, Q. Z., & Jiang, J. Y. (2010) Bilateral decompressive craniectomy for patients with malignant diffuse brain swelling following severe traumatic brain injury: 37 cases report. J. Neurotrauma, 27(2), 341–347. doi: 10.1089/neu.2009.1040
Eberle, B. M., Schnüriger, B., Inaba, K., Gruen, J. P., Demetriades, D., & Belzberg H. (2010) Decompressive craniectomy: surgical control of traumatic intracranial hypertension may improve outcome. Injury, 41(9), 894–898. doi: 10.1016/j.injury.2010.02.023
Ho, C. L., Wang, C. M., Lee, K. K., Ng, I., & Ang, B. T. (2008) Cerebral oxygenation, vascular reactivity, and neurochemistry following decompressive craniectomy for severe traumatic brain injury. J. Neurosurg, 108(5), 943–949. doi: 10.3171/JNS/2008/108/5/0943
Johnson, U., Nilsson, P., Ronne-Engstrom, E., Howells, T., & Enblad P. (2011). Favorable outcome in traumatic brain injury patients with impaired cerebral pressure autoregulation when treated at low cerebral perfusion pressure levels. Neurosurgery, 68(3), 714–721. doi: 10.1227/NEU.0b013e3182077313
Qiu, W., Guo, C., Shen, H., Chen, K., Wen, L., Huang, H., et al. (2009) Effects of unilateral decompressive craniectomy on patients with unilateral acute posttraumatic brain swelling after severe traumatic brain injury. Crit. Care, 13(6), R185. doi: 10.1186/cc8178
Soustiel, J. F., Sviri, G. E., Mahamid, E., Shik, V., Abeshaus, S., & Zaaroor, M. (2010) Cerebral blood flow and metabolism following decompressive craniectomy for control of increased intracranial pressure. Neurosurgery, 67(1), 65–72. doi: 10.1227/01.neu.0000370604.30037.f5
Taylor, A., Butt, W., Rosenfeld, J., Shann, F., Ditchfield, M., Lewis, E., et al. (2001) A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs. Nerv. Syst., 17(3), 154–162. doi: 10.1007/s003810000410
Zweifel, C., Lavinio, A., Steiner, L. A., Radolovich, D., Smielewski, P., Timofeev, I., et al. (2008) Continuous monitoring of cerebrovascular pressure reactivity in patients with head injury. Neurosur. Focus, 25(4), E2. doi: 10.3171/FOC.2008.25.10.E2
Wang, E. C., Ang, B. T., Wong, J., Lim, J., & Ng, I. (2006) Characterization of cerebrovascular reactivity after craniectomy for acute brain injury. Br. J. Neurosurg, 20(1), 24–30. doi: 10.1080/02688690600598257
Weiner, G. M., Lacey, M. R., Mackenzie, L., Shah, D. P., Frangos S. G., Grady M.S., et al. (2010) Decompressive craniectomy for elevated intracranial pressure and its effect on the cumulative ischemic burden and therapeutic intensity levels after severe traumatic brain injury. Neurosurgery, 66(6), 1111–1118. doi: 10.1227/01.NEU.0000369607.71913.3E
Whitfield, P. C., Patel, H., Hutchinson, P. J., Czosnyka, M., Parry, D., Menon D., et al. (2007) Bifrontal decompressive craniectomy in the management of posttraumatic intracranial hypertension. Br. J. Neurosurg., 15(6), 500–507. doi: 10.1080/02688690120105110 •
Timofeev, I., Czosnyka, M., Nortje, J., Smielewski, P., Kirkpatrick, P., Gupta, A., et al. (2008) Effect of decompressive craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury. J. Neurosurg., 108(1), 66–73. doi: 10.3171/JNS/2008/108/01/0066
Aarabi, B., Hesdorffer, D. C., Ahn, E. S., Aresco, C., Scalea, T. M., & Eisenberg, H. (2006) Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J. Neurosurg., 104(4), 469–479. doi: 10.3171/jns.2006.104.4.469
Bor-Seng-Shu, E., Hirsch, R., Teixeira, M. J., De Andrade, A. F., & Marino, R. Jr. (2006) Cerebral hemodynamic changes gauged by transcranial Doppler ultrasonography in patients with posttraumatic brain swelling treated by surgical decompression. J. Neurosurg., 104(1), 93–100. doi: 10.3171/jns.2006.104.1.93
Nirula, R. Millar, D., Greene, T., McFadden, M., Shah, L., Scalea, T. M., et al. (2014) Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis. The journal of trauma and acute care surgery, 76(4), 944–952. doi: 10.1097/ta.0000000000 000194
Hutchinson, P. J., Kolias, A. G., Timofeev, I. S., Corteen, E. A., Czosnyka, M,, Timothy, J., et al. (2016) Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. The New England journal of medicine, 375(12), 1119–1130. doi: 10.1056/NEJMoa1605215
Josan, V. A., & Sgouros, S. (2006) Early decompressive craniectomy may be effective in the treatment of refractory intracranial hypertension after traumatic brain injury. Child’s nervous system, 22(10), 1268–1274. doi: 10.1007/s00381-006-0064-0
Thomale, U. W., Graetz, D., Vajkoczy, P., & Sarrafzadeh, A. S. (2010) Severe traumatic brain injury in children–a single center experience regarding therapy and long-term outcome. Child’s nervous system, 26(11), 1563–1573. doi: 10.1007/s00381-010-1103-4
Rubiano, A. M., Villarreal, W., Hakim, E. J., Aristizabal, J., Hakim, F., Dìez, J. C., et al. (2009) Early decompressive craniectomy for neurotrauma: an institutional experience. Ulusal travma ve acil cerrahi dergisi, 15(1), 28–38.
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