Page 58 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE
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Chapter 2
decisions depending on neurological improvement should be made, preferably after proxy consultation.
Penetrating brain injury
The difference between combat and civilian PBI can explain outcome results. Combat casualties include more blast injury and civilian more gunshot wounds. Also, almost 90% of patients (mean age 25 years) underwent neurosurgical intervention. The combination of young healthy military patients with aggressive neurosurgical intervention might be beneficial. However, in the study reporting favorable results there is 43% loss to follow-up and only 22% of total PBI patients were treated at this institution. In the literature, PBI mortality rates range from 23 to 93% with higher rates (87-100%) in presence of well-known risk factors for poor outcome: GCS <5, pupillary abnormalities, hypotension, high ICP and higher age.113
As in all TBI patients, surgical treatment should be meaningful and the indication for surgery balanced against the likelihood of survival, particularly in patients with a low GCS in the civilian setting. Some authors don’t recommend surgical intervention in patients with small to zero change of achieving favorable outcome,48, 49 low admission GCS scores and extensive brain injury 114, 115 or patients with a GCS 3 to 5 without operable hematomas.61 Nevertheless, it does not preclude possible recovery and some patients may survive. A recent study for example, reported a survival rate of 40% in patients with a GCS of 3-4 on admission, whilst 11% achieved favorable outcome.116 These investigators attribute their better results to a more aggressive management policy.
We believe that clinical (GCS Score and presence of pupillary abnormalities) and radiological signs should guide physicians decision-making. We advocate minimal surgery in civilian PBI cases with a GCS of 3-5 and optimal medical management for at least 24 hours. In case of improvement, more extensive surgery can be considered. An early decompressive craniectomy with watertight dural closure is a valid surgical option. The removal of retained bone fragments at the cost of healthy brain tissue is not advised and in case of dural defects grafting is possible by using autologous materials like fascia lata or periosteum. Finally, the adequate cranialization of violated air sinuses and the watertight closure of CSF fistulas should be performed as soon as possible.
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