Page 31 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Decision-making in very severe traumatic brain injury
INTRODUCTION
Patients with severe traumatic brain injury (s-TBI) are generally defined as those 2 with a Glasgow Coma Scale Score (GCS) between 3 and 8. These patients are, in most
instances in Western World, directly intubated and transported to the nearest level
I trauma center. Obviously, s-TBI has high emotional, humanitarian and financial
impact on patients, their proxy’s as well as on society. Of hospitalized TBI patients about 1 out of 25 are classified as having s-TBI.1 The nature and extent of brain injury in this group may vary from closed to penetrating trauma,2, 3 including intracranial hematomas (epidural, subdural or hemorrhagic contusion injury) observed in up to 35% of the s-TBI patients and varying degrees of diffuse axonal injury.2, 4 Mortality rates are high (40%) and chance for clinically favorable outcome, as assessed by the Glasgow Outcome Scale (GOS), relatively low (40%).5-8
Within the population of s-TBI, very severe TBI (vs-TBI) is being proposed by the authors to sub-classify the group of patients with an extremely low initial coma score, categorized as having a very low GCS, ranging between 3 and 5. Obviously, for the latter patients, mortality and severe disability rates are higher, and clinical outcome is worse than for the entire group of severe TBI. Still, this sub-classification is useful to analyze detailed outcome for this group specifically, because vs-TBI is the most challenging group of patients in treatment decision-making for neurosurgeons, traumatologists, intensivists and neurologists. As time is limited in the acute phase, communication with family and friends of the patient is short, if ever performed at all. It creates difficulties for those, who have to determine whether or not to treat these patients surgically in the acute setting. Surgical options, range from inserting an intracranial pressure (ICP) monitoring device up to a large decompressive craniectomy, in order to try to control “severe brain swelling”, which may develop secondarily. The latter treatment may increase the chance for survival, but also increases the chance for survival of a patient with severe disability,9-13 which might not be acceptable for all people and to society.
The goal of this literature review was to investigate reported outcome for patients with vs-TBI, in particular the effect of different neurosurgical interventions. Besides important essential factual information, the authors try to identify gaps in the diagnostic and treatment evidence, for which more research will be needed to eventually improve surgical treatment for this important group of TBI patients.
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