Page 36 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 2
Monitoring ICP, with therapeutic consequences, was reported to be associated with an 8.3% reduction in risk-adjusted mortality rate.23 Reduction in risk-adjusted mortality rate increased to 13.3% for low GCS Score (3) and to 32.9% in high (>25) and low GCS Score (3) combined.23 But there was no consensus. Some found a lower GCS Score to be a predictor for mortality 21, 25 and others showed no significant difference for GCS 5-6 and GCS 3-4 subgroups.27 Even the opposite was found. A higher hospital and 28-day mortality in patients with GCS>5, but not in patients with GCS<6.26
Despite ICP guided treatment, up to 12% was diagnosed as sustaining a persistent vegetative state at 6 months, besides which 24% having severe cognitive and somatic disabilities.28 Favorable outcome (GOS 4-5) was reached in 48% (GCS 3-5) and 79% (GCS 6-8) of patients.28
Although possibly due to selection bias, ICP monitored patients showed longer duration of mechanical ventilation,25-27 a higher need for tracheostomy 27 and significantly longer intensive care unit (ICU) stay 22, 25-27 compared to non-ICP monitored patients. Also more complications and poorer functional outcome at discharge are reported.25
Decompressive craniectomy
Seventeen of 45 selected studies concerned decompressive craniectomy (DC) procedures. Results (Table II)15-17, 29-42 showed a predominance of young males (age range: 25-56 years) and most cohorts involved less than 50 patients, with one prospective study and other studies being retrospective.29 Most studies used the Glasgow Outcome Scale (GOS) and one study used the modified Rankin Scale (mRS).30
Wide ranges in outcome were identified for overall s-TBI mortality rates (11% to 68.5%).30, 31 Rates for vs-TBI patients were higher near 80%,32, 33 up to 100% in two GCS=3 subgroups.30, 34 Favorable outcome in vs-TBI patients ranged from 0% (mRS 0-2) to 63% (GOS3-5).30, 35 Up to 80% of patients with initial GCS≥6 achieved favorable outcome.36
Nine studies investigated outcome of standard DC, without comparing different ICU and surgical treatment methods.15-17, 31, 32, 34, 36-38 A bilateral decompression for bilateral injury or diffuse edema/swelling was used in 3.3-34% of total procedures. The identified two typical reasons for performing DC are: 1) directly to prevent secondary injury; 2) posttraumatic ICP elevation, after failed ICU treatment; and 3) posttraumatic
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