Page 37 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Decision-making in very severe traumatic brain injury
surgical lesions like epidural hematoma (EDH), acute subdural hematoma (ASDH) or
cerebral contusions, depending on their location, extent and presence of brain edema
and CT recorded midline shift.31, 34, 36-38 With 34% of all patients receiving bilateral 2 decompressive surgery for posttraumatic intractable intracranial hypertension, overall
84% achieved unfavorable outcome increasing to 96.6% for vs-TBI.17
Timing of surgery varied between cohorts from 86% of patients within first hour after admission, to 33% within 6 hours from trauma.31, 36 One study with only ASDH patients, showed a 30-day mortality rate of nearly 40 percent. The vs-TBI subgroup showed higher mortality rates (64% vs. 26%) and more 6-month unfavorable outcome (GOS1-3) (91% vs. 55%) compared to patients with GCS>5.34 A second study (79% ASDH) found similar unfavorable outcome rates for vs-TBI patients after 6 months approaching 90%, but found higher mortality rates (79.3%).32 With 86% of cohort being patients with ASDH, Huang et al. found 59.7% 30-day mortality for vs-TBI subgroup and 12.4% mortality for GCS 6-8 16. In other studies ASDH was the most prevalent focal intracranial space- occupying lesion (32-86%).16, 17, 30, 31, 38 A study investigating “malignant” brain swelling reported no difference in mortality rates, but worse outcome for vs-TBI patients (70% vs. 16.7%) than GCS>5 patients.37 Within a cohort of 66 vs-TBI patients, neurosurgeons performed 86% of all DC within approximately one hour after admission and this study reported an overall 1-year mortality rate of 11%, with good outcome in 68%.31 Worse outcome was reported in patients with higher initial ICPs and GCS<5.31 A relatively favorable overall mortality rate (12.5%) was found in Italy, where 37% of GCS 3-5 patients achieved favorable outcome.15
Five studies compared different surgical techniques and varying timing of surgery.30, 35, 39-41 All studies were retrospective and contained a subgroup of GCS 3-5 patients. Early bilateral decompressive craniectomy as a first treatment option in s-TBI was compared to secondary DC for refractory ICP.39 It was shown to be an effective treatment option for ICP control, resulting in overall significant better one-year favorable outcome of 50% and 27.8%, respectively.39 Compared to the GCS 6-8 subgroup, the vs-TBI subgroup showed a 2 times higher rate of mortality (50% vs. 25%) and splits favorable outcome (45% vs. 25%) 39. Ultra-early DC (<4 h of trauma onset) compared with DC after 4 hours did not seem to improve patient outcome.30 Worse mortality rates were found for vs- TBI patients (GCS 3:100%, GCS 4-5:82.2%, GCS>5:41%) and showed 0% favorable outcome, compared to 4.7% in GCS>5 patients.30 Another study reported significantly better outcome for patients with GCS 6-8 who were operated within 24 h compared to patients with GCS 3-5, operated within the same time window.41
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