Page 39 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Decision-making in very severe traumatic brain injury
Neurosurgical interventions
Eleven studies discussed surgical interventions, mainly craniotomy for hematoma
evacuation (Table III).19, 43-51 One study used prospectively collected data and six 2 discussed cohorts with exclusively GCS 3-5 patients, with four only including GCS=3
patients.
The choice between surgical intervention or not and which technique showed substantial variation between centers (9-77%). Fewer patients with a cerebral contusion received surgical intervention (34%) compared to patients having an EDH or ASDH (88%, 68%).43 Factors positively associated with quantities of surgical intervention appeared to be fall injury, more severe injuries (according to ISS and head AIS), bradycardia and injuries like skull fractures, EDH and ASDH. Negative associating factors seem to be a diagnosis of intracerebral hemorrhage and hypotension or tachycardia at ED presentation.44 Although suffering from more extra-axial bleedings, significantly lower rates of surgical intervention were found in patients with bilaterally fixed dilated pupils, compared to patients with reactive pupils (16.4% vs. 34.8%).45 The execution of bilateral surgery instead of unilateral surgery seems to be associated with absence of pupillary response, lower GCS (6.7% vs. 9.2%), more large-volume lesions, complete cistern compression and CT-visible deep lesions.46 Timing of surgical intervention was not always mentioned, but 50 and 73% was performed <24 hours 43, 47 up to 83% within 4 hours in one cohort.44 Several studies show lower GCS scores to be linked to worse outcome and higher mortality rates.46, 48 Unfavorable outcome (GOS 1-3) in up to 94.11% was found for GCS 3-5 subcategories.49
Surgical intervention resulted in improved mortality.43, 44, 46, 49 One study found better prognosis for both GCS 6-8 and GCS 3-5 surgical treatment subgroups and poorer outcome for conservative treatment especially in patients with GCS≥6.46 A significant 4-fold survival benefit was found for surgically treating mass lesions in patients with GCS=3, but this study also found surgery to be significantly related to more complications, especially pneumonia (P<0.001).44 Significant higher mortality (48% vs. 23%) and poorer outcome was found in the conservative group.43 Two studies reported no significant difference in surgical interventions between survivors and non-survivors and another found no effect from immediate neurosurgery on outcome in patients without a mass lesion.44, 50
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