Page 59 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Decision-making in very severe traumatic brain injury
Limitations of the study
Our strict inclusion criteria resulted in the inclusion of studies reporting on surgical
treatment and outcome of vs-TBI patients with a definite GCS 3-5. Most included 2 studies were relatively small observational single center cohort studies and only few
used prospectively collected data. As is typical for TBI itself, the huge heterogeneity
between patient cohorts regarding injury, treatment and outcome, resulted in
inevitable selection bias and makes comparing results and drawing conclusions
difficult. For this reason, it was considered impossible to conduct a solid meta-analysis.
The independent effect of surgical treatment on outcome is also hard to establish
because parameters known to be associated with outcome, were often not mentioned
or investigated. Results of this review should be interpreted with care and conclusion
only drawn with the recognition of the remarks.
Three promising studies (DECRA, RESCUEicp, STITCH) from the past years did not meet our inclusion criteria but unfortunately also didn’t change the controversy of decompressive craniectomy.117-119 We are looking forward to the results of two ongoing trials, respectively comparing primary DC with craniotomy in adults with an ASDH (RESCUE-ASDH: www.rescueasdh.org) and investigating the effect of therapeutic and prophylactic DC in s-TBI patients with mass lesions (PRECIS).120
Future research
Given the current heterogeneity and variability, future research should focus on patient cohorts, (surgical) treatments and outcome measures that are as equal as possible, to improve comparability and generalizability of study results. Alternatively, variability can also contribute to investigating the effectiveness of (surgical) treatment by comparing variation in local practice using a method called “Comparative Effectiveness Research” (CER). International initiatives like CENTER-TBI (www.center- tbi.eu), and a Dutch initiative called Net-QuRe (www.net-qure.nl) are using this method investigating (surgical) treatment effectiveness. Because postdischarge information is considered very important, Net-Qure has a 24 month follow-up period and includes data on the rehabilitation phase. Knowing how much a specific patient will benefit from which specific treatment in terms of functional recovery and quality of life is essential in future decision-making and informed consent conversations. Therefore a long-term follow-up period is necessary and particularly relevant to patients with vs- TBI, as reports show that improvement may not be uncommon between 1 and 3 years after injury.
57