Severe diffuse brain injury. Justifiability of decompressive craniectomy
Keywords:severe traumatic brain injury, diffuse brain injury, intracranial pressure, intracranial hypertension, decompressive craniectomy
Objective: To study the possibility of improvement of response to treatment of injured persons with severe diffuse brain injury (SDBI) through the intracranial pressure (ICP) monitoring and active correction of intracranial hypertension (ICH) with the use of decompressive craniectomy (DC).
Material and methods: A prospective analysis of response to treatment of 57 injured persons with SDBI was carried out. The first period of research (2000 – 2005): 34 patients. The second period (2006 – 2012): 23 patients. The main criterion of enrolment to the research is a severe brain injury (8 points or less according GSC scale).
L.F. Marshall classification of diffuse injury to brain was used. ICP measurement during the second period was carried using the parenchymal sensors on the monitor Brain Pressure Monitor REF HDM 26.1/FV500 Spiegelberg (Germany).
Results: Augmentation of signs of axial and lateral dislocation with the transition from type I to type IV of SDBI of the brain is related to the increased rate of detection and intensity of ICH. ICH was discovered among 25% of patients with type II of SDBI, and among 57% with type III and 80% with type IV of SDBI. Average ICP in the group of injured persons with type II of SDBI constituted (14.4±6.6) mm Hg, with type III – (30±20.6) mm Hg, with type IV – (37.6±14.1) mm Hg.
As long as the rate of ICH detection increases, the necessity to use more aggressive treatment methods increases as well, including the DC. DC was not used for type I and type II of SDBI. During the first period, DC was carried out only for 15.4% of injured persons with the injury of type IV. During the second period, DC was carried out for 42.9% of injured persons with type III and for 100 injured persons with type IV of SDBI. The average ICP in the group of injured persons with SDBI, who were subjected to DC, constituted (41±18.6) mm Hg prior to the operation and (20.1±18) mm Hg after the operation. DC fulfillment resulted in ICP reduction by a mean of 46.6%.
Lethality during the first observation period constituted 52.9%, and during the second one – 39.1% (χ2=10.9; р<0.004). During the first period of research the benign outcome (good recovery + moderate disability according to the Glasgow outcome scale) was achieved among 17.7% of injured persons, and during the second period - among 26% (р<0.05).
Conclusions: SDBI types according to L.F. Marshall classification that are determined on the basis of primary CT of brain, correlate with the ICH rate and intensity, lethality rate, and they must be taken into consideration when determining the treatment policy.
1. Lebedev VV, Volkov PV. [Diffuse axonal cerebral injury]. Russian Journal of Neurosurgery. 2002;(3):10-5. Russian.
2. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger J, Jack E. Guidelines for the surgical management of traumatic brain injury. Neurosurgery. 2006 Mar;58(3):25–46. [CrossRef] [PubMed]
3. Jiang JY, Xu W, Li WP, Xu WH, Zhang J, Bao YH, Ying YH, Luo QZ. Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: a multicenter, prospective, randomized controlled study. J Neurotrauma. 2005 Jun;22(6):623-8. [CrossRef] [PubMed]
4. Krylov VV, Talypov AE, Puras IuV. [Choice of trephining in surgery for severe brain injury]. Zh Vopr Neirokhir Im N N Burdenko. 2007 Jan-Mar;(1):11-6. Russian. [PubMed]
5. [Clinical protocols of medical care to patients with traumatic brain injury]. Ukrainian Neurosurgical Journal. 2008;(3):137-69. Ukrainian.
7. Nussbaum E, Wolf A, Sebring L, Mirvis S. Complete temporal lobectomy for surgical resuscitation of patients with transtentorial herniation secondary to unilateral hemispheric swelling. Neurosurgery. 1991 Jul;29(1):62-6. [CrossRef] [PubMed]
8. Lee EJ, Chio CC, Chen HH. Aggressive temporal lobectomy for uncal herniation in traumatic subdural hematoma. J Formos Med Assoc. 1995 Jun;94(6):341-5. [PubMed]
9. Tseng SH. Reduction of herniated temporal lobe in patients with severe head injury and uncal herniation. J Formos Med Assoc. 1992 Jan;91(1):24-8. [PubMed]
14. Hutchinson PJ, Corteen E, Czosnyka M, Mendelow AD, Menon DK, Mitchell P, Murray G, Pickard JD, Rickels E, Sahuquillo J, Servadei F, Teasdale GM, Timofeev I, Unterberg A, Kirkpatric PJ. Decompressive craniectomy in traumatic brain injury: the randomized multicenter RESCUEICP study. Acta Neurochirg. 2006;96:17-20. [CrossRef] [PubMed]
15. Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, Klug G, Wallace D, Henning R, Tibballs J. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst. 2001 Feb;17(3):154-62. [CrossRef] [PubMed]
16. Monro A. Observations on the structure and functions of the nervous system: illustrated with tables [Internet]. Edinburgh: Creech&Jonson, 1783. [cited 2015 February 20]. Available at: http://digi.ub.uni-heidelberg.de/diglit/monro1783/0025.
17. Kellie G An account of the appearances observed in the dissection of two of the three individuals presumed to have perished in the storm of the 3rd, and whose bodies were discovered in the vicinity of Leith on the morning of the 4th November 1821 with some reflections on the pathology of the brain. Trans Med Chir Sci, Edinburgh. 1824;1:84–169.
18. Yang XF, Wen L, Shen F, Li G, Lou R, Liu WG, Zhan RY. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir. 2008 Dec;150(12):1241-8. [CrossRef] [PubMed]
20. Yang XJ, Hong GL, Su SB, Yang SY. Complications induced by decompressive craniectomies after traumatic brain injury. Chin J Traumatol. 2003 Apr;6(2):99-103. [PubMed]
23. Marshall LF, Marshall SB, Klauber MR. A new classification of head injury based on computerized tomography. J Neurosurg. 1991; 75:14-20. [PubMed]
24. Maas AI, Hukkelhoven CW, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and computed tomographic predictors. Neurosurgery. 2005;57:1173-1182. [CrossRef] [PubMed]
26. Yau YH, Piper IR, Clutton RE, Whittle IR. Experimental evaluation of the Spiegelberg intracranial pressure and intracranial compliance monitor. Technikal note. J Neurosurg. 2000;93:1072-7. [CrossRef] [PubMed]
27. Pedachenko EG, Dzyak LA, Sirko AG, Suk VM, inventors; Romodanov Neurosurgery Institute, Kiev, Ukraine, assignee. Method of determining the effect of decompressive neurosurgical operation in severe traumatic brain injury. Ukraine Patent 54363A. 2010 November 10.
30. Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow Outcome scale and the Extended Glasgow Outcome scale: guidelines for their use. J Neurotrauma. 1998; 15(8):573-85. [CrossRef] [PubMed]
31. KonovalovAN, Likhterman LB, Potapov AA. Formalizovannaya istoriya bolezni [Formalized history of the disease]. In: Likhterman LB, Potapov AA, editors. Otraslevaya nauchno-tekhnicheskaya programma S09 “Travma tsentral'noy nervnoy sistemy” [Branch scientific and technical program C09 "Injury of the central nervous system”]. Moscow; 1986-1990. Russian.
32. Potapov AA, Zakharova NE, Pronin IN, Kornienko VN, Gavrilov AG, Kravchuk AD, Oshorov AV, Sychev AA, Zaitsev OS, Fadeeva LM, Takushi SV. [Prognostic value of monitoring of intracranial and cerebral perfusion pressure, indicators of regional blood flow in diffuse and focal brain damage]. Zh Vopr Neirokhir Im N N Burdenko. 2011;75(3):3-18. Russian. [PubMed]
33. Zakharova N, Kornienko V, Potapov A, Pronin I. Clinical and prognostic value of neuroimaging in traumatic brain injury. New York: Springer Int. Publ.; 2014. p.1-24. [CrossRef]
How to Cite
Copyright (c) 2015 Eugene Pedachenko, Lyudmila Dzyak, Andriy Sirko
This work is licensed under a Creative Commons Attribution 4.0 International License.
Ukrainian Neurosurgical Journal abides by the CREATIVE COMMONS copyright rights and permissions for open access journals.
Authors, who are published in this Journal, agree to the following conditions:
1. The authors reserve the right to authorship of the work and pass the first publication right of this work to the Journal under the terms of Creative Commons Attribution License, which allows others to freely distribute the published research with the obligatory reference to the authors of the original work and the first publication of the work in this Journal.
2. The authors have the right to conclude separate supplement agreements that relate to non-exclusive work distribution in the form of which it has been published by the Journal (for example, to upload the work to the online storage of the Journal or publish it as part of a monograph), provided that the reference to the first publication of the work in this Journal is included.