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Significance of intracranial pressure monitoring after early decompressive craniectomy in patients with severe traumatic brain injury.

Kim DR, Yang SH, Sung JH, Lee SW, Son BC - J Korean Neurosurg Soc (2014)

Bottom Line: The two-week mortality rate was significantly different between two groups [50.9% (27 patients) and 24% (6 patients), respectively, p=0.025].After adjusting for confounding factors, including sex, low GCS score, and pupillary abnormalities, ICP monitoring was associated with a 78% lower likelihood of 2-week mortality (p=0.021).ICP monitoring in conjunction with postoperative treatment, after early DC, is associated with a significantly reduced risk of death.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Eulji University School of Medicine, Eulji General Hospital, Seoul, Korea.

ABSTRACT

Objective: Early decompressive craniectomy (DC) has been used as the first stage treatment to prevent secondary injuries in cases of severe traumatic brain injury (TBI). Postoperative management is the major factor that influences outcome. The aim of this study is to investigate the effect of postoperative management, using intracranial pressure (ICP) monitoring and including consecutive DC on the other side, on the two-week mortality in severe TBI patients treated with early DC.

Methods: Seventy-eight patients with severe TBI [Glasgow Coma Scale (GCS) score <9] underwent early DC were retrospectively investigated. Among 78 patients with early DC, 53 patients were managed by conventional medical treatments and the other, 25 patients were treated under the guidance of ICP monitoring, placed during early DC. In the ICP monitoring group, consecutive DC on the other side were performed on 11 patients due to a high ICP of greater than 30 mm Hg and failure to respond to any other medical treatments.

Results: The two-week mortality rate was significantly different between two groups [50.9% (27 patients) and 24% (6 patients), respectively, p=0.025]. After adjusting for confounding factors, including sex, low GCS score, and pupillary abnormalities, ICP monitoring was associated with a 78% lower likelihood of 2-week mortality (p=0.021).

Conclusion: ICP monitoring in conjunction with postoperative treatment, after early DC, is associated with a significantly reduced risk of death.

No MeSH data available.


Related in: MedlinePlus

Lateral plain radiograph of the skull shows subdural Intracranial pressure monitoring sensor (arrow), placed at the posterior temporal bone margin, after the initial decompressive craniectomy.
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Figure 1: Lateral plain radiograph of the skull shows subdural Intracranial pressure monitoring sensor (arrow), placed at the posterior temporal bone margin, after the initial decompressive craniectomy.

Mentions: The patient was induced for general anesthesia endotracheally. The unilateral decompression procedure involved making a large curvilinear incision in the fronto-temporo-parietal region. This was followed by preparing a myocutaneous flap and craniectomy, elevating large bone flaps, with a diameter of at least 12 cm, including the frontal, parietal, temporal, and parts of the occipital squama. Additional bone was removed at the temporal region, down to the floor of the middle fossa, to release the compression of the basal cistern. The dura mater was attached to the craniotomy edge, to prevent epidural bleeding. The dura was then opened at the temporal base, in a stellate fashion, to provide additional space for brain swelling. When the dura was opened, the underlying brain or hematoma typically herniated outward. The contused brain tissue was gently removed and extra-cerebral clots were also evacuated. After meticulous hemostasis around injured lesions, a subdural ICP monitoring catheter (Integra NeuroSciences, San Diego, CA, USA), zeroed relative to atmospheric pressure, was placed underneath the incised dura, at the posterior temporal bone margin and secured with dura sutures, to prevent displacement (Fig. 1). The dura was then expanded with the synthetic dural substitute to allow the brain to bulge outward. The temporalis muscle and skin flap were then re-approximated with sutures. The bone flap was maintained in wet gauze at -70℃ and cranioplasty was performed 3-6 months after surgery for surviving patients.


Significance of intracranial pressure monitoring after early decompressive craniectomy in patients with severe traumatic brain injury.

Kim DR, Yang SH, Sung JH, Lee SW, Son BC - J Korean Neurosurg Soc (2014)

Lateral plain radiograph of the skull shows subdural Intracranial pressure monitoring sensor (arrow), placed at the posterior temporal bone margin, after the initial decompressive craniectomy.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3928344&req=5

Figure 1: Lateral plain radiograph of the skull shows subdural Intracranial pressure monitoring sensor (arrow), placed at the posterior temporal bone margin, after the initial decompressive craniectomy.
Mentions: The patient was induced for general anesthesia endotracheally. The unilateral decompression procedure involved making a large curvilinear incision in the fronto-temporo-parietal region. This was followed by preparing a myocutaneous flap and craniectomy, elevating large bone flaps, with a diameter of at least 12 cm, including the frontal, parietal, temporal, and parts of the occipital squama. Additional bone was removed at the temporal region, down to the floor of the middle fossa, to release the compression of the basal cistern. The dura mater was attached to the craniotomy edge, to prevent epidural bleeding. The dura was then opened at the temporal base, in a stellate fashion, to provide additional space for brain swelling. When the dura was opened, the underlying brain or hematoma typically herniated outward. The contused brain tissue was gently removed and extra-cerebral clots were also evacuated. After meticulous hemostasis around injured lesions, a subdural ICP monitoring catheter (Integra NeuroSciences, San Diego, CA, USA), zeroed relative to atmospheric pressure, was placed underneath the incised dura, at the posterior temporal bone margin and secured with dura sutures, to prevent displacement (Fig. 1). The dura was then expanded with the synthetic dural substitute to allow the brain to bulge outward. The temporalis muscle and skin flap were then re-approximated with sutures. The bone flap was maintained in wet gauze at -70℃ and cranioplasty was performed 3-6 months after surgery for surviving patients.

Bottom Line: The two-week mortality rate was significantly different between two groups [50.9% (27 patients) and 24% (6 patients), respectively, p=0.025].After adjusting for confounding factors, including sex, low GCS score, and pupillary abnormalities, ICP monitoring was associated with a 78% lower likelihood of 2-week mortality (p=0.021).ICP monitoring in conjunction with postoperative treatment, after early DC, is associated with a significantly reduced risk of death.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Eulji University School of Medicine, Eulji General Hospital, Seoul, Korea.

ABSTRACT

Objective: Early decompressive craniectomy (DC) has been used as the first stage treatment to prevent secondary injuries in cases of severe traumatic brain injury (TBI). Postoperative management is the major factor that influences outcome. The aim of this study is to investigate the effect of postoperative management, using intracranial pressure (ICP) monitoring and including consecutive DC on the other side, on the two-week mortality in severe TBI patients treated with early DC.

Methods: Seventy-eight patients with severe TBI [Glasgow Coma Scale (GCS) score <9] underwent early DC were retrospectively investigated. Among 78 patients with early DC, 53 patients were managed by conventional medical treatments and the other, 25 patients were treated under the guidance of ICP monitoring, placed during early DC. In the ICP monitoring group, consecutive DC on the other side were performed on 11 patients due to a high ICP of greater than 30 mm Hg and failure to respond to any other medical treatments.

Results: The two-week mortality rate was significantly different between two groups [50.9% (27 patients) and 24% (6 patients), respectively, p=0.025]. After adjusting for confounding factors, including sex, low GCS score, and pupillary abnormalities, ICP monitoring was associated with a 78% lower likelihood of 2-week mortality (p=0.021).

Conclusion: ICP monitoring in conjunction with postoperative treatment, after early DC, is associated with a significantly reduced risk of death.

No MeSH data available.


Related in: MedlinePlus