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Christopher S Ogilvy - One of the best experts on this subject based on the ideXlab platform.
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craniotomy versus decompressive Craniectomy for acute subdural hematoma systematic review and meta analysis
World Neurosurgery, 2017Co-Authors: Kevin Phan, Justin M Moore, Christoph J Griessenauer, Adam A Dmytriw, Daniel B Scherman, Sharaf Sheikali, Nimer Adeeb, Christopher S Ogilvy, Ajith J Thomas, Jeffrey V RosenfeldAbstract:Background Acute subdural hematoma (SDH) is a major cause of morbidity after severe traumatic brain injury. Surgical evacuation of the hematoma, either via craniotomy or Craniectomy, is the mainstay of treatment in patients with progressive neurologic deficits or significant mass effect. However, the decision to perform either procedure remains controversial. Methods A literature search using major online databases and a manual search of references on the topic of craniotomy and Craniectomy for evacuation of subdural hematoma until September 2016 was performed. The outcome variables were analyzed which included residual SDH, revision rate, and clinical outcome. Results Six comparison studies, with a total number of 2006 craniotomy and 451 Craniectomy patients, fulfilled the inclusion criteria. Patients who underwent Craniectomy scored significantly lower on the Glasgow Coma Scale at the time of initial presentation. Postoperatively, the rate of residual SDH was significantly lower in the Craniectomy group than the craniotomy group ( P = 0.004), with no difference in the revision rate. The odds of a poor outcome at follow-up was found to be lower in the craniotomy group (50.1% vs. 60.1%, respectively; P = 0.004). Similarly, mortality rates was lower in the craniotomy group than the Craniectomy group ( P = 0.004). Conclusions The safety and efficacy of craniotomy versus decompressive Craniectomy in treatment of acute SDH remain controversial. In this study, Craniectomy was associated with worse clinical presentation and postoperative outcome compared with craniotomy. However, Craniectomy was associated with lower rate of residual SDH after treatment.
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Craniectomy in acute ischemic stroke
Neurosurgery, 2014Co-Authors: Pankaj K Agarwalla, Christopher J Stapleton, Christopher S OgilvyAbstract:Anterior and posterior circulation acute ischemic stroke carries significant morbidity and mortality as a result of malignant cerebral edema. Decompressive Craniectomy has evolved as a viable neurosurgical intervention in the armamentarium of treatment options for this life-threatening edema. In this review, we highlight the history of Craniectomy for stroke and discuss recent data relevant to its efficacy in modern neurosurgical practice.
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proposed use of prophylactic decompressive Craniectomy in poor grade aneurysmal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas
Neurosurgery, 2002Co-Authors: Edward R Smith, Bob S Carter, Christopher S OgilvyAbstract:OBJECTIVE: As a group, patients who present in poor neurological grade after aneurysmal subarachnoid hemorrhage (SAH) often have poor outcomes. There may be subgroups of these patients, however, in which one pathological process predominates and for which the initiation of specific therapeutic interventions that target the predominant pathological process may result in improved outcome. We report the use of prophylactic decompressive Craniectomy in patients presenting in poor neurological condition after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas. Craniectomy allowed significant parenchymal swelling in the posthemorrhagic period without increased intracranial pressure (ICP) or herniation syndrome. METHODS: Eight patients (mean age, 56.5 yr; age range, 42-66 yr) presented comatose with SAH (five Hunt and Hess Grade IV, three Hunt and Hess Grade V). Radiographic evaluations demonstrated middle cerebral artery aneurysm and associated large sylvian fissure hematoma (mean clot volume, 121 ml; range, 30-175 ml). Patients were brought emergently to the operating room and treated with a modification of the pterional craniotomy and aneurysm clipping that included a planned Craniectomy and duraplasty. A large, reverse question mark scalp flap was created, followed by bone removal with the following margins: anterior, frontal to the midpupillary line; posterior at least 2 cm behind the external auditory meatus; superior up to 2 cm lateral to the superior sagittal sinus; and inferior to the floor of the middle cranial fossa. Generous duraplasty was performed using either pericranium or suitable, commercially available dural substitutes. RESULTS: All of the eight patients tolerated the Craniectomy without operative complications. Postoperatively, all patients experienced immediate decreases in ICP to levels at or below 20 mm Hg (presentation mean ICP, 31.6 mm Hg; postoperative mean ICP, 13.1 mm Hg). ICP control was sustained in seven of eight patients, with the one exception being due to a massive hemispheric infarction secondary to refractory vasospasm. Follow-up (> or = 1 yr, except for one patient who died during the hospital stay) demonstrated that the Craniectomy patients had a remarkably high number of good or excellent outcomes. The outcomes in the hemiCraniectomy group were five good or excellent, one fair, and two poor or dead. CONCLUSION: The data gathered in this study demonstrate that decompressive Craniectomy can be performed safely as part of initial management for a subcategory of patients with SAH who present with large sylvian fissure hematomas. In addition, the performance of decompressive Craniectomy in the patients described in this article seemed to be associated with rapid and sustained control of ICP. Although the number of patients in this study is small, the data lend support to the hypothesis that decompressive Craniectomy may be associated with good or excellent outcome in a carefully selected subset of patients with SAH.
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proposed use of prophylactic decompressive Craniectomy in poor grade aneurysmal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas
Neurosurgery, 2002Co-Authors: Edward R Smith, Bob S Carter, Christopher S OgilvyAbstract:Objective As a group, patients who present in poor neurological grade after aneurysmal subarachnoid hemorrhage (SAH) often have poor outcomes. There may be subgroups of these patients, however, in which one pathological process predominates and for which the initiation of specific therapeutic interventions that target the predominant pathological process may result in improved outcome. We report the use of prophylactic decompressive Craniectomy in patients presenting in poor neurological condition after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas. Craniectomy allowed significant parenchymal swelling in the posthemorrhagic period without increased intracranial pressure (ICP) or herniation syndrome. Methods Eight patients (mean age, 56.5 yr; age range, 42-66 yr) presented comatose with SAH (five Hunt and Hess Grade IV, three Hunt and Hess Grade V). Radiographic evaluations demonstrated middle cerebral artery aneurysm and associated large sylvian fissure hematoma (mean clot volume, 121 ml; range, 30-175 ml). Patients were brought emergently to the operating room and treated with a modification of the pterional craniotomy and aneurysm clipping that included a planned Craniectomy and duraplasty. A large, reverse question mark scalp flap was created, followed by bone removal with the following margins: anterior, frontal to the midpupillary line; posterior at least 2 cm behind the external auditory meatus; superior up to 2 cm lateral to the superior sagittal sinus; and inferior to the floor of the middle cranial fossa. Generous duraplasty was performed using either pericranium or suitable, commercially available dural substitutes. Results All of the eight patients tolerated the Craniectomy without operative complications. Postoperatively, all patients experienced immediate decreases in ICP to levels at or below 20 mm Hg (presentation mean ICP, 31.6 mm Hg; postoperative mean ICP, 13.1 mm Hg). ICP control was sustained in seven of eight patients, with the one exception being due to a massive hemispheric infarction secondary to refractory vasospasm. Follow-up (> or = 1 yr, except for one patient who died during the hospital stay) demonstrated that the Craniectomy patients had a remarkably high number of good or excellent outcomes. The outcomes in the hemiCraniectomy group were five good or excellent, one fair, and two poor or dead. Conclusion The data gathered in this study demonstrate that decompressive Craniectomy can be performed safely as part of initial management for a subcategory of patients with SAH who present with large sylvian fissure hematomas. In addition, the performance of decompressive Craniectomy in the patients described in this article seemed to be associated with rapid and sustained control of ICP. Although the number of patients in this study is small, the data lend support to the hypothesis that decompressive Craniectomy may be associated with good or excellent outcome in a carefully selected subset of patients with SAH.
Jeffrey V Rosenfeld - One of the best experts on this subject based on the ideXlab platform.
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patient outcomes at twelve months after early decompressive Craniectomy for diffuse traumatic brain injury in the randomized decra clinical trial
Journal of Neurotrauma, 2020Co-Authors: Jeffrey V Rosenfeld, James D Cooper, Lynnette Murray, Yaseen M Arabi, Jennie Ponsford, Ian Seppelt, Andrew Ross Davies, Peter L ReillyAbstract:Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive Craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive Craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients. We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. At 12 months, the odds ratio (OR) for worse functional outcomes in the Craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after Craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after Craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes. Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased. Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive Craniectomy did not improve outcomes and increased vegetative survivors.
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craniotomy versus decompressive Craniectomy for acute subdural hematoma systematic review and meta analysis
World Neurosurgery, 2017Co-Authors: Kevin Phan, Justin M Moore, Christoph J Griessenauer, Adam A Dmytriw, Daniel B Scherman, Sharaf Sheikali, Nimer Adeeb, Christopher S Ogilvy, Ajith J Thomas, Jeffrey V RosenfeldAbstract:Background Acute subdural hematoma (SDH) is a major cause of morbidity after severe traumatic brain injury. Surgical evacuation of the hematoma, either via craniotomy or Craniectomy, is the mainstay of treatment in patients with progressive neurologic deficits or significant mass effect. However, the decision to perform either procedure remains controversial. Methods A literature search using major online databases and a manual search of references on the topic of craniotomy and Craniectomy for evacuation of subdural hematoma until September 2016 was performed. The outcome variables were analyzed which included residual SDH, revision rate, and clinical outcome. Results Six comparison studies, with a total number of 2006 craniotomy and 451 Craniectomy patients, fulfilled the inclusion criteria. Patients who underwent Craniectomy scored significantly lower on the Glasgow Coma Scale at the time of initial presentation. Postoperatively, the rate of residual SDH was significantly lower in the Craniectomy group than the craniotomy group ( P = 0.004), with no difference in the revision rate. The odds of a poor outcome at follow-up was found to be lower in the craniotomy group (50.1% vs. 60.1%, respectively; P = 0.004). Similarly, mortality rates was lower in the craniotomy group than the Craniectomy group ( P = 0.004). Conclusions The safety and efficacy of craniotomy versus decompressive Craniectomy in treatment of acute SDH remain controversial. In this study, Craniectomy was associated with worse clinical presentation and postoperative outcome compared with craniotomy. However, Craniectomy was associated with lower rate of residual SDH after treatment.
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decompressive Craniectomy in diffuse traumatic brain injury
The New England Journal of Medicine, 2011Co-Authors: James D Cooper, Jeffrey V Rosenfeld, Lynnette Murray, Yaseen M Arabi, Andrew Davies, Thomas Kossmann, Jennie Ponsford, Ian Seppelt, Peter L Reilly, Rory WolfeAbstract:Patients in the Craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing Craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the Craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P = 0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P = 0.02). Rates of death at 6 months were similar in the Craniectomy group (19%) and the standard-care group (18%). Conclusions In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive Craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.)
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the role of decompressive Craniectomy in the management of traumatic brain injury a critical review
Journal of Clinical Neuroscience, 2005Co-Authors: Chris D Winter, Jeffrey V Rosenfeld, Alexis A AdamidesAbstract:Brain swelling and intracranial hypertension following severe head injury are known to contribute to secondary brain damage, and have been shown to adversely affect patient outcome. The use of unilateral Craniectomy following the evacuation of a mass lesion, such as acute subdural haematoma or traumatic intracerebral haematoma, is accepted practice. The following review focuses on a bi-fronto-temporal decompressive Craniectomy, used as an isolated operation for the control of intracranial hypertension, secondary to diffuse brain swelling refractory to medical management. Though the operation is being increasingly used, current opinion is still divided regarding its overall effects on outcome. This review examines the experimental and clinical evidence for and against the use of decompressive Craniectomy, highlights the lack of class I evidence relevant to this topic and emphasises the necessity for well-designed prospective randomised controlled trials.
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a randomized trial of very early decompressive Craniectomy in children with traumatic brain injury and sustained intracranial hypertension
Childs Nervous System, 2001Co-Authors: Anna Taylor, Jeffrey V Rosenfeld, Warwick Butt, Frank Shann, Michael Ditchfield, Elizabeth Lewis, Geoffrey L Klug, David Wallace, Robert Henning, James TibballsAbstract:Object: The object of our study was to determine, in children with traumatic brain injury and sustained intracranial hypertension, whether very early decompressive Craniectomy improves control of intracranial hypertension and long-term function and quality of life. Methods: All children were managed from admission onward according to a standardized protocol for head injury management. Children with raised intracranial pressure (ICP) were randomized to standardized management alone or standardized management plus cerebral decompression. A decompressive bitemporal Craniectomy was performed at a median of 19.2 h (range 7.3–29.3 h) from the time of injury. ICP was recorded hourly via an intraventricular catheter. Compared with the ICP before randomization, the mean ICP was 3.69 mmHg lower in the 48 h after randomization in the control group, and 8.98 mmHg lower in the 48 hours after Craniectomy in the decompression group (P=0.057). Outcome was assessed 6 months after injury using a modification of the Glasgow Outcome Score (GOS) and the Health State Utility Index (Mark 1). Two (14%) of the 14 children in the control group were normal or had a mild disability after 6 months, compared with 7 (54%) of the 13 children in the decompression group. Our conclusion was that when children with traumatic brain injury and sustained intracranial hypertension are treated with a combination of very early decompressive Craniectomy and conventional medical management, it is more likely that ICP will be reduced, fewer episodes of intracranial hypertension will occur, and functional outcome and quality of life may be better than in children treated with medical management alone (P=0.046; owing to multiple significance testing P <0.0221 is required for statistical significance). This pilot study suggests that very early decompressive Craniectomy may be indicated in the treatment of traumatic brain injury.
Peter J Hutchinson - One of the best experts on this subject based on the ideXlab platform.
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the history of decompressive Craniectomy in traumatic brain injury
Frontiers in Neurology, 2019Co-Authors: Zefferino Rossini, Peter J Hutchinson, Angelos G. Kolias, Federico Nicolosi, Paolo De Sanctis, Franco ServadeiAbstract:Decompressive Craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive Craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive Craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive Craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.
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a new improved method for assessing brain deformation after decompressive Craniectomy
PLOS ONE, 2014Co-Authors: Tim L Fletcher, Peter J Hutchinson, Angelos G. Kolias, Michael P F SutcliffeAbstract:Background: Decompressive Craniectomy (DC) is a surgical intervention used following traumatic brain injury to prevent or alleviate raised intracranial pressure. However the clinical effectiveness of the intervention remains in doubt. The location of the Craniectomy (unilateral or bifrontal) might be expected to change the brain deformation associated with the operation and hence the clinical outcome. As existing methods for assessing brain deformation have several limitations, we sought to develop and validate a new improved method. Methods: Computed tomography (CT) scans were taken from 27 patients who underwent DC (17 bifrontal patients and 10 unilateral patients). Pre-operative and post-operative images were processed and registered to determine the change in brain position associated with the operation. The maximum deformation in the herniated brain, the change in volume and estimates of the Craniectomy area were determined from the images. Statistical comparison was made using the Pearson’s correlation coefficient r and a Welch’s two-tailed T-test, with statistical significance reported at the 5% level. Results: There was a reasonable correlation between the volume increase and the maximum brain displacement (r=0.64), a low correlation between the volume increase and the Craniectomy area (r=0.30) and no correlation between the maximum displacement and the Craniectomy area (r= 20.01). The maximum deformation was significantly lower (P =0.023) in the bifrontal patients (mean=22.5 mm) compared with the unilateral patients (mean=29.8 mm). Herniation volume was significantly lower (P=0.023) in bifrontal (mean=50.0 ml) than unilateral patients (mean=107.3 ml). Craniectomy area was not significantly different for the two Craniectomy locations (P=0.29). Conclusions: A method has been developed to quantify changes in brain deformation due to decompressive Craniectomy from CT images and allow comparison between different Craniectomy locations. Measured displacement is a reasonable way to characterise volume changes.
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decompressive Craniectomy operative technique and perioperative care
Advances and technical standards in neurosurgery, 2012Co-Authors: Ivan Timofeev, Angelos G. Kolias, Thomas Santarius, Peter J HutchinsonAbstract:With improvements in neurocritical care advanced measures of treating raised intracranial pressure (ICP) are more frequently utilised. Decompressive Craniectomy is an effective ICP-lowering procedure; however its benefits are maximised with optimal surgical technique and perioperative care, as well as by paying attention to possible complications. This article focuses on the current indications and rationale for decompressive Craniectomy, and the surgical technique of bifrontal and unilateral decompression. The key surgical points include a large Craniectomy window and opening of the dura, leaving it unsutured or performing a wide non-constricting duroplasty. Perioperative care and possible complications are also discussed.
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the surgical approach to the management of increased intracranial pressure after traumatic brain injury
Anesthesia & Analgesia, 2010Co-Authors: Ivan Timofeev, Marek Czosnyka, Peter J HutchinsonAbstract:Increased intracranial pressure occurring after severe traumatic brain injury is a common and potentially devastating phenomenon. It has been clearly demonstrated that increased intracranial pressure that is refractory to initial medical measures is a poor prognostic sign. Current optimal management is based on a sequential, target-driven approach combining both medical and surgical treatment strategies. The surgical measures in current common practice include external ventricular drain insertion and decompressive Craniectomy. There is evidence that both of these measures reduce intracranial pressure but the effect on outcome, particularly in the long term, is equivocal. Current Brain Trauma Foundation guidelines recommend timely evacuation of mass lesions and there is clear guidance regarding the indications for intracranial pressure monitoring; however, decompressive Craniectomy is only cautiously recommended as a possible option for selected patients. In this review, we highlight the ongoing debate about the use of decompressive Craniectomy to control intracranial pressure after traumatic brain injury; included is a summary of review of the most recent literature on the effect of decompressive Craniectomy on increased intracranial pressure after traumatic brain injury and associated long-term outcome. The RESCUEicp and DECRA studies are discussed in detail. It is hoped that these 2 randomized controlled trials, which are evaluating the short- and longer-term outcomes of decompressive Craniectomy, will provide conclusive evidence regarding the role of decompressive Craniectomy in managing increased intracranial pressure after trauma.
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effect of decompressive Craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury
Journal of Neurosurgery, 2008Co-Authors: Ivan Timofeev, Jurgens Nortje, Peter Smielewski, Peter J Kirkpatrick, Marek Czosnyka, A.k. Gupta, Peter J HutchinsonAbstract:Object Decompressive Craniectomy is an advanced treatment option for intracranial pressure (ICP) control in patients with traumatic brain injury. The purpose of this study was to evaluate the effect of decompressive Craniectomy on ICP and cerebrospinal compensation both within and beyond the first 24 hours of Craniectomy. Methods This study was a retrospective analysis of the physiological parameters from 27 moderately to severely head-injured patients who underwent decompressive Craniectomy for progressive brain edema. Of these, 17 patients had undergone prospective digital recording of ICP with estimation of ICP waveform–derived indices. The pressure-volume compensatory reserve (RAP) index and the cerebrovascular pressure reactivity index (PRx) were used to assess those parameters. The values of parameters prior to and during the 72 hours after decompressive Craniectomy were included in the analysis. Results Decompressive Craniectomy led to a sustained reduction in median (interquartile range) ICP value...
Chaohua Yang - One of the best experts on this subject based on the ideXlab platform.
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prospective randomized evaluation of therapeutic decompressive Craniectomy in severe traumatic brain injury with mass lesions precis study protocol for a controlled trial
BMC Neurology, 2016Co-Authors: Hexiang Zhao, Yi Liao, Qiangping Wang, Qi Gan, Chao You, Chaohua YangAbstract:For cases of severe traumatic brain injury, during primary operation, neurosurgeons usually face a dilemma of whether or not to remove the bone flap after mass lesion evacuation. Decompressive Craniectomy, which involves expansion of fixed cranial cavity, is used to treat intra-operative brain swelling and post-operative malignant intracranial hypertension. However, due to indefinite indication, the decision to perform this procedure heavily relies on personal experiences. In addition, decompressive Craniectomy is associated with various complications, and the procedure lacks strong evidence of better outcomes. In the present study, we designed a prospective, randomized, controlled trial to clarify the effect of decompressive Craniectomy in severe traumatic brain injury patients with mass lesions. PRECIS is a prospective, randomized, assessor-blind, single center clinical trial. In this trial, 336 patients with traumatic mass lesions will be randomly allocated to a therapeutic decompressive Craniectomy group or a prophylactic decompressive Craniectomy group. In the therapeutic decompressive Craniectomy group, the bone flap will be removed or replaced depending on the emergence of brain swelling. In the prophylactic decompressive Craniectomy group, the bone flap will be removed after mass lesion evacuation. A stepwise management of intracranial pressure will be provided according to the Brain Trauma Foundation guidelines. Salvage decompressive Craniectomy will be performed for craniotomy patients once there is evidence of imaging deterioration and post-operative malignant intracranial hypertension. Participants will be assessed at 1, 6 and 12 months after randomization. The primary endpoint is favorable outcome according to the Extended Glasgow Outcome Score (5–8) at 12 months. The secondary endpoints include quality of life measured by EQ-5D, mortality, complications, intracranial pressure and cerebral perfusion pressure control and incidence of salvage Craniectomy in craniotomy patients at each investigation time point. This study will provide evidence to optimize primary decompressive Craniectomy application and assess outcomes and risks for mass lesions in severe traumatic brain injury. ISRCTN20139421
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prospective randomized evaluation of therapeutic decompressive Craniectomy in severe traumatic brain injury with mass lesions precis study protocol for a controlled trial
BMC Neurology, 2016Co-Authors: Hexiang Zhao, Yi Liao, Qiangping Wang, Ding Xu, Chaohua YangAbstract:Background For cases of severe traumatic brain injury, during primary operation, neurosurgeons usually face a dilemma of whether or not to remove the bone flap after mass lesion evacuation. Decompressive Craniectomy, which involves expansion of fixed cranial cavity, is used to treat intra-operative brain swelling and post-operative malignant intracranial hypertension. However, due to indefinite indication, the decision to perform this procedure heavily relies on personal experiences. In addition, decompressive Craniectomy is associated with various complications, and the procedure lacks strong evidence of better outcomes. In the present study, we designed a prospective, randomized, controlled trial to clarify the effect of decompressive Craniectomy in severe traumatic brain injury patients with mass lesions.
Shirley I Stiver - One of the best experts on this subject based on the ideXlab platform.
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calvarial fracture patterns on ct imaging predict risk of a delayed epidural hematoma following decompressive Craniectomy for traumatic brain injury
American Journal of Neuroradiology, 2014Co-Authors: Jason F Talbott, Alisa D Gean, Shirley I StiverAbstract:BACKGROUND AND PURPOSE: The development of a delayed epidural hematoma as a result of decompressive Craniectomy represents an urgent and potentially lethal complication in traumatic brain injury. The goal of this study was to determine the incidence of delayed epidural hematoma and whether patterns of skull fractures on the preoperative CT scan could predict risk of a delayed epidural hematoma. MATERIALS AND METHODS: We retrospectively evaluated medical records and imaging studies for patients with acute traumatic brain injury who underwent a decompressive Craniectomy during a 9-year period. We compared patterns of skull fractures contralateral to the side of the Craniectomy with the occurrence of a postoperative delayed epidural hematoma. RESULTS: In a series of 203 patients undergoing decompressive Craniectomy for acute traumatic brain injury, the incidence of a delayed epidural hematoma complication was 6% (12 of 203). All 12 patients who developed a delayed epidural hematoma had a contralateral calvarial fracture on preoperative CT at the site where the delayed epidural hematoma subsequently formed. A contralateral calvarial fracture has perfect sensitivity (100%) for subsequent development of delayed epidural hematoma in our study population. Moreover, a contralateral calvarial fracture involving 2 or more bone plates had an especially high diagnostic odds ratio of 41 for delayed epidural hematoma. CONCLUSIONS: Recognition of skull fracture patterns associated with delayed epidural hematoma following decompressive Craniectomy may reduce morbidity and mortality by prompting early postoperative intervention in high-risk situations.
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complications of decompressive Craniectomy for traumatic brain injury
Neurosurgical Focus, 2009Co-Authors: Shirley I StiverAbstract:Decompressive Craniectomy is widely used to treat intracranial hypertension following traumatic brain injury (TBI). Two randomized trials are currently underway to further evaluate the effectiveness of decompressive Craniectomy for TBI. Complications of this procedure have major ramifications on the risk-benefit balance in decision-making during evaluation of potential surgical candidates. To further evaluate the complications of decompressive Craniectomy, a review of the literature was performed following a detailed search of PubMed between 1980 and 2009. The author restricted her study to literature pertaining to decompressive Craniectomy for patients with TBI. An understanding of the pathophysiological events that accompany removal of a large piece of skull bone provides a foundation for understanding many of the complications associated with decompressive Craniectomy. The author determined that decompressive Craniectomy is not a simple, straightforward operation without adverse effects. Rather, numero...
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complications of decompressive Craniectomy for traumatic brain injury
Neurosurgical Focus, 2009Co-Authors: Shirley I StiverAbstract:Decompressive Craniectomy is widely used to treat intracranial hypertension following traumatic brain injury (TBI). Two randomized trials are currently underway to further evaluate the effectiveness of decompressive Craniectomy for TBI. Complications of this procedure have major ramifications on the risk-benefit balance in decision-making during evaluation of potential surgical candidates. To further evaluate the complications of decompressive Craniectomy, a review of the literature was performed following a detailed search of PubMed between 1980 and 2009. The author restricted her study to literature pertaining to decompressive Craniectomy for patients with TBI. An understanding of the pathophysiological events that accompany removal of a large piece of skull bone provides a foundation for understanding many of the complications associated with decompressive Craniectomy. The author determined that decompressive Craniectomy is not a simple, straightforward operation without adverse effects. Rather, numerous complications may arise, and they do so in a sequential fashion at specific time points following surgical decompression. Expansion of contusions, new subdural and epidural hematomas contralateral to the decompressed hemisphere, and external cerebral herniation typify the early perioperative complications of decompressive Craniectomy for TBI. Within the 1st week following decompression, CSF circulation derangements manifest commonly as subdural hygromas. Paradoxical herniation following lumbar puncture in the setting of a large skull defect is a rare, potentially fatal complication that can be prevented and treated if recognized early. During the later phases of recovery, patients may develop a new cognitive, neurological, or psychological deficit termed syndrome of the trephined. In the longer term, a persistent vegetative state is the most devastating of outcomes of decompressive Craniectomy. The risk of complications following decompressive Craniectomy is weighed against the life-threatening circumstances under which this surgery is performed. Ongoing trials will define whether this balance supports surgical decompression as a first-line treatment for TBI.