Decompressive Craniectomy in Severe Traumatic Brain Injury

1. Paul Jones, PGY3 CCFP(EM) – Preceptor Dr. John Opie Decompressive Craniectomy in Severe Traumatic Brain Injury

2. Objectives • Severe TBI • Treatment Aims • Indications for Neurosurgical Interventions • Predictors of Poor Outcome • Dilated Fixed Pupils (DFPs) • Unilateral vs Bilateral DFPs • Time to OR • Controversies

3. Case • 64 yofemale unhelmeted bicyclist struck by a truck on sidewalk • EMS reports patient found with decreased LOC on scene and “posturing”, pupils were unequal and nonreactive. sBP 220, GCS 6, airway not secure.

4. Severe TBI • Severe Brain Injury = GCS 3-8 • Many patients with severe TBI die before reaching a hospital, almost 90% of prehospital trauma-related deaths involve brain injury.

5. Clinical Question • Does DecompressiveCraniectomyin the severe TBI patient improve outcomes?

6. Treatment Aims • Prevent Secondary Injury • Provide adequate oxygenation • Maintain BP that is sufficient to perfuse the brain

7. Case • GCS 6 (E1 V1 M4) • Left pupil 5 mm nonreactive to light • Right pupil 2 mm nonreactive to light • Brief hypoxia spO2 85% post intubation secondary to aspiration of vomitus but improved after suctioning

8. Herniation

9. Pressure • CPP = MAP – ICP • Target a CPP > 70-80 mmHg • Why do we care? • CPP maintains cerebral blood flow (CBF) and hence oxygen and metabolite delivery.

10. CT • http://radiopaedia.org/cases/intracranial-herniation

11. Indications for DC • Indication of DC • Traumatic brain injury • Malignant cerebral infarction • Others – Cerebral venous sinus thrombosis, intracerebralhematoma, metabolic encepahlopathies .

12. Predictors of Poor Outcome

13. Unilateral vs. Bilateral FDPs Clusmann et al. Fixed and dilated pupils after trauma, stroke, and previous intracranial surgery: management and outcome. J NeurolNeurosurg Psychiatry 2001;71:175–181

14. DC in setting of Fixed Dilated Pupils • The mortality was 94.7% with conservative treatment, and 59.3% with surgery (p<0.05, table 4). Clusmann et al. Fixed and dilated pupils after trauma, stroke, and previous intracranial surgery: management and outcome. J NeurolNeurosurg Psychiatry 2001;71:175–181

15. Time to Surgical Intervention Sakas DE, Bullock MR, Teasdale GM. One-year outcome following craniotomy for traumatic hematoma in patients with fixed dilated pupils. J Neurosurg 1995;82:961–5.

16. Case Outcome • Patient had Left frontal decompressivecraniectomy with drain, was transferred to the ICU. • POD #10 patient remained intubated and sedated with of GCS 5. R pupil 2 mm reactive, L pupil 2 mm sluggish.

17. Conclusion • Herniation = Badness • Document GCS EVM, Pupils • Treatment = Pharm +/- Decompressive Surgery (Ideally < 3 hrs from injury) • Earlier decompression seems to improve outcomes • Decompression not without risks • Late decompression for refractory elevated ICP may offer little benefit

18. Controversies • Primary vs Secondary • Refractory ICP ?

19. Uncertainty “It is unclear whether decompressivecraniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.” Cooper et al. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. NEJM 2011;364:1493-502.

20. dos and don’ts… Do • Call NeuroSx early • Get CT early • Get trauma/preop labs • Elevate HOB • Treat Hypotension • Treat Hypoxia Don’t • Delay transport to definitive care • Don’t fiddle with CVCs • Don’t hyperventilate the patient • Don’t do Burr hole*

21. References • Clusmann et al. Fixed and dilated pupils after trauma, stroke, and previous intracranial surgery: management and outcome. J NeurolNeurosurg Psychiatry 2001;71:175–181 • SakasDE, Bullock MR, Teasdale GM. One-year outcome following craniotomy for traumatic hematoma in patients with fixed dilated pupils. J Neurosurg 1995;82:961–5. • Sahuquillo, J. Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury (Review). 2009. The Cochrane Database of Systematic Reviews. Issue 2. • Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, KossmannT, Ponsford J, Seppelt I, Reilly P, Wolfe R; DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Decompressivecraniectomy in diffuse traumaticbraininjury. N Engl J Med. 2011 Apr21;364(16):1493-502. doi: 10.1056/NEJMoa1102077. Epub 2011 Mar 25. Erratum in: N Engl J Med. 2011 Nov 24;365(21):2040. PubMed PMID: 21434843. • Cooper DJ, Rosenfeld JV, Murray L, Wolfe R, Ponsford J, Davies A, D'Urso P, Pellegrino V, Malham G, Kossmann T. Early decompressive craniectomy for patients with severe traumatic brain injury and refractory intracranial hypertension—a pilot randomized trial. J Crit Care. 2008 Sep;23(3):387-93. doi:10.1016/j.jcrc.2007.05.002. Epub 2007 Dec 11. PubMed PMID: 18725045. • Honeybul S, Ho KM, Lind CR, Gillett GR. Decompressive craniectomy for diffuse cerebral swelling after trauma: long-term outcome and ethical considerations. J Trauma. 2011 Jul;71(1):128-32. doi: 10.1097/TA.0b013e3182117b6c. PubMed PMID: 21460742.