Neurotrauma Management for the Severely Injured Polytrauma Patient by James M. Ecklund & Leon E. Moores

Author:James M. Ecklund & Leon E. Moores
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Current Guidelines

In 1995, the Brain Trauma Foundation (BTF) in collaboration with the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) reviewed the published literature to develop guidelines for the management of severe traumatic brain injury. It was most recently updated in 2007 [29]. In addition, the BTF published another set of guidelines in 2006 for the surgical management of closed TBI [19]. In 2001 the International Brain Injury Association, in collaboration with the AANS and CNS, reviewed all published literature between 1966 and 2000 to publish a set of guidelines for the surgical management of penetrating brain injury [26]. Since then, there have been many publications from large civilian institutions and from the Iraq and Afghanistan wars that have added valuable knowledge to the growing body of literature. A review of the guidelines is beyond the scope of this chapter but is available for further review [18, 19, 26].

The primary indications for a decompressive craniectomy are severe TBI with refractory ICP to medical management and malignant cerebral edema secondary to a large hemispheric stroke [19, 26, 30–32]. Severe TBI can be associated with epidural, subdural, and traumatic parenchymal hematomas each with their own criteria for surgical evacuation. There are no comparative studies favoring craniotomy over craniectomy however craniectomy is usually reserved for patients with diffuse contusions, large extra-axial collections with significant mid line shift, and impending herniation [19]. In addition complex skull fractures can limit closure necessitating a craniectomy and delayed cranioplasty.

There are important clinical and radiographic factors that are considered prior to DC. Clinical factors associated with poor outcome in penetrating or closed head TBI include low GCS, age, bilateral fixed pupils, hemodynamic status, and coagulopathy [8, 33–39]. Radiographic findings of bihemispheric injury, ventricular or brain stem involvement also portend a worse prognosis in penetrating TBI [40–43]. While some have implemented aggressive surgical protocols for low GCS scores in closed TBI, others argue against decompression when the post-resuscitative GCS is 3–5 and there is no demonstrable hematoma on CT [39, 44]. The debate is ongoing and the presence of these factors does not exclude patients from surgery but are important prognosticators to be aware of when selecting patients for DC. In addition, resource limitations, regional capabilities, and time to definitive care can also influence the timing of decompression [45].

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