Consensus in Treating Traumatic Brain Injury

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Traumatic brain injury (TBI) is a public health and major socioeconomic problem worldwide. According to the World Health Organization (WHO), more than 5 million people die each year from this trauma, which is 9 percent of world deaths. In the past 10 years, the TBI community has witnessed various research efforts, including several randomized trials to deal with aspects of decompressive craniectomy (DC) such as surgical techniques, timing and indications in different patient populations.

Two international trials discussing different clinical questions to assess the effectiveness of decompression craniectomy (DC) after traumatic brain injury (TBI) were introduced in recent years: DECRA in 2011 and RESCUEicp in 2016. DECRA assessed the efficacy of bi-frontotemporoparietal DC in patients Adult TBI with diffuse brain injury, for example there are no mass lesions that require surgical evacuation, where first-level intensive care and neurosurgical therapy have not maintained intracranial pressure(ICP) below the target received. Whereas RESCUEicp assesses the efficacy of DC after the first and second level of therapy failed to control intracranial hypertension which is difficult to cure and is sustained in TBI patients.

The results of the trial have led to debate among doctors and researchers working in the field of TBI throughout the world, it is deemed necessary to provide general guidance on the use of DC after TBI, and identify areas of ongoing uncertainty through a consensus-based approach.

An international consensus meeting discussing the role of decompression craniectomy (DC) in the management of traumatic brain injury (TBI) took place in Cambridge, England, on September 28 and 29, 2017. The meeting was organized by the World Federation of Neurosurgical Societies (WFNS), AO / Global Neuro, and the NIHR Global Health Research Group on Neurotrauma.

Participants who were invited to discuss the evidence been previously published, and propose a consensus statement. The proposed statement requires a threshold of more than 70% with blind voting for final approval. The meeting brought results in six themes. First, primary DC for mass lesions included 8 consensus statements regarding primary DCs for mass lesions and 2 areas of uncertainty about primary DC for mass lesions. Second, secondary DC for intracranial hypertension, included 12 consensus statements regarding secondary DC for intracranial hypertension. Third, perioperative care included 8 consensus statements regarding perioperative care. Fourth, surgical techniques included 5 consensus statements regarding surgical techniques in DC and 6 areas of disagreement or uncertainty regarding surgical techniques in DC. Fifth, skull reconstruction ( cranioplasty ) included – 6 consensus statements regarding skull reconstruction ( cranioplasty)) and 3 areas of disagreement or uncertainty regarding skull reconstruction ( cranioplasty ). Sixth, DC in low and middle income countries, included 6 consensus statements regarding DC in low and middle income countries.

This article presents a final recommendation based on consensus on the use of decompression craniectomy (DC) after traumatic brain injury (TBI). The author has also identified areas of uncertainty, where further research is needed, including the role of primary DC, the role of hinge craniotomy (HC), and the optimal time and material for skull reconstruction.

Author: dr. Tedy Apriawan, Sp.BS.

Details of research available at:

Authors: Peter J. Hutchinson, Angelos G. Kolias, Tamara Tajsic, Amos Adeleye, Abenezer Tirsit Aklilu, Tedy Apriawan, Abdul Hafid Bajamal, Ernest J. Barthélemy, B. Indira Devi, Dhananjaya Bhat, Diederik Bulters, Randall Chesnut, Giuseppe Citerio, D. Jamie Cooper, Marek Czosnyka, Idara Edem, Nasser M.F. El-Ghandour, Anthony Figaji, Kostas N. Fountas, Clare Gallagher, Gregory W.J. Hawryluk, Corrado Iaccarino, Mathew Joseph, Tariq Khan, Tsegazeab Laeke, Oleg Levchenko, Baiyun Liu, Weiming Liu, Andrew Maas, Geoffrey T. Manley, Paul Manson, Anna T. Mazzeo, David K. Menon, Daniel B. Michael, Susanne Muehlschlegel, David O. Okonkwo, Kee B. Park, Jeffrey V. Rosenfeld, Gail Rosseau, Andres M. Rubiano, Hamisi K. Shabani, Nino Stocchetti, Shelly D. Timmons, Ivan Timofeev, Chris Uff, Jamie S. Ullman, Alex Valadka, Vicknes Waran, Adam Wells, Mark H. Wilson, Franco Servadei. 2019. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury. Acta Neurochirurgica (2019) 161:1261–1274. Review Article – Conference Report.

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