Yue John K, Kanter John H, Barber Jason K, Huang Michael C, van Essen Thomas A, Elguindy Mahmoud M, Foreman Brandon, Korley Frederick K, Belton Patrick J, Pisică Dana, Lee Young M, Kitagawa Ryan S, Vassar Mary J, Sun Xiaoying, Satris Gabriela G, Wong Justin C, Ferguson Adam R, Huie J Russell, Wang Kevin K W, Deng Hansen, Wang Vincent Y, Bodien Yelena G, Taylor Sabrina R, Madhok Debbie Y, McCrea Michael A, Ngwenya Laura B, DiGiorgio Anthony M, Tarapore Phiroz E, Stein Murray B, Puccio Ava M, Giacino Joseph T, Diaz-Arrastia Ramon, Lingsma Hester F, Mukherjee Pratik, Yuh Esther L, Robertson Claudia S, Menon David K, Maas Andrew I R, Markowitz Amy J, Jain Sonia, Okonkwo David O, Temkin Nancy R, Manley Geoffrey T
Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States.
Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States.
Lancet Reg Health Am. 2024 Oct 17;39:100915. doi: 10.1016/j.lana.2024.100915. eCollection 2024 Nov.
Contemporary surgical practices for traumatic brain injury (TBI) remain unclear. We describe the clinical profile of an 18-centre US TBI cohort with cranial surgery.
The prospective, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (2014-2018; ClinicalTrials.gov #NCT02119182) enrolled subjects who presented to trauma centre and received head computed tomography within 24-h (h) post-TBI. We performed a secondary data analysis in subjects aged ≥17-years with hospitalisation. Clinical characteristics, surgery type/timing, hospital and six-month outcomes were reported.
Of 2032 subjects (age: mean = 41.4-years, range = 17-89-years; male = 71% female = 29%), 260 underwent cranial surgery, comprising 65% decompressive craniectomy, 23% craniotomy, 12% other surgery. Subjects with surgery (vs. without surgery) presented with worse neurological injury (median Glasgow Coma Scale = 6 vs. 15; midline shift ≥5 mm: 48% vs. 2%; cisternal effacement: 61% vs. 4%; p < 0.0001). Median time-to-craniectomy/craniotomy was 1.8 h (interquartile range = 1.1-5.0 h), and 67% underwent intracranial pressure monitoring. Seventy-three percent of subjects with decompressive craniectomy and 58% of subjects with craniotomy had ≥3 intracranial lesion types. Decompressive craniectomy (vs. craniotomy) was associated with intracranial injury severity (median Rotterdam Score = 4 vs. 3, p < 0.0001), intensive care length of stay (median = 13 vs. 4-days, p = 0.0002), and six-month unfavourable outcome (62% vs. 30%; p = 0.0001). Earlier time-to-craniectomy was associated with intracranial injury severity.
In a large representative cohort of patients hospitalised with TBI, surgical decision-making and time-to-surgery aligned with intracranial injury severity. Multifocal TBIs predominated in patients with cranial surgery. These findings summarise current TBI surgical practice across US trauma centres and provide the foundation for analyses in targeted subpopulations.
National Institute of Neurological Disorders and Stroke; US Department of Defense; Neurosurgery Research and Education Foundation.
目前创伤性脑损伤（TBI）的外科治疗方法仍不明确。我们描述了一个美国18个中心的颅脑手术TBI队列的临床概况。
前瞻性观察性创伤性脑损伤转化研究与临床知识研究（2014 - 2018年；ClinicalTrials.gov编号：#NCT02119182）纳入了在创伤中心就诊且在TBI后24小时内接受头部计算机断层扫描的受试者。我们对年龄≥17岁且住院的受试者进行了二次数据分析。报告了临床特征、手术类型/时间、住院情况和6个月的预后。
在2032名受试者中（年龄：平均41.4岁，范围17 - 89岁；男性占71%，女性占29%），260人接受了颅脑手术，其中65%为去骨瓣减压术，23%为开颅手术，12%为其他手术。接受手术的受试者（与未接受手术的受试者相比）神经损伤更严重（格拉斯哥昏迷量表中位数 = 6对15；中线移位≥5毫米：48%对2%；脑池消失：61%对4%；p < 0.0001）。去骨瓣减压术/开颅手术的中位时间为1.8小时（四分位间距 = 1.1 - 5.0小时），67%的患者接受了颅内压监测。73%接受去骨瓣减压术的受试者和58%接受开颅手术的受试者有≥3种颅内病变类型。去骨瓣减压术（与开颅手术相比）与颅内损伤严重程度（鹿特丹评分中位数 = 4对3，p < 0.0001）、重症监护住院时间（中位数 = 13对4天，p = 0.0002）以及6个月不良预后（62%对30%；p = 0.0001）相关。更早的去骨瓣减压术时间与颅内损伤严重程度相关。
在一个具有代表性的大量TBI住院患者队列中，手术决策和手术时间与颅内损伤严重程度一致。颅脑手术患者中多灶性TBI占主导。这些发现总结了美国创伤中心目前的TBI手术实践，并为针对特定亚群的分析提供了基础。
美国国立神经疾病和中风研究所；美国国防部；神经外科研究与教育基金会。
