Research On Prognostic Factors And Post-traumatic Hydrocephalus Of Decompressive Craniectomy For Traumatic Brain Injury

BackgroundTraumatic brain injury(TBI)is one of the most common emergency and severe cases in neurosurgery,which has a high rate of disability and mortality.Especially for severe traumatic brain injury(sTBI),its treatment has always been the focus and difficulty of neurosurgery diagnosis at home and abroad,which not only affects the quality of life and prognosis of patients,but also causes serious trauma and economic burden to the family and society.Compared with other countries in the world,China has the largest number of patients with TBI.Among them,the percentage of sTBI is more than 25%.The incidence of TBI is about 55-64/100,000,which can cause approximately 100,000 patients dead and hundreds of thousands of patients disabled per year.The mortality rate of TBI is about 13/100,000,which is a devastating disaster for patients and their families and a serious public health problem as well.Multiple studies have shown that traffic accidents and fall injuries are main causes of TBI.Since the drunk driving is sentenced to criminal punishment in 2011,China’s big data shows that the number of TBI cases caused by motor vehicles has decreased,while the number of TBI cases involved in electric bicycles and tricycles has increased significantly.Acute intractable intracranial hypertension is the main cause of death in TBI patients.Malignant high intracranial hypertension that cannot be controlled by conservative treatment including open airway,sedation,analgesia,dehydration drugs,hyperventilation,mild hypothermia hibernation therapy,decompressive craniectomy(DC)has become the ultimate treatment for TBI.By removing part of the skull,DC swells the swollen and ischemic brain tissue in the direction of the decompression window,reduces the damage of intracranial high pressure on important brain structures which hence treats the patient.The concept of DC was firstly proposed by Professor Mareotte in 1886.In 1905,Professor Cushing firstly applied this surgical treatment to non-surgical operation of increased intracranial pressure.In 1977,Professor Becker of the United States proposed and firstly applied the standard decompressive craniectomy for traumatic brain injury.In 1997,Professor Polin published a research report on the treatment of malignant traumatic brain edema with bifrontal craniectomy.For more than 20 years,clinical medicine experts and scholars in China have demonstrated the important status in the emergency treatment of cranicerebral trauma,from the objection and controversy to the acceptance and application of standard decompressive craniectomy.The 2015 Chinese Expert Consensus on Decompressive Craniectomy of Traumatic Brain Injury and Guidelines for the Management of Severe Traumatic Brain Injury(Fourth Edition of the United States,2017)have guiding significance for the treatment of TBI with DC in China.According to the current literature,age,Glasgow Coma Scale(GCS)score,pupil dilations,pupil reactivity,midline shift,basal cistern morphology,Helsinki CT score,subdural effusion,post-traumatic hydrocephalus(PTH),intracranial infection,and advanced cranioplasty(CP)are related to the survival prognosis of DC in TBI patients.The common complications after DC include subdural hygroma,interhemispheric hygroma,postoperative delayed contusion and hematom,PTH,pulmonary infection,encephalocele,epilepsy,surgical incision incarceration,skull defect syndrome,intracranial infection and so on.However,in the clinical practice,there are still many controversies on the selection of cases,the surgical timing and skills,intracranial pressure monitoring,related prognostic factors,postoperative complications management,surgical efficacy and other aspects of DC,and the related literature research reports are inconsistent.This study was divided into two parts.The first part explored the preoperative,intraoperative and postoperative clinical data of 112 TBI patients with DC,found out the risk factors related to short-term and long-term survival prognosis through the univariate and multivariate analysis,probed into the effectiveness of risk factors in predicting survival prognosis,and provided reference indicators and a theoretical basis for the diagnosis and prognostic evaluation of DC for TBI.This part of the study suggested that PTH was an independent risk factor for long-term favorable prognosis of TBI patients undergoing DC.In the second part,we further explored the risk factors of hydrocephalus formation in 92 TBI patients after DC,explored the potential relationship between subdural hygroma,interhemispheric hygroma and hydrocephalus,analyzed and compared the treatment and prognosis of PTH,and optimized the clinical management strategy after PTH formation,aiming to provide a new reference for the occurrence and development,risk prediction,early diagnosis and precise treatment of PTH.Part ⅠI Research on Prognostic Factors of DecompressiveCraniectomy for Traumatic Brain InjuryResearch Objective This research was to explore the epidemiological characteristics,clinical characteristics,and prognostic risk factors of decompressive craniectomy for traumatic brain injury,and analyzed the effectiveness of risk factors in predicting survival prognosis,aiming to provide reference indicators and a theoretical basis for the diagnosis and prognostic evaluation of decompressive craniectomy for traumatic brain injury.Research Methodology With the approval of the Medical Ethics Committee of the hospital,112 patients with traumatic brain injury who underwent decompressive craniectomy between January 2017 and December 2018 were selected from the Neurosurgery Department of Liaocheng People’s Hospital,The epidemiological data,preoperative clinical and imaging data,surgical conditionss,postoperative clinical data,complications and follow-up data that may affect the survival prognosis of patients were collected and summarized,and the risk factors of short-term death and long-term survival were determined by univariate and multivariate Logistic regression analysis.The author drew the receiver operating characteristic(ROC)curves of independent risk factors that could affect the short-term mortality of the enrolled patients,analyzed the optimal threshold and area under curve(AUC)and evaluated its predictive performance of short-term mortality.Kaplan-Meier survival analysis was used to assess the short-term survival of each independent risk factor.Research Results 1.Among 112 patients of decompressive craniectomy for traumatic brain injury,70 cases(62.5%)were male,42 cases(37.5%)were female,the mean age was 48.11±14.43 years;preoperative GCS score was 5.24 ±1.97;89 cases(79.5%)were operated within 24 hours of injury,23 cases(20.5%)were operated after 24 hours of injury;unilateral frontotemporoparietal hemicraniectomy was performed in 96(85.7%)cases,bilateral hemicraniectomy in 13(11.6%)cases and bifrontal craniectomy in 3(2.7%)cases.The most common causes of injuries were traffic accidents(70 cases,62.5%),61.4%of which involved electric bicycles and tricycles.2.37 patients(33.0%)died within 30 days after DC.The main causes of death were uncontrollable brain swelling(64.9%)and large area cerebral ischemia and infarction(24.3%).Univariate and multivariate logistic regression analysis showed that age(OR 1.139[95%CI 1.011-1.283];P=0.033),D-dimer level at admission(OR 1.366[95%CI 1.027-1.816];P=0.032)and postoperative hypernatremia(OR 16.931[95%CI 1.772-161.822];P=0.014)were independent prognostic factors for short-term mortality.The quantitative analysis of the ROC curve showed that the accuracy of age,D-dimer level at admission and postoperative hypernatremia were 74.1%(threshold 49.5 years),67.0%(threshold 67.4ug/ml)and 77.7%,respectively;the combined analysis of three risk factors showed a specificity of 97.3%,a sensitivity of 97.3%and an accuracy of 96.4%.3.At the six-month follow-up,the final outcome was favorable in 48(64.0%)patients among 75 TBI patients who alive 30 days after DC and the mortality rate was 45.5%.Univariate analysis and multivariate Logistic regression analysis showed that the independent risk factor affecting long-term survival of patients was the occurrence of PTH(OR 672.702[95%CI 5.561-81370.584];p=0.008).Research ConclusionsAlthough decompressive craniectomy is an effective and ultimate treatment for patients with traumatic brain injury to control refractory cranial hypertension,its mortality and disability rate are still very high.Age,D-dimer level at admission and postoperative hypernatremia were independent risk factors for short-term death of TBI patients undergoing DC.PTH was an independent risk factor for long-term favorable prognosis of TBI patients undergoing DC,According to the age,D-dimer level and postoperative hypernatremia of TBI patients with DC,we can evaluate their short-term survival,and make an accurate treatment strategy to prevent and control the occurrence and progress of PTH,which is helpful to improve their long-term prognosis.Part Ⅱ Research on Hydrocephalus after Decompressive Craniotomy for Traumatic Brain InjuryResearch ObjectiveThis research was to explore the risk factors for the occurrence and development of hydrocephalus after decompressive craniectomy for traumatic brain injury,probe into the potential relationship between subdural hygroma,interhemispheric hygroma and hydrocephalus,and study the clinical management strategy after PTH,aiming to provide a new reference for the occurrence and development,risk prediction,early diagnosis and precise treatment of PTH.Research MethodologyThis study was approved by the Medical Ethics Committee of the hospital,and 92 TBI patients who underwent DC met the entry criteria between January 2017 and December 2018 were screened out from the Neurosurgery Department of Liaocheng People’s Hospital.The epidemiological data,preoperative clinical and imaging data,surgical conditionss,postoperative clinical data,complications and follow-up data that may affect the occurrence and development of PTH were collected and summarized,explored the potential correlation between subdural hygroma,interhemispheric hygroma and hydrocephalus,found the risk factors of the occurrence of hydrocephalus through the univariate and multivariate logistic regression analysis and analyzed the precise treatment and prognosis of PTH.Research Results1.Among 92 patients with TBI who underwent DC,56 were male(60.9%)and 36 were female(39.1%);the men age was 47.03±14.27 years(16-76 years);the preoperative GCS score was 5.47±2.05;the mean distance of midline shift was 9.78±4.50 mm(0-23.4 mm);43 patients(46.7%)with subdural hygroma,21(22.8%)interhemispheric hygroma and 44(47.8%)ventricular dilatation.2.PTH occurred in 22 patients(23.9%)with TBI after DC and the time of formation was 32.4±11.7 days(15-56 days);subdural hygroma was found in 15 patients(68.2%)before PTH formation and the formation time was 13.0 ±7.3 days(6-31 days);interhemispheric hygroma was found in 10 patients(45.5%)before PTH formation and the formation time was 18.7 ±9.9 days(11-43 days).There was a correlation on the same time axis between subdural hygroma and/or interhemispheric hygroma and hydrocephalus after DC.3.Univariate analysis showed that DC classification,midline shift,surgical time,intraoperative bleeding volume,tracheotomy,subdural hygroma,interhemispheric hygroma,ventricular dilatation,postoperative large area cerebral infarction and ischemia and PTH formation were correlated.Multivariate logistic regression analysis showed that the independent prognostic factor affecting PTH formation was the occurrence of subdural hygroma(OR 3.392[95%CI 1.259-9.137];p=0.016).4.Among 22 PTH patients,9 patients(40.9%)underwent continuous lumbar cistern drainage to release cerebrospinal fluid,10 patients(45.5%)underwent CP,and 5 patients(22.3%)ventriculoperitoneal shunt(VPS),1 case(4.5%)lumbarperitoneal shunt(LPS),and 2 cases(9.1%)lateral external ventricular drainv(LEVD).Compared with 12 patients who received lumbar puncture and/or lumbar drainage and/or LEVD(non-surgical group),10 PTH patients with CP and/or hydrocephalus shunt(surgical group)had a significantly better prognosis(p＝0.029).Research ConclusionsThe incidence of hydrocephalus after DC is high,which seriously affects the survival and prognosis of patients.Early identification of TB1 patients at high risk for PTH will be beneficial to improve survival and prognosisimprove.There was a correlation on the same time axis between subdural hygroma and/or interhemispheric hygroma and hydrocephalus after DC,and the progressive increase of subdural hygroma and/or interhemispheric hygroma was a sign of PTH formation.The appearance of subdural hygroma(p=0.016)was an independent risk factor for the formation of PTH.Acute progressive PTH requires active shunt surgery,scientifically adjusted pressure to find the most suitable valve pressure,and timely CP according to the condition;slowly progressing PTH can be treated with CP,establish a new cerebrospinal fluid circulation balance,relieve hydrocephalus,follow-up observation,and shunt hydrocephalus if necessary according to the evolution of the disease.PTH combined with skull defects should be individualized according to the specific conditions of patients,and precise treatment strategies should be formulated to control the malignant progress of hydrocephalus and improve the long-term quality of life and prognosis of patients.