Surgical management of traumatic brain injury - Evidence, controversies and perspectives for the future

Abstract

The surgical treatment of traumatic brain injury is challenging. Evidence-based recommendations provide guidance, but the underpinning evidence is relatively weak. This lack of strong evidence has been quoted to emphasise the need for more clinical trials. Clinical trials should, however, not be seen as the only approach. The existing variability in surgical management offers opportunities for comparative effectiveness research (CER) based upon large-scale observational studies. CER has the potential to provide high-quality evidence in a cost efficient way. Controversies are greatest concerning the surgical management of contusions and indications for decompressive craniectomy (DC). Lesion progression is frequent in contusions and mainly occurs within six-nine hours after injury. Surgical treatment can be motivated by both mass and toxic effects. On-going studies, such as the Surgical trial in traumatic intracerebral hemorrhage (STITCH), will hopefully provide further guidance on 'best surgical approaches'. Currently, early computed tomography (CT) follow-up is recommended with surgical decisions based on CT evolution and risk assessment. The increasing enthusiasm for DC has been tempered by the results of the recent multicentre prospective randomised trial of early decompressive craniectomy in patients with severe traumatic brain injury (DECRA) study, showing more unfavourable outcome following DC. It is unlikely though that these results will change clinical practice, as the study population was highly selected and focused only on diffuse injuries. The results cannot be extrapolated to patients with focal or mass lesions. DC should not be considered a risk-free procedure. Complication rates of up to 50% have been reported. Major complications include subdural effusions, hydrocephalus and syndrome of the trephined. Early cranioplasty is preferred following DC, as complications may resolve more rapidly and recovery is enhanced.