Applicability was adjudicated and found to differ across questions and studies. , Ley EJ, Bukur Met al. The final phase of the evidence review is the synthesis of individual studies into information that the Clinical Investigators and the Methods Team use to develop recommendations. NEW–Secondary DC, performed as a treatment for either early or late refractory ICP elevation, is suggested to reduce ICP and duration of intensive care, though the relationship between these effects and favorable outcome is uncertain. Clark DJ, Kolias AG, Corteen EA et al. DECRA and RESCUEicp were consistent in demonstrating that DC reduces ICP and duration of intensive care. RESCUEicp and DECRA Quality Assessment. W Seattle International severe traumatic Brain Injury Consensus Conference. Secondary DC involves the removal of the bone flap later in the patient's course–typically to treat the elevation of ICP refractory to other treatments. Discovery at this contextual level will be necessary, but not sufficient, for the generation of strong evidence. ABSTRACT. This material is based upon work supported by (1) the US Army Contracting Command, Aberdeen ProvingGround, Natick ContractingDivision, through a contract awarded to Stanford University (W911 QY-14-C-0086). … The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Studies of DC covered several questions (Table 1). • Jugular venous saturation of <50% may be a threshold to avoid in order to reduce mortality and improve outcomes. DECRA compared outcomes for patients with diffuse brain injury treated with early bifrontal DC to those treated with medical management. All patients arriving at VUMC as a Level 1 trauma, including isolated gunshot wounds to the head will be evaluated by the Trauma Surgery Service. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. It is reasonable to consider how different research designs might be used to identify which treatments work best, for whom, and under what circumstances. EL Table 2 contains revised recommendations for all 3 types of monitoring. Several meta-analyses and the 2012 American College of Chest Physicians clinical practice guidelines have assessed randomised trials of various methods of thromboprophylaxis in patients undergoing neurosurgical procedures. A paucity of literature currently informs primary DC, or the practice of leaving the bone flap off following an initial surgery to evacuate an intracranial mass lesion. There are 7 Third Edition recommendations that are restated here but are no longer substantiated by evidence meeting current standards. Different cultures, families, and patients define what is meaningful function and what makes life worth living differently; the answers to these questions are more philosophical than medical. Farahvar Therefore, the application of these guidelines will vary depending upon the medical environment in which they are used. Traditionally, the scope of practice for neurosurgeons included acute and postoperative critical care for their patients and thus, neurosurgeons have not needed special privileges for ICU admission. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, Predicting the Extent of Resection in Low-Grade Glioma by Using Intratumoral Tractography to Detect Eloquent Fascicles Within the Tumor, Structural and Functional Imaging in Glioma Management, Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium, Aneurysmal Subarachnoid Hemorrhage: Trends, Outcomes, and Predictions From a 15-Year Perspective of a Single Neurocritical Care Unit, First in Man Pilot Feasibility Study in Extracranial Carotid Robotic-Assisted Endovascular Intervention, https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/, http://creativecommons.org/licenses/by/4.0/, Receive exclusive offers and updates from Oxford Academic, Decompressive Craniectomy for Traumatic Intracranial Hypertension, Decompressive Craniectomy Is Not an Independent Risk Factor for Communicating Hydrocephalus in Patients With Increased Intracranial Pressure, Decompressive Craniectomy for Elevated Intracranial Pressure and Its Effect on the Cumulative Ischemic Burden and Therapeutic Intensity Levels After Severe Traumatic Brain Injury, LONG-TERM OUTCOME OF SUBCUTANEOUSLY PRESERVED AUTOLOGOUS CRANIOPLASTY. Using the dichotomized score (1-3 vs 4-8, a different dichotomization from that used in DECRA), 42.8% of patients in the DC group had favorable outcomes vs 34.6% of patients in the No DC group (P = .12). JJ (1) They compared group differences in control of ICP, mortality, and distribution of the GOS-E ratings. TR. At 12 mo, there was a trend to worse functional outcomes in the craniectomy group (OR 1.68, 95% CI 0.96-2.93; P = .07) as well as unfavorable functional outcomes (OR 1.58; 95% CI 0.84-2.99; P = .16), though these results were not statistically significant as they were in the 6-mo data. , Roquilly A, Demeure dit latte Det al. ... Increasing Adherence to Brain Trauma Foundation Guidelines for Hospital Care of Patients With Traumatic Brain Injury. Although we reviewed and report on these monitoring modalities separately, it is important to acknowledge that clinical practice in most high-income countries incorporates multiple monitoring approaches as well as ongoing clinical assessment. This synthesis is described for each topic in the section titled Evaluation of the Evidence, after the Recommendations and preceding the Evidence Summary, which can be found in the comprehensive guideline document available online at https://www.braintrauma.org/coma/guidelines. S , Chiu YL, Carney N, Hartl R, Ghajar J. Talving Unfortunately, neither DECRA nor RESCUEicp, together or separately, provides definitive evidence for or against the performance of DC, and they are both complex and challenging to interpret. • Although propofol is recommended for the control of ICP, it is not recommended for improvement in mortality or 6-month outcomes. A T The updated recommendations were then extensively discussed and revised. The comprehensive guideline document includes an examination of the current condition of brain trauma clinical research, outlines how this condition is defining and shaping the future, and proposes a solution in establishing a formal evidence-based consortium. These recommendations are related to the influence on patient outcomes of 3 types of monitoring: ICP, cerebral perfusion pressure monitoring, and advanced cerebral monitoring. Guidelines for safe transfer of the brain‐injured patient: trauma and stroke, 2019 Guidelines from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society. Neurosurgical Representative on … RESCUEicp was intended to study patients with intracranial mass lesions and those undergoing lateral decompressions. Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Recommendations in this edition are designated as Level I, Level II-A, Level II-B, or Level III. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this publication. Level IIB and III recommendations were based on a low-quality body of evidence. ISRCTN66202560. Several particularly important gaps in knowledge are evident from this analysis of the body of evidence. It is also important to consider that current literature predominantly relates to secondary DC, in which the bone flap is removed in a delayed fashion to treat refractory elevation of ICP. The importance of incising the falx when a bifrontal DC is performed was questioned in conjunction with the interpretation of the DECRA trial, but this too remains insufficiently understood. Research Assistant Professor of Epidemiology, Board Certified or Board Eligible AP/CP Full-Time or Part-Time Pathologist, Components of overall quality–classes 1 and 2, Copyright © 2020 Congress of Neurological Surgeons. For instance, one might hypothesize that a bifrontal DC is better suited to a patient with frontal contusions, while a lateral decompression may be preferable for those with extra-axial hematomas but this remains uninformed by evidence. KEY WORDS: Severe traumatic brain injury, Adults, Critical care, Evidence-based medicine, Guidelines, Sys-tematic review Neurosurgery 0:1–10, 2016 DOI: 10.1227/NEU.0000000000001432 www.neurosurgery-online.com I n the Fourth Edition of the “Brain Trauma Foundation’s Guidelines for the Management of Severe Traumatic Brain Injury,” there are M This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. Assessing the quality of the body of evidence involves 4 domains: the aggregate quality of the studies, the consistency of the results, whether the evidence provided is direct or indirect, and the precision of the evidence. GL The assessment of the body of evidence for each subtopic is included in a table in each topic section in the comprehensive guideline document (https://braintrauma.org/coma/guidelines). S The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines. A Trauma Care Facility often referred to as Zd µu v [ is a healthcare institution that has As new studies are generated and added to the evidence base, we expect to see changes in the assessment of the quality of the body of evidence. Neurosurgery. There are now 28 evidence-based recommendations; 14 are new or changed from the previous edition, while 14 have not changed. Mosquito control-advice for family/community (1772KB) ... A new trauma centre is catering to the needs of all trauma patients under one roof. Recommendations from the prior (Third) Edition not supported by evidence meeting current standards. Gregory W J Hawryluk, MD, PhD, FRCSC, Andres M Rubiano, MD, Annette M Totten, PhD, Cindy O’Reilly, BS, Jamie S Ullman, MD, Susan L Bratton, MD, Randall Chesnut, MD, Odette A Harris, MD, MPH, Niranjan Kissoon, MD, Lori Shutter, MD, Robert C Tasker, MBBS, MD, Monica S Vavilala, MD, Jack Wilberger, MD, David W Wright, MD, Angela Lumba-Brown, MD, Jamshid Ghajar, MD, PhD, Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations, Neurosurgery, Volume 87, Issue 3, September 2020, Pages 427–434, https://doi.org/10.1093/neuros/nyaa278. The unordered test comparing the distribution of the GOS-E ratings over the 2 groups yielded a χ2 of 30.69 (7 df, P < .001) (individual P values not reported). , Tanguy M, Laviolle B, Tirel O, Malledant Y. Seguin (1) They compared group differences in control of ICP, days of mechanical ventilation, days in intensive care unit (ICU), and mortality. Major Changes from 3rd to 4th Edition, Appendix E. Inclusion and Exclusion Criteria, Appendix G. Criteria for Quality Assessment of Individual Studies, Appendix H. Quality of the Body of Evidence Assessment, Appendix I. Hypothermia Interventions Detail. Patients with evidence of “good” brain function who decline as a direct consequence of ICP elevation are likely the best candidates for decompression; however, identifying such patients remains challenging. , Stein DM, Hu PF, Aarabi B, Sheth K, Scalea TM. , Murray GD, McHugh GSet al. Crit Care Nurse. The design of meaningful and effective future research needs to be consistent with this clinical reality. The guidelines address treatment interventions, monitoring, and treatment thresholds that are specific to TBI or that address a risk that is greater in patients with TBI. , Nilsson P, Ronne-Engstrom E, Howells T, Enblad P. Huang The AANS and CNS recognize that clinical practice guidelines are potentially useful tools for improving the quality of clinical patient care. , Diaz-Arrastia R, Madden C, Gentilello L. Berry A large frontotemporoparietal DC (not less than 12 × 15 cm or 15 cm diameter) is recommended over a small frontotemporoparietal DC for reduced mortality and improved neurologic outcomes in patients with severe TBI.”12, The first recommendation was based on the 6-mo outcomes from DECRA.9 The second recommendation was based on 2 studies: Jiang et al (2005)14 and Qiu et al (2009).15, By virtue of the updated body of evidence, including 12-mo outcome data from DECRA and RESCUEicp, both published subsequent to the 2017 guidelines, we have removed the first recommendation and restated the second. The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for … Farahvar A, Gerber LM, Chiu YL et al. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons Even if a recommendation was not made, the evidence was included to acknowledge its place in the body of evidence and make it accessible for future consideration. , Diedler J, Kasprowicz Met al. The information contained in the Guidelines for the Management of Severe Traumatic Brain Injury reflects the current state of knowledge at the time of publication. Most level 1 hospitals have this kind of practice. The authors debated the extent to which the bifrontal surgical procedures performed in the DECRA and RESCUEicp studies should be extrapolated to the lateral decompressions more popular in North America. I M. H. Nathanson. The publication reports on 5 Class 1 studies, 46 Class 2 studies, 136 Class 3 studies, and 2 meta-analyses. Daley As with DECRA, RESCUEicp demonstrated that DC effectively lowered ICP and reduced the duration of intensive care management. Contributors Col Randall McCafferty, USAF, MC CDR … Learn how you can contribute. Our literature search protocol is detailed in the comprehensive guideline document, and the search strategies are in Appendix D to the same document. U J • High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. More recently, the DECRA investigators published the 12-mo outcome data from their study. , Chen YS, Hong WCet al. RESCUEicp compared outcomes of patients who received DC as a salvage treatment for ICP elevation with those who received medical management. The Neurosurgery Division of Trauma/Critical Care provides care to the critically injured patient who suffers brain or spinal trauma. This Fourth Edition of the Guidelines is transitional. Developing protocols that integrate TBI-specific, evidence-based recommendations with general best practices for trauma patients, and that provide guidance, suggestions, or options in areas of TBI management where the evidence is insufficient, is outside the scope of these guidelines. The 41 studies listed in Table 4 contributed to additions or changes to the recommendations. . For full access to this pdf, sign in to an existing account, or purchase an annual subscription. These were provided to the guideline panel and summarized by topic in the guideline document (see summary by topic in the comprehensive guideline document available online at https://www.braintrauma.org/coma/guidelines). Using the dichotomized score (1-4 vs 5-8), both unadjusted and adjusted odds of unfavorable outcomes were significantly greater in the DC group. As a result, the guidelines include changes in the evaluation of previous work, an increase in the quality of the included studies, and essential improvements in the precision of the recommendations. Published online in Neurosurgery, the official journal of the Congress of Neurological Surgeons (CNS), in August, the “Concussion Guidelines Step 2: Evidence for Subtype Classification,” provides support for re-thinking the way we diagnose concussion.. Angela K. Lumba-Brown, MD, co-director of the Stanford Brain Performance Center, Assistant Professor of Emergency Medicine at … D This synopsis provides an overview of the process, includes … • There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for deep vein thrombosis. Alali Honor Your Neurosurgical Mentor. Seguin DC continues to be performed. Variability in research protocols, patient assessments, and data collection and management could be washing out the potential effects of the interventions we are studying. Specialized branches have developed to cater to special and difficult conditions. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. We could begin the critical self-examination of our research methods by returning to the recommendations of the Clinical Trials in Head Injury Study Group.45 They encouraged (in part): Identification and testing of specific (appropriate) subgroups of patients with TBI, Standardized clinical management across centers, Independent monitoring of patient management and data quality, Identification of relevant outcome measures and adequate time to follow-up, Identification of clinically relevant effect size. , Gerber LM, Ni Q, Ghajar J. Lepelletier The relationship between secondary DC and neurological outcome following severe TBI has been investigated in many studies; however, 2 RCTs provide the best evidence currently available. PEDIATRIC TRAUMA GUIDELINES PAGE Pediatric Head Trauma CT Decision 132 Cervical Spine Clearance in Children After Trauma 133-134 Pediatric Blunt Cerebral Vascular Injury 135-136 Urgent Pediatric MRI for Trauma (After-Hours) 137 Pediatric Blunt Spleen/Liver Trauma Management 138-139 Pediatric Blunt Renal Trauma Management … New recommendation #1 relates to the positive findings of the RESCUEicp study,11 while new recommendation #2 relates to the negative findings of the DECRA study.9,10 Recommendation #4 reflects findings consistent in both studies.9-11, The scope of this update was limited to the addition of the RESCUEicp study and the 12-mo DECRA outcome data to the existing body of evidence. Using group differences assessed at 6 mo postenrollment–the primary outcome–they found the DC group had lower ICP, fewer days on mechanical ventilation and in the ICU, and no difference between groups for mortality. Hutchinson A brief assessment called the SPinal Emergency Evaluation of Deficits (SPEED) uses foot motor and sensory function to indicate injury severity and C3 dermatome sensation, handgrip strength and location of spinal pain to indicate the level of injury. Both RCTs that compared sizes of DCs were rated class 2.14,15 The class 3 studies on the questions of DC vs craniotomy and the timing of DC questions were not incorporated into the recommendations and are not included in Table 2, given higher level evidence was available. Refer to the comprehensive guideline document available online at https://www.braintrauma.org/coma/guidelines for a complete definition of Applicability. For example, preoperative magnetic resonance imaging scans could reveal devastating structural brain lesions (such as in the brainstem) not seen on computed tomography, which would predict a lack of benefit from surgical decompression. In this edition, we consider the applicability of individual studies in the Quality of the Body of Evidence and Applicability section immediately after the recommendations. 3. • Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS. , Chiu YL, Gerber LM, Ghajar J, Greenfield JP. P The design of DECRA targeted the effects of DC as applied to early stages of resistant intracranial hypertension, whereas RESCUEicp studied patients with more established resistance. The hospital provides round the clock facility for neurotrauma cases and has two hyperbaric chambers for follow up treatment. Each chapter includes symptoms and signs, surgical pathology, diagnostic modalities, differential … Currently, there is a lack of standards and developed methods in this area, so we elected to cite applicability issues that were identified and discussed by the authors. DE Both documents are available online at https://www.braintrauma.org/coma/guidelines. . He has a general neurosurgical practice with a sub-specialist interest in the management of neuro-trauma, specifically head and traumatic brain injury. According to the Brain Trauma Foundation press release, this update … LM . Consideration of applicability could result in a Level III recommendation (eg, a “moderate-quality body of evidence” with significant applicability concerns). These recommendations served to update the first published clinical practice guidelines for DC provided in conjunction with the Brain Trauma Foundation's Guidelines for the Surgical Management of Traumatic Brain Injury published in 2006.13 Here, we present an update of the 2017 recommendations following the adjudication and consideration of the evidence provided by RESCUEicp11 as well as DECRA’s recently published 12-mo outcome data.10 One of the previous recommendations was retained and 3 new level-IIA recommendations are now provided on this topic. The guidelines are not intended to cover all topics relevant to the care of patients with severe TBI. Although it used a secondary outcome measure with a more generous dichotomization scheme, 12-mo data in RESCUEicp seem to indicate that the outcome benefits of decompression continue to improve beyond the pre-specified six-month test period. Development and implementation of guidelines in neurosurgery. SJ Pediatric Neurosurgery Consult 131 TABLE OF CONTENTS. Brenner RESCUEicp underwent an independent assessment for quality by 2 reviewers using the same instrument as used to assess the DECRA trial and all other studies included in the fourth edition. This study is a randomized, controlled trial that evaluates decompressive craniectomy as a secondary procedure, after ICP-targeted medical therapies have failed.2 The results of this trial will be evaluated and may impact recommendations related to decompressive craniectomy as well as ICP thresholds. Class 1 is the highest class and is limited to good-quality randomized trials. Bullock MR, Chesnut R, Ghajar J et al. The information contained in these guidelines reflects published scientific evidence at the time of completion of the guidelines and cannot anticipate subsequent findings and/or additional evidence, and therefore should not be considered inclusive of all proper procedures and tests or exclusive of other procedures and tests that are reasonably directed to obtaining the same result. , Yeh TC, Sung KC, Wang CC, Chen CW, Chio CC. Chesnut This dedicated team is led by Dr. Hooman Azmi, Chief of Neurosurgery-Trauma/Critical Care and Dr. John Locurto, Chief of Trauma/Surgical Critical Care and Injury Prevention. The EPIC study analyzes use of prehospital Brain Trauma Foundation guidelines TBI management by... GE. ... trauma, pediatrics neurosurgery, vascular surgery, minimal invasive neurosurgery. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries 3. Using the median score for each group of the GOS-E measured at 6 mo postinjury (3: DC, 4: No DC), the unadjusted odds ratio (OR) for worse outcomes in the DC group was 1.84 (95% CI 1.05-3.24), P = .03, but after adjustment, the OR was no longer significant. In this edition, applicability alone was not used to downgrade a recommendation. , Fowler RA, Mainprize TGet al. RM Research is beginning to unravel the complexities of the injured CNS and is opening new doors for scientists, clinicians, and patients. Anecdotal evidence suggests that these new RCTs have not markedly changed practice. , Brown CV. These recommendations are intended to provide the foundation on which protocols can be developed that are appropriate to different treatment environments. 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