CHAPTER 5

SURGICAL MANAGEMENT OF TRAUMATIC

PARENCHYMAL LESIONSM. Ross Bullock, M.D., Ph.D.Department of Neurological Surgery,Virginia Commonwealth UniversityMedical Center,Richmond, Virginia

Randall Chesnut, M.D.Department of Neurological Surgery,University of WashingtonSchool of Medicine,Harborview Medical Center,Seattle, Washington

Jamshid Ghajar, M.D., Ph.D.Department of Neurological Surgery,Weil Cornell Medical College ofCornell University,New York, New York

David Gordon, M.D.Department of Neurological Surgery,Montefiore Medical Center,Bronx, New York

Roger Hartl, M.D.Department of Neurological Surgery,Weil Cornell Medical College ofCornell University,New York, New York

David W. Newell, M.D.Department of Neurological Surgery,Swedish Medical Center,Seattle, Washington

Franco Servadei, M.D.Department of Neurological Surgery,M. Bufalini Hospital,Cesena, Italy

Beverly C. Walters, M.D., M.Sc.Department of Neurological Surgery,New York UniversitySchool of Medicine,New York, New York

Jack Wilberger, M.D.Department of Neurological Surgery,Allegheny General Hospital,Pittsburgh, Pennsylvania

Reprints requests:Jamshid Ghajar, M.D., Ph.D.,Brain Trauma Foundation,523 East 72nd Street,New York, NY 10021.Email: ghajar@braintrauma.org

RECOMMENDATIONS(see Methodology)

Indications• Patients with parenchymal mass lesions and signs of progressive neurological

deterioration referable to the lesion, medically refractory intracranial hypertension,or signs of mass effect on computed tomographic (CT) scan should be treatedoperatively.

• Patients with Glasgow Coma Scale (GCS) scores of 6 to 8 with frontal or temporalcontusions greater than 20 cm3 in volume with midline shift of at least 5 mm and/orcisternal compression on CT scan, and patients with any lesion greater than 50 cm3

in volume should be treated operatively.• Patients with parenchymal mass lesions who do not show evidence for neurological

compromise, have controlled intracranial pressure (ICP), and no significant signs ofmass effect on CT scan may be managed nonoperatively with intensive monitoringand serial imaging.

Timing and Methods• Craniotomy with evacuation of mass lesion is recommended for those patients with

focal lesions and the surgical indications listed above, under Indications.• Bifrontal decompressive craniectomy within 48 hours of injury is a treatment option

for patients with diffuse, medically refractory posttraumatic cerebral edema andresultant intracranial hypertension.

• Decompressive procedures, including subtemporal decompression, temporal lo-bectomy, and hemispheric decompressive craniectomy, are treatment options forpatients with refractory intracranial hypertension and diffuse parenchymal injurywith clinical and radiographic evidence for impending transtentorial herniation.

KEY WORDS: Coma, Computed tomographic parameters, Craniotomy, Decompressive craniectomy, Headinjury, Herniation, Intracranial pressure monitoring, Parenchymal mass lesion, Surgical technique, Timingof surgery, Traumatic brain injury

Neurosurgery 58:S2-25-S2-46, 2006 DOI: 10.1227/01.NEU.0000210365.36914.E3 www.neurosurgery-online.com

OVERVIEW

Traumatic parenchymal mass lesions arecommon sequelae of traumatic brain injury(TBI), occurring in up to 8.2% of all TBI (37)and 13 to 35% of severe TBI, (6, 35, 44, 47, 57,58) and comprising as much as 20% of opera-tive intracranial lesions in representative se-ries (44, 68). Most small parenchymal lesionsdo not require surgical evacuation (18, 19, 57).However, the development of mass effect fromlarger lesions may result in secondary brain in-jury, placing the patient at risk of further neu-

rological deterioration, herniation, and death(6). Because parenchymal lesions tend to evolve,(36, 54, 55, 58) and because timing of surgerywith respect to the occurrence of neurologicaldeterioration clearly affects outcome (41), mucheffort has been directed at defining patients atrisk of progressive neurological compromise asa result of their traumatic injuries (6, 50). Beckeret al. (3) advocated early evacuation of traumaticintracranial hematomas and contusions for thepurpose of avoiding secondary complications.A selective approach was envisioned by Gall-braith and Teasdale (18), who stated, “if those

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who are going to deteriorate could be identified soon after thehematoma has been detected they could be operated on imme-diately without incurring the risks of delay, and the remainderwould be spared unnecessary operation.” The literature address-ing these issues in the CT era is reviewed here in an attempt todefine appropriate surgical indications, methods, and timing forthe patient with traumatic parenchymal injuries.

Although the majority of relevant data retrospectively ad-dresses prognostic variables, differential classification, andclinical course of parenchymal lesions, several studies attemptto assess the efficacy of surgical intervention in a retrospective,historically controlled fashion. Only one randomized, con-trolled trial has been published (61). In addition, the topics ofdelayed traumatic intracerebral hematoma (DTICH) and de-compressive operations for diffuse parenchymal injury andpersistent intracranial hypertension deserve specific consider-ation, and are also addressed here.

PROCESS

A MEDLINE computer search using the following keywords: “intracerebral” or “intraparenchymal” or “ICH” or“IPH and “hematoma” or “hematoma” or “hemorrhage” and“surgery” or “craniotomy” or “craniectomy” or “burr hole” or“craniostomy” and “trauma” or “traumatic” or “TBI” or“CHI” between 1975 and 2001 and limited to humans wasperformed. A total of 330 documents were found. An addi-tional search using the following key words: “brain” or “cor-tex” and “laceration” between 1975 and 2001 was performed,yielding 101 additional articles. This search was narrowed toinclude the following key words: “surgery” or “operative” or“craniotomy” or “craniectomy” or “decompressive craniec-tomy” or “repair” and “outcome,” yielding 49 articles. A thirdsearch using the following key words: “contusion” or “hem-orrhagic contusion” and “brain” and “surgery” or “craniot-omy” or “craniectomy” or “burr hole” or “craniostomy” wasperformed, yielding 174 articles. A fourth search, using thekey words “DTICH” or “DTIPH,” yielded 11 articles. A fifthsearch, using the key word “TICH,” yielded eight articles. Allfive searches were combined. Duplicates between searcheswere discarded. A total of 495 references resulted. In addition,the reference lists of selected articles were reviewed, and atotal of 51 articles were selected for critical analysis. Theresults of this analysis were incorporated into the reviewpresented here. Papers primarily addressing the followingtopics were not included: nontraumatic lesions (e.g., sponta-neous intraparenchymal hemorrhage or infarction), patientswith other associated nontraumatic lesions (e.g., tumors orarteriovenous malformations), posttraumatic aneurysms,chronic lesions, penetrating trauma, carotid-cavernous fistu-lae, patients undergoing anticoagulation therapy, patientswith associated illnesses (e.g., acquired immunodeficiencysyndrome; concomitant infection; hemophilia; thromboticthrombocytopenic purpura; or hemolysis, elevated liver en-zymes, and low platelet count), pregnant patients, birthtrauma, traumatic intraventricular hemorrhage, traumatic hy-

drocephalus, external ventricular drainage, sagittal sinus in-jury, pre-CT era reports, and book chapters. Papers with thefollowing characteristics were also excluded: case series withfewer than 10 patients evaluated by CT scan and with incom-plete outcome data (mortality or Glasgow outcome score[GOS]), case reports, operative series with operations occur-ring greater than 14 days from injury. Posterior fossa paren-chymal injuries are addressed in Surgical Management of Pos-terior Fossa Mass Lesions. Selected articles were evaluated fordesign, prognostic significance, therapeutic efficacy, and over-all outcome. In addition, several articles were reviewed for thepurposes of historical perspective.

SCIENTIFIC FOUNDATION

Traumatic Parenchymal Lesions

Traumatic parenchymal lesions are a heterogeneous group,and are traditionally divided into focal and nonfocal lesions.Focal lesions include intracerebral hematomas (ICH), DTICH,contusions, and infarctions. Nonfocal lesions include cerebraledema, hemispheric swelling, and diffuse injury. Althoughthese lesions often do not occur in isolation, their presence hasbeen shown to adversely affect prognosis (16, 44). Indeed,Fearnside et al. (16) prospectively collected data on 315 se-verely head-injured patients and found that “the model whichprovided the most accurate prediction of poor outcome in-cluded age, hypotension and three different CT characteristics:subarachnoid blood, ICH or intracerebral contusion (accuracy72.5%).” Parenchymal lesions have been further subclassifiedby multiple authors, and outcome has clearly been shown todiffer among lesion types (19, 35, 39–41, 44, 65). Marshall (39)demonstrated that CT-defined injury type was a highly sig-nificant independent predictor of mortality, even when ageand GCS motor score were included in the predictive model.Given the heterogeneity of the pathophysiology and prognos-tic significance of “parenchymal” lesions, the task of definingclear surgical indications and methods becomes difficult.

Prognostic Factors

Despite proven differences among lesion types, outcomewithin the broad category of “parenchymal” lesions correlateswith known prognostic variables of TBI in general (5). Theseinclude age (26, 44, 45, 56, 58, 66, 70), admission or postresus-citation GCS (6, 19, 23, 40, 44, 45, 49, 51, 58), presence of cranialfracture (56), presence of pupillary response/brainstem re-flexes (7, 44), respiratory insufficiency (8), ICP (6, 7, 23, 39, 44,50, 51), and the status of the basal cisterns (6, 41, 62) or thirdventricle (6, 41, 62) on CT scan. Moreover, other variables signif-icantly correlate with outcome. These include location of thelesion (2, 32, 50, 58), ICH volume (8, 63), GCS at time of follow-upCT (63), lowest recorded GCS (7), severity of surrounding edema(6), timing of surgery (41, 51, 53), occurrence of preoperativeneurological deterioration (41), and presence of acute hemi-spheric swelling or concomitant subdural hematoma (7, 35). Al-though their study included nontraumatic lesions, Andrews et al.

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(2) showed that patients with a temporal or temporoparietal ICHof 30 cm3 or greater, as defined by product of anteroposterior,mediolateral, and superoinferior diameters on CT scan, weresignificantly more likely to develop signs of brainstem compres-sion or tentorial herniation, implying that these patients shouldundergo early evacuation of the offending mass lesion. However,these prognostic variables alone do not define the patient whoshould undergo operative intervention.

Operative Indications

As stated above, in Overview, several studies have focusedon defining the patient at risk for subsequent neurologicaldeterioration, making the assumption that operative interven-tion for this patient will improve the likelihood of a morefavorable outcome. Predictors of failure of nonoperative man-agement (defined by subsequent neurological deteriorationand need for craniotomy) include lesion location (50), intra-cranial hypertension (6, 18, 50), presence of subarachnoidhemorrhage (41), cisternal effacement (41), lesion volume (41),and hypoxic events (41).

Bullock et al. (6) prospectively studied 85 patients with ICHwhose initial need for craniotomy was uncertain. These pa-tients underwent ICP monitoring in an attempt to better de-fine the need for surgical intervention. The authors then ret-rospectively reviewed the CT scans of those patients for whomICP monitoring failed to predict late deterioration and, thus,the need for ICH evacuation. With multiple linear regressionanalysis, they found the peak ICP to be the strongest predictorof outcome. However, ICP monitoring failed to predict latedeterioration or death secondary to high ICP in 5 of 30 patientswho did not undergo initial surgery. After critical analysis ofCT factors, they concluded that the decision to operate“should be based on a spectrum of clinical, CT scanning andICP findings”. CT and clinical predictors included cisternalstatus, edema severity, and admission GCS. Interestingly, theauthors found that the weight of each predictor depended onthe location of the ICH. For temporoparietal lesions, hema-toma size, degree of edema, GCS, basal cistern status, and ICPdata correlated with outcome. However, for frontal lesions,peak ICP alone was predictive of outcome. These findingsexpand on those reported by Gallbraith and Teasdale (18),who found that all patients with “intradural” lesions (includ-ing subdural hematoma, ICH, and “burst lobes”) and sus-tained ICP greater than 30 mm Hg, versus only one patientwith an ICP less than 20 mm Hg, required operative interven-tion, as defined by clinical deterioration or failure to improvein the setting of increased ICP.

Mathiesen et al. (41) reviewed data collected prospectively forthe Head Injury Trial-2 nimodipine trial on 218 TBI patients notobeying commands within 24 hours of injury. These authorsfound that the initial CT characteristics of presence of subarach-noid hemorrhage, presence of focal lesion with volume greaterthan 40 cm3, and compressed or absent cisterns were associatedwith neurological deterioration, defined as a fall in GCS by 2points or from 4 to 3, or as the development of pupillary dilation.

They also found that the incidence of secondary (greater than 5 dafter injury) deterioration was associated with the occurrence ofhypoxic events. The occurrence of neurological deterioration, inturn, was found to adversely affect outcome from craniotomy,suggesting that patients with factors strongly associated withneurological deterioration should be considered for early surgery(i.e., before the onset of neurological deterioration). The authorsdirectly demonstrated that a subgroup of patients with admis-sion GCS of at least 6 and focal lesion volume of at least 20 cm3

who underwent surgery without previous neurological deterio-ration had significantly better outcomes compared with thosewho either did not undergo surgery or who underwent surgeryafter deterioration. Furthermore, if a radiological sign of masseffect (i.e., compression or obliteration of the cisterns and/or amidline shift � 5 mm) was present, craniotomy significantlyimproved the outcome in this group. Craniotomy was also di-rectly shown to improve outcome in a small subgroup of patientswith admission GCS of at least 10, temporal contusions, and aradiological sign of mass effect (i.e., a midline shift and/or com-pression or obliteration of the basal cisterns. Additionally, pa-tients admitted with a GCS of at least 6 and a lesion volume of atleast 50 cm3 had better outcome with surgery before or immedi-ately after deterioration than without surgery or with delayedoperation.

Although the goal of identifying those patients who arelikely to deteriorate neurologically is paramount, the questionof whether surgery itself is beneficial remains unanswered.Few studies compare surgical outcome with matched, nonsur-gically managed controls. In a retrospective study of 21 pa-tients with frontal lobe contusions and medically intractableintracranial hypertension (�40 mm Hg), mortality was signif-icantly decreased in the surgical group compared with a non-surgical historical group (22% versus 88%, respectively) (28).These patients were matched for age, sex, GCS, and ICP levels,although statistics for these variables are not provided by theauthors. Choksey et al. (8) retrospectively reviewed 202 pa-tients with traumatic ICH and showed, with logistic regres-sion analysis, that craniotomy significantly improved theprobability of good outcome. Factors taken into considerationfor this analysis included low GCS and hematoma volumegreater than 16 cm3, each of which independently predictedpoor outcome in these patients. Several other studies examineoutcome relative to specific decompressive procedures, andare discussed in the surgical treatment section.

For the purposes of CT classification, Marshall (39) defineda �mass lesion� as a lesion of volume greater than 25 cm3. Theyshowed differential outcome between patients with evacuatedand nonevacuated mass lesions (23% versus 11% favorableoutcome, respectively) in a series of 746 severe TBI patients(i.e., after resuscitation, GCS � 8). In contrast, a recent paperfrom the European Brain Injury Consortium (54) evaluating aseries of 724 TBI patients with a GCS of 3 to 12 showed a 45%rate of favorable results in evacuated mass lesions versus 42%in nonevacuated mass lesions using the same classificationsystem. Sample size between these two studies was noticeablydifferent: the former series included 276 patients with evacu-

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ated mass lesions and 36 with nonevacuated mass lesions,whereas the latter included 195 and 148 patients, respectively.These studies reviewed illustrate that a classification systembased solely on lesion volume is unable to consistently showthe relationship between surgery and outcome. Surgical indi-cations are, in fact, related to many factors, including CTparameters (i.e., volume, midline shift, and basal cistern com-pression), clinical status, and the occurrence of clinical deteri-oration, among others.

One fundamental problem in using initial CT parameters asindependent indications for surgery is that CT pathology hasclearly been shown to be a dynamic process. Using the TraumaticComa Data Bank classification system (39), Lobato et al. (36)showed that 51.2% of 587 severely injured patients (GCS � 8)developed significant changes between initial and “control” CTscans, the latter of which more accurately predicted outcome.Similarly, Servadei et al. (54) showed that 16% of moderately-to-severely injured patients (GCS of 3–12) with diffuse injuryshowed radiological progression across Traumatic Coma DataBank classes. Yamaki et al. (69) showed that only 56% of ICHgreater than 3 cm in diameter developed within 6 hours of injury,and that only 84% of ICH reached maximal size within 12 hours.These studies highlight the dynamic nature of parenchymal in-juries and the dangers inherent in placing too much emphasis ona single, static CT scan for management decisions.

The data reviewed shows that there are subpopulations ofpatients with traumatic intraparenchymal lesions that willbenefit from surgical intervention. However, the precise char-acteristics of these subpopulations are not, as yet, clearly de-fined. The literature supports taking into account an amalgamof clinical and radiographic criteria, including GCS, location,volume, CT appearance, ICP, and the presence of neurologicaldeterioration, to make an informed decision to subject a pa-tient with a parenchymal lesion to a craniotomy. It seems thatall factors must be taken into consideration to best define thepatient population that will benefit from surgery.

DTICH

ICH have been shown to evolve over time (55, 58, 69). Theentity of DTICH was initially described by Bollinger in 1891(4), and is now defined by most authors as occurring in areasof radiographically normal brain in patients with otherwiseabnormal initial CT scans (20, 22, 59, 63). It is defined byGentleman et al. (20) as a �lesion of increased attenuationdeveloping after admission to hospital, in a part of the brainwhich the admission CT scan had suggested was normal”.Other authors, however, have noted DTICH to occur in areasof contusion on initial, high-resolution CT scan (72). The inci-dence of DTICH ranges from 3.3 to 7.4% in patients withmoderate-to-severe TBI (15, 20, 22, 29, 59, 63). EvacuatedDTICH represent approximately 1.6% of all evacuated trau-matic ICH (20), and mortality ranges from 16 to 72% (15, 20,22, 59, 63) Therefore, the importance of careful monitoring andof serial CT scanning cannot be overemphasized (55, 63, 72).

In a retrospective review of 32 patients with DTICH, Tseng(63) found that greater lesion volume, cisternal compression,earlier timing of appearance, occurrence of clinical deteriora-tion, and lower GCS at time of a second, follow-up CT ad-versely affected outcome. Mortality occurred only with clini-cal presentation of DTICH within 48 hours of injury. In thissmall series, no patient with DTICH requiring craniotomypresented after 72 hours of injury. Sprick et al. (59) similarlyfound that approximately 70% of clinically significant DTICHpresented within 48 hours of injury. Additionally, DTICH hasbeen shown to be significantly associated with an increasedincidence of secondary, systemic insults (22), an increasedincidence after decompressive surgery for other mass lesions(22), and an increased incidence of abnormal clotting param-eters (29), suggesting a complex etiology for this lesion beyondthe mechanical disruption of the parenchyma (22, 27).

Although DTICH is most likely a distinct pathophysiologi-cal entity, it is still a parenchymal lesion from which manypatients either fail to recover or clinically deteriorate. Thefindings of Mathiesen et al. (41) indicate that patients withintracerebral lesions undergoing surgery before neurologicaldeterioration have improved outcomes. It follows logicallythat a subset of DTICH patients would benefit from rapidsurgical intervention after discovery of the lesion. However noCT-era studies have critically examined surgical outcome. Be-cause the majority of studies show that all patients who de-velop clinically relevant DTICH have abnormal initial CTscans (20, 63, 72), it is essential that patients with initiallyabnormal scans undergo intensive monitoring and serial im-aging to ensure rapid intervention, if necessary.

Surgical Methods

The standard surgical treatment of focal lesions, such asintracerebral hemorrhages or contusions, is craniotomy withevacuation of the lesion. Location of the lesion and proximityto critical structures are considerations when contemplatingthe choice of surgical options. Evacuation of traumatic masslesions is often effective in amelioration of brain shift andreduction of ICP, and can decrease the requirement for inten-sive medical treatment. Other methods, such as stereotacticevacuation of focal mass lesions, have also been used, al-though much less commonly (12). These procedures, however,become less effective when the patient’s intracranial pathol-ogy is diffuse and involves intracranial hypertension as aresult of posttraumatic edema or hemispheric swelling—fac-tors known to be associated with poor outcome (6, 19, 35, 38,44, 51). Even with focal ICH, a significant proportion of pa-tients have medically intractable intracranial hypertension af-ter standard craniotomy, and these patients fare the worst (44).

Surgical Treatment of Intracranial Hypertension

Rationale

A variety of operations have been developed for, or applied to,decompression of the brain at risk for the sequelae of traumati-

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cally elevated ICP. These include Cushing’s subtemporal decom-pression (13), temporal lobectomy (34, 48), manual reduction ofthe temporal lobe (64), circumferential craniotomy (9), and themore widely used hemispheric decompressive craniectomy (52)and bifrontal decompressive craniectomy (30). The rationale forsuch an approach is supported from a physiological perspectiveby both human and animal studies. Particular attention has beendirected at the study of changes in ICP and CT scan features,such as cisternal effacement and midline shift, after decompres-sion, with the goal of correlating significant postoperative reduc-tion of these parameters with improved outcome.

Hatashita and Hoff (25) showed that decompressive fronto-parietal craniectomy in cats led to significant reduction in ICP,reduction in cortical gray and white matter tissue pressure, in-creased pressure-volume index, and increased tissue compliance.The authors found that craniectomy significantly increased thevolumetric compensatory capacity of the intracranial cavity, afinding consistent with those of Hase et al. (24), in which ven-tricular catheter ICP measurements in 47 severe TBI patients, 33of whom underwent external decompression, documented a dra-matic increase in intracranial compliance after decompression.Yoo et al. (71) studied intraoperative ventricular pressures in acohort of 20 patients with refractory intracranial hypertensionafter both traumatic and nontraumatic insults who underwentbilateral frontotemporoparietal decompressive craniectomy withdural expansion and grafting. These authors found a 50.2 �16.6% reduction of initial ICP after craniectomy, and a furtherreduction to 15.7 � 10.7% of initial ICP after dural opening.

Polin et al. (51) showed a significant decrease in ICP afterbifrontal decompressive craniectomy, as well as a significantdifference in postoperative ICP when compared with ICPmeasured 48 to 72 hours after injury in a cohort of historicallymatched controls. Gower et al. (21) found that 7 of 10 patientswho underwent subtemporal decompression for medically re-fractory intracranial hypertension had an average decrease inICP of 34%. Kunze et al. (33) found a reduction in mean ICP from41.7 to 20.6 mm Hg in 28 patients after unilateral or bilateraldecompressive craniectomy for posttraumatic edema refractoryto maximal medical therapy. And Whitfield et al. (67) demon-strated a significant reduction of ICP from 37.5 to 18.1 mm Hg (P� 0.003) in 26 patients who underwent bifrontal decompressivecraniectomy for refractory intracranial hypertension managedusing a standardized ICP/cerebral perfusion pressure (CPP)treatment algorithm. The amplitude of the ICP waveform and ofslow waves were significantly reduced, and compensatory re-serve was significantly increased postoperatively in a subgroupof eight patients in this study. Munch et al. (45), however, failedto show a significant postoperative reduction in ICP or increasein CPP after unilateral hemispheric decompression. From a ra-diological perspective, however, this group found a significantimprovement in the visibility of mesencephalic cisterns and asignificant decrease in midline shift after decompressive craniec-tomy—both known to correlate with improved outcome. Fur-thermore, the change in cistern visibility correlated with thedistance between the lower craniectomy border and cranial base.Additionally, Alexander et al. (1) found an average increase in

intracranial volume of 26 cm3 in an analysis of CT scans inpatients with traumatic and nontraumatic lesions undergoingsubtemporal decompression. In contrast, experimental evidencefrom Cooper et al. (10) supports the notion that decompressiveprocedures may aggravate cerebral edema formation, thus, re-sulting in increased secondary injury. Such studies may helpexplain why, despite laboratory success, actual improvement inpatient outcome has not been consistently demonstrated.

Procedures and Outcome

There are several studies that suggest an important role fordecompressive procedures in the management of parenchy-mal injury. In a retrospective review of 28 patients undergoingunilateral or bilateral decompressive craniectomy for posttrau-matic edema and intracranial hypertension refractory to headelevation, moderate hyperventilation, osmodiuretics, barbitu-rates, tromethamine, and cerebrospinal fluid drainage, 57% ofpatients had good outcome or moderate disability at 1 year.However, the authors excluded patients with “vast” primarylesions, hypoxia, ischemic infarction, brainstem injury, “central”herniation, and primary anisocoria, thus, biasing results towardfavorable recovery (33). Nussbaum et al. (48) showed that com-plete temporal lobectomy performed within 2 hours of the de-velopment of clinical signs of transtentorial herniation in 10patients with unilateral hemispheric swelling and a GCS of lessthan 7 resulted in 40% functional independence. All patientsdemonstrated displacement of the brainstem, compression of thecontralateral peduncle, and progressive obliteration of the para-sellar and interpeduncular cisterns on CT scan, along with fixedpupillary dilation, and therefore, represent a particularly com-promised patient population.

Guerra et al. (23) prospectively performed decompressivecraniectomy following a standardized treatment protocol withstandardized surgical technique for posttraumatic diffusebrain swelling in 57 severe TBI patients (GCS, 4–6). Thirty-nine of these patients underwent primary decompression, and18 others underwent secondary decompression because ofpersistent intracranial hypertension after evacuation of a sur-gical mass lesion. Intracranial hypertension in these patientswas refractory to a standardized medical protocol that in-cluded hemodynamic stabilization, head elevation, sedationwith or without muscle relaxation, controlled hyperventilationto an arterial carbon dioxide pressure of 28 to 32 mm Hg,mannitol, tromethamine for acute rises in ICP, and electroen-cephalogram burst suppression with barbiturates. Fifty-eightpercent of the first group and 65% of the second group expe-rienced good outcome or moderate disability at 1 year. Theseresults compare favorably with published outcomes of alter-native second-tier therapy. However, a direct comparisonwith matched nonsurgical controls was not performed. Whit-field et al. (67) demonstrated a favorable outcome (GOS, 4–5)in 61% of a severe TBI population that underwent bifrontaldecompressive craniectomy for ICP greater than 30 mm Hgwith CPP less than 70 mm Hg, or for ICP greater than 35 mmHg, irrespective of CPP, despite a medical management pro-

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tocol that involved head elevation, propofol sedation, manni-tol and/or hypertonic saline, normocarbia, mild hypothermiato 33°C to 35°C, and electroencephalogram burst suppression.Only 55% of eligible patients, however, underwent craniec-tomy, and the reasons for nonsurgical management despiteeligibility were not documented or discussed.

Munch et al. (45) were able to show a significant differencein outcome between patients undergoing rapid decompressivecraniectomy and those undergoing delayed decompressivecraniectomy. However, the nature of the lesions differed be-tween the two groups, and, thus, the outcomes cannot bemeaningfully compared. Tseng (64) noted that the addition ofgentle elevation of the temporal lobe until the tentorium wasvisualized and CSF egress was noted decreased mortality andimproved the incidence of good outcome when comparedwith a standard craniotomy with hematoma evacuation andcontusion resection in a series of 32 severe TBI patients withanisocoria, hemiparesis, and CT evidence for uncal herniation.However, no statistical analysis was performed, and the au-thor notes that preoperative selection was biased and thatoperative timing and intraoperative judgements may haveinfluenced the choice of surgical procedure. Gower et al. (21)retrospectively studied 115 patients with admission GCS of 8or less who had adequate ICP monitoring data and no oper-ative mass lesion on admission. These patients were managedunder a standard treatment protocol. Outcome was comparedbetween 10 patients who underwent subtemporal decompres-sion and 17 patients managed by induction of pentobarbitalcoma. They found that subtemporal decompression affordedsignificantly lower mortality than pentobarbital coma, despitethe fact that the surgical group had a lower (but not statisti-cally significant) average admission GCS. However, 10 of thepatients treated medically had been determined not to beoperative candidates and subsequently died, greatly biasingresults in favor of the operative group. In a retrospectivereview of 29 patients undergoing operation for a combinationof acute subdural hematoma and severe contusion and swell-ing of the temporal lobe with uncal herniation, Lee et al. (34)documented a significant improvement in outcome with theaddition of temporal lobectomy to subtemporal decompres-sion and debridement of contused brain. Mortality decreasedfrom 56% to 8%, with a concomitant increase in average GOSfrom 2.2. to 4.0. These two surgical groups did not differ withrespect to preoperative GCS, age, or sex. However, patientswith intraoperative “overswelling,” defined as herniation ofbrain more than 2 cm above the craniectomy window, wereexcluded and underwent decompressive craniectomy withdural expansion, thus, potentially biasing these results.

Coplin et al. (11) retrospectively reviewed 29 consecutivepatients with GCS of at most 9 and CT scans with a midlineshift greater than the volume of a surgically amenable lesion toevaluate the safety and feasibility of decompressive craniec-tomy with duraplasty versus traditional craniotomy as theinitial surgical procedure. No significant differences in age,gender, admission GCS, time to surgery, or serum ethanolconcentration existed between the two groups. Despite a sig-

nificantly lower GCS at time of surgery and significantlygreater percentage of Diffuse Injury III and IV injuries (39),there was no significant difference in mortality, GOS, acutehospital length of stay, functional independence measurescore on admission to a rehabilitation unit, change in func-tional independence measure score, or length of rehabilitationstay between craniectomy and craniotomy groups. Althoughthis study is subject to the biases inherent in a retrospective,uncontrolled design, it strongly supports the safety of decom-pressive craniectomy as a first-line surgical intervention asopposed to its traditional role as a salvage procedure.

The studies briefly outlined here support the potential use-fulness of decompressive procedures, but are clearly ham-pered by inherent biases.

The study by Polin et al. (51) deserves particular mention,because it offers more concrete evidence that a decompressiveprocedure may result in improved patient outcome. Theseauthors report a retrospective evaluation of outcome in 35patients undergoing bifrontal decompressive craniectomy forrefractory posttraumatic cerebral edema matched for age, ad-mission GCS, sex, and maximal ICP with historical controlsselected from the Traumatic Coma Data Bank. Only patientswith Diffuse Injury III (39) were eligible as controls. Highestpostoperative ICP less than 24 hours after surgery in cases wasmatched with highest ICP 48 to 72 hours after injury in con-trols. Preoperative ICP in cases was matched with highest ICPless than 48 hours after injury in controls. Several findings areparticularly relevant. In the operative group, surgery per-formed less than 48 hours after injury was significantly asso-ciated with favorable outcome when compared with surgeryperformed longer than 48 hours after injury (46% versus 0%,respectively). Medical management alone carried a 3.8 timesrelative risk of unfavorable outcome compared with decom-pressive craniectomy. Maximum benefit was achieved in pa-tients undergoing decompression within 48 hours of injuryand whose ICP elevations had not yet been sustained above 40mm Hg (60% favorable outcome versus 18% in matched con-trols). This study argues strongly in favor of bifrontal decom-pressive craniectomy for patients with medically refractoryposttraumatic cerebral edema and resultant intracranial hy-pertension not yet sustained above 40 mm Hg within 48 hoursof injury, but does not have contemporaneous controls (51).

Overall, the literature suggests, but does not prove, that de-compressive procedures may be the intervention of choice giventhe appropriate clinical context. A recent study by Taylor et al.(61) examined the use of early (median 19.2 h after injury) bitem-poral craniectomy in addition to intensive medical managementversus intensive medical management alone in 27 children withsustained intracranial hypertension in a prospective, random-ized, controlled fashion. Their results showed a trend towardsgreater improvement in ICP, less time required in the intensivecare unit, and improved outcome with surgical decompression.These trends, although promising, did not reach statistical sig-nificance. Additional prospective, controlled studies are, thus,needed to strengthen the argument for the use of surgical de-

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compression in the management of intracranial hypertensionand refractory cerebral edema.

SUMMARY

The majority of studies regarding surgical treatment ofparenchymal lesions are case series. Only one prospectiveclinical trial of treatment using surgical versus nonsurgicalmanagement has been published (61). The majority of evi-dence indicates that the development of parenchymal masslesions, which are associated with progressive neurologicaldysfunction, medically refractory intracranial hypertension, orradiological signs of mass effect, are associated with a pooroutcome if treated nonsurgically. Specific surgical criteria,however, have not been firmly established.

Evidence also suggests that decompressive craniectomymay be the procedure of choice in patients with posttraumaticedema, hemispheric swelling, or diffuse injury, given the ap-propriate clinical context. This context has yet to be defined.

KEY ISSUES FOR FUTURE INVESTIGATION

The majority of studies on traumatic parenchymal lesions isobservational, and the studies offer no means to meaningfullycompare outcome between surgical and nonsurgical groups.Those studies that attempt this comparison fail to adequatelycontrol for known prognostic variables between surgicallyand nonsurgically managed groups in a prospective fashion.Prospective, controlled trials, such as that of Taylor et al. (61)need to be pursued and supported to define appropriate clin-ical criteria and surgical methods.

Additionally, the data of Coplin et al. (11) and Taylor et al.(61) strongly support the feasibility of performing trials ofdecompressive operations in the first instance, as opposed to asecond- or third-tier therapy for posttraumatic intracranialhypertension.

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TRAUMATIC PARENCHYMAL LESIONS

NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-33

TAB

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cy35

2080

No

resp

irat

ory

insu

ffici

ency

167

5743

Evac

uatio

n84

6238

Non

evac

uatio

n11

842

58

Age

0–2

0yr

5629

71

Age

21–

40yr

5467

33

Age

41–

64yr

4468

32

Age

�65

yr48

4258

GC

S3–

711

231

69

GC

S8

–11

4562

38

SURGICAL MANAGEMENT OF TBI AUTHOR GROUP

S2-34 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS/

D(%

)

GC

S12

–15

4587

13

Vol

ume

1–5

cm3

2681

19

Vol

ume

6–1

5cm

358

5743

Vol

ume

16–3

5cm

367

4654

Vol

ume

�36

cm3

5133

67

Neu

rolo

gica

lde

teri

orat

ion

135

4753

No

neur

olog

ical

dete

rior

atio

n49

8020

Initi

alG

CS

�4

200

100

Fron

tal

9348

52

Pari

etal

1250

50

Tem

pora

l63

6337

Occ

ipita

l9

6733

Cen

tral

2520

80

Cop

linet

al.

(11)

29III

GC

S3–

9D

ecom

pres

sive

cran

iect

omy

GO

Sat

disc

harg

e;FI

Mat

adm

issi

onan

ddi

scha

rge

from

reha

bilia

tion

Ret

rosp

ectiv

ere

view

of29

cons

ecut

ive

patie

nts

with

GC

S�

9an

dC

Tsc

ans

with

mid

line

shift

grea

ter

than

the

volu

me

ofa

surg

ical

lyam

enab

lele

sion

toev

alua

teth

esa

fety

and

feas

ibili

tyof

deco

mpr

essi

vecr

anie

ctom

yw

ithdu

rapl

asty

vers

ustr

aditi

onal

cran

ioto

my

asth

ein

itial

surg

ical

proc

edur

e.Ex

clus

ion

crite

ria

incl

uded

age

�16

yr,

inju

ry�

24h

befo

read

mis

sion

,D

iffus

eIn

jury

II(T

CD

Bcl

assi

ficat

ion)

,is

olat

edED

H,

pree

xist

ing

illne

sslim

iting

life

expe

ctan

cyto

�1

yrfr

omic

tus,

age

�40

yrw

ithex

tens

orpo

stur

ing,

and

bila

tera

lun

reac

tive

pupi

ls�

4m

min

diam

eter

.

●N

onsi

gnifi

cant

diffe

renc

ebe

twee

ncr

anio

tom

yan

dcr

anie

ctom

ygr

oups

with

rega

rds

toag

e(P

�0.

8),

gend

er(P

�1.

0),

adm

issi

onG

CS

scor

e(P

�0.

07),

time

tosu

rger

y(P

�1.

0),

seru

met

hano

lco

ncen

trat

ion

(P�

0.6)

.●

Cra

niec

tom

ygr

oup

had

sign

ifica

ntly

low

erG

CS

scor

eat

surg

ery

(P�

0.04

).●

Cra

niec

tom

ygr

oup

had

sign

ifica

ntly

mor

epa

tient

sw

ithD

iffus

eIn

jury

IIIan

dIV

(56%

vers

us9%

).●

No

sign

ifica

ntdi

ffere

nce

betw

een

grou

psw

ithre

spec

tto

mor

talit

y,G

OS,

acut

eho

spita

lle

ngth

ofst

ay,

initi

alFI

Msc

ore,

chan

gein

FIM

scor

e,or

leng

thof

reha

bilit

atio

nst

ay.

●D

espi

tesi

gnifi

cant

lylo

wer

GC

Sat

time

ofsu

rger

yan

dw

orse

inju

rycl

assi

ficat

ion

byC

Tsc

an,

deco

mpr

essi

vecr

anie

ctom

yw

ithdu

rapl

asty

affo

rded

equi

vale

ntou

tcom

eto

trad

ition

alcr

anio

tom

y,es

tabl

ishi

ngits

safe

tyan

dfe

asib

ility

asa

first

-lin

esu

rgic

alin

terv

entio

nas

oppo

sed

toits

trad

ition

alro

leas

a“s

alva

ge”

proc

edur

e.●

Aut

hors

emph

asiz

eim

port

ance

ofcr

anie

ctom

yex

tend

ing

dow

nto

the

floor

ofth

em

iddl

ecr

ania

lfo

ssa

atth

ero

otof

the

zygo

ma.

All

Cra

niot

omy

Cra

niec

tom

yP

valu

e

No.

ofpa

tient

s29

1712

Dis

char

geG

OS

44

40.

8

Mor

talit

y(%

)34

.541

.225

0.4

Hos

pita

lle

ngth

ofst

ay(d

)17

1818

0.4

Adm

issi

onFI

M63

6438

0.7

Dis

char

geFI

M90

9271

0.6

Cha

nge

inFI

M27

2723

1.0

Cor

addu

etal

.(1

2)37

IIIG

CS

3–5

to�

7St

ereo

tact

icev

acua

tion

Mor

talit

yat

disc

harg

eR

etro

spec

tive

seri

esof

37pa

tient

sw

ithtr

aum

atic

ICH

trea

ted

byst

ereo

tact

icev

acua

tion

thro

ugh

anen

larg

edbu

rrho

leto

eval

uate

outc

ome

usin

gth

iste

chni

que.

Surg

ical

indi

catio

nsin

clud

edco

ma,

dete

rior

atin

gco

nsci

ousn

ess,

orfo

cal

neur

olog

ical

defic

it.

●N

om

orta

lity

with

adm

issi

onG

CS

�7.

●A

dmis

sion

GC

Sre

late

din

vers

ely

tom

orta

lity

(no

stat

istic

s).

●Te

mpo

ral

loca

tion

had

high

erm

orta

lity

(no

stat

istic

s).

No.

ofpa

tien

tsD

(%)

ICH

,to

tal

3730

GC

S3–

510

80

GC

S6

–712

25

GC

S�

715

0

Fron

tal

185.

5

Tem

pora

l18

55

TRAUMATIC PARENCHYMAL LESIONS

NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-35

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

De

Luca

etal

.(1

4)22

IIIG

CS

3–12

Dec

ompr

essi

vecr

anie

ctom

yG

OS

atdi

scha

rge

Ret

rosp

ectiv

ere

view

of22

patie

nts

who

unde

rwen

tde

com

pres

sive

cran

iect

omy

for

cere

bral

edem

aw

ithre

frac

tory

intr

acra

nial

hype

rten

sion

orfo

r�i

mm

inen

the

rnia

tion�

duri

ngth

eev

acua

tion

ofa

spac

e-oc

cupy

ing

trau

mat

icle

sion

.Su

rgic

alm

etho

dsar

ede

scri

bed.

No.

ofpa

tien

tsG

R/M

D(%

)SD

(%)

VS

(%)

D(%

)

Dec

ompr

essi

vecr

anie

ctom

y22

4118

2318

Dia

zet

al.

(15)

9III

Unk

now

nSu

rger

yM

orta

lity

atdi

scha

rge

Ret

rosp

ectiv

ese

ries

of9

patie

nts

with

DTI

CH

toev

alua

tecl

inic

alch

arac

teri

stic

san

dou

tcom

e.

●55

.6%

mor

talit

y.●

Incl

uded

with

n�

9fo

rw

ell-

pres

ente

dda

taon

DTI

CH

.●

Def

initi

onof

DTI

CH

:1)

hist

ory

ofhe

adin

jury

with

head

inm

otio

npr

oduc

ing

tran

sien

tor

perm

anen

tLO

C,

foca

lne

urol

ogic

alfin

ding

s,or

cran

ial

frac

ture

;2)

inte

rval

betw

een

inju

ryan

dde

velo

pmen

tof

DTI

CH

of�

2w

k.

No.

ofpa

tien

tsD

(%)

DTI

CH

955

.6

Gaa

bet

al.

(17)

37III

Unk

now

nD

ecom

pres

sive

cran

iect

omy

GO

S1

yrPr

ospe

ctiv

ese

ries

of37

patie

nts

who

unde

rwen

tde

com

pres

sive

cran

iect

omy

beca

use

oftr

aum

atic

brai

nsw

ellin

gto

asse

ssef

ficac

yof

trea

tmen

tpr

otoc

olat

1yr

afte

rtr

aum

a.Su

rgic

alin

dica

tions

and

excl

usio

ncr

iteri

ade

taile

d.

●14

.7%

mor

talit

yus

ing

stan

dard

ized

prot

ocol

.●

Initi

alG

CS

�6,

day

1G

CS

�8

asso

ciat

edw

ithbe

tter

outc

ome

(no

stat

istic

s).

●A

llpa

tient

sw

ithG

OS

1–2

had

GC

S3

with

pupi

llary

abno

rmal

ity.

●R

epre

sent

sea

rly

repo

rtof

Gue

rra

etal

.st

udy.

No.

ofpa

tien

tsFu

ll(%

)D

isab

led

(%)

VS

(%)

D(%

)

Dec

ompr

essi

vecr

anie

ctom

y34

41.2

35.3

8.8

14.7

Gen

nare

lliet

al.

(19)

1107

IIIG

CS

3–8

Surg

ery

and

nons

urgi

cal

GO

S3

mo

Mul

ticen

ter

pros

pect

ive

seri

esof

1107

patie

nts

with

seve

rebl

unt

trau

mat

icbr

ain

inju

ry(G

CS

�8)

toex

amin

edi

ffere

nces

inty

peof

inju

ry,

seve

rity

ofin

jury

,an

dG

OS

at3

mo.

Subg

roup

sof

patie

nts

with

�oth

erfo

cal

inju

ry�

(n�

205)

and

�diff

use

inju

ry�

(n�

487)

wer

eex

amin

edfo

rth

isch

apte

r.O

fno

te,

�oth

erfo

cal

inju

ry�

incl

uded

ICH

,co

ntus

ions

,bu

tal

sode

pres

sed

cran

ial

frac

ture

,SD

H,

and

EDH

that

wer

eno

tth

epr

imar

yle

sion

s,an

dco

mbi

ned

EDH

/SD

Hin

whi

chth

em

ost

impo

rtan

tle

sion

was

unkn

own.

●Lo

wer

GC

Sw

asst

rong

lyco

rrel

ated

with

wor

seou

tcom

efo

rea

chle

sion

type

.●

Giv

enth

esa

me

pres

entin

gG

CS,

lesi

onty

pes

diffe

red

mar

kedl

yw

ithre

spec

tto

outc

ome.

●A

utho

rsm

ain

poin

tis

that

outc

ome

diffe

rsm

arke

dly

amon

gle

sion

type

sw

ithin

the

real

mof

seve

rehe

adin

jury

,an

dth

atou

tcom

ede

pend

sin

part

onty

peof

lesi

onas

wel

las

onin

jury

seve

rity

asm

easu

red

byG

CS.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

Oth

erfo

cal

lesi

on,

tota

l20

521

1819

339

GC

S3–

511

27

1418

456

GC

S6

–8

9338

2319

218

Ope

rate

d71

2115

204

39

Ope

rate

d,G

CS

3–5

359

920

657

Ope

rate

d,G

CS

6–

836

3322

193

22

Non

oper

ated

134

2119

183

39

Non

oper

ated

,G

CS

3–5

776

1717

456

Diff

use

inju

ry,

tota

l48

734

1711

532

GC

S3–

523

716

1014

851

GC

S6

–8

250

5224

92

13

Com

a6

–24

h92

6315

21

15

Com

a6

–24

h,G

CS

3–5

2752

77

430

Com

a6

–24

h,G

CS

6–

865

6818

50

9

Com

a�

24h

395

2817

136

36

SURGICAL MANAGEMENT OF TBI AUTHOR GROUP

S2-36 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

Com

a�

24h,

GC

S3–

521

011

1015

954

Com

a�

24h,

GC

S6

–8

185

4625

103

15

Com

a�

24h,

not

dece

rebr

ate

219

3821

125

24

Com

a�

24h,

not

dece

rebr

ate,

GC

S3–

577

218

1312

47

Com

a�

24h,

not

dece

rebr

ate,

GC

S6

–8

142

4729

111

11

Com

a�

24h,

dece

rebr

ate

176

1513

147

51

Com

a�

24h,

dece

rebr

ate,

GC

S3–

513

66

1216

957

Com

a�

24h,

dece

rebr

ate,

GC

S6

–8

4048

158

328

Gen

tlem

anet

al.

(20)

23III

Com

ave

rsus

not

com

a

Surg

ery

and

nons

urgi

cal

GO

S6

mo

Ret

rosp

ectiv

ere

view

of27

01he

ad-i

njur

edpa

tient

sdi

still

edto

aco

hort

of23

patie

nts

with

DTI

CH

.V

olum

eof

hem

atom

aan

dtim

ing

ofre

peat

CT

scan

are

rela

ted

tom

anag

emen

t.O

pera

tive

vers

usno

nope

rativ

em

anag

emen

tis

rela

ted

toG

OS

at6

mo.

●O

pera

tive

vers

usno

nope

rativ

ele

sion

sdi

ffere

din

aver

age

volu

me

(24

vers

us7

cm3 )

and

time

tore

peat

CT

base

don

clin

ical

crite

ria

(41

vers

us99

h).

Out

com

ebe

twee

ngr

oups

was

not

stat

istic

ally

sign

ifica

nt.

●39

%of

DTI

CH

requ

ied

evac

uatio

n;cr

iteri

ano

tde

scri

bed.

●A

llpa

tient

sw

ithD

TIC

Hha

dab

norm

alC

Ton

adm

issi

on.

●D

efin

ition

ofD

TIC

H:

�les

ion

ofin

crea

sed

atte

nuat

ion

deve

lopi

ngaf

ter

adm

issi

onto

hosp

ital,

ina

part

ofth

ebr

ain

whi

chth

ead

mis

sion

CT

scan

had

sugg

este

dw

asno

rmal

.�

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS/

D(%

)

Ope

rate

dD

TIC

H9

5644

b

Non

oper

ated

DTI

CH

1457

43

DTI

CH

,to

tal

2357

43b

P�

n.s.

Gow

eret

al.

(21)

10III

GC

S�

8Su

btem

pora

lde

com

pres

sion

vers

uspe

ntob

arbi

tal

com

a

Mor

talit

y1

yrR

etro

spec

tive

seri

esof

115

patie

nts

with

GC

S�

8w

ithno

oper

ativ

em

ass

lesi

onat

time

ofad

mis

sion

man

aged

ona

stan

dard

trea

tmen

tpr

otoc

ol.

10pa

tient

sun

derw

ent

subt

empo

ral

deco

mpr

essi

onbe

caus

eof

med

ical

lyre

frac

tory

intr

acra

nial

hype

rten

sion

,an

dou

tcom

ew

asco

mpa

red

with

thos

epa

tient

sm

anag

edby

pent

obar

bita

lco

ma

with

out

surg

ery.

Tech

niqu

ede

scri

bed.

●Pa

tient

sun

derg

oing

subt

empo

ral

deco

mpr

essi

onha

dsi

gnifi

cant

lylo

wer

mor

talit

yth

anth

ose

trea

ted

with

pent

obar

bita

lco

ma

desp

iteha

ving

low

er(b

utno

tst

atis

tical

lysi

gnifi

cant

)av

erag

ead

mis

sion

GC

S(4

.9ve

rsus

6.1)

.H

owev

er,

10pa

tient

sun

derg

oing

pent

obar

bita

lco

ma

wer

ede

term

ined

not

tobe

oper

ativ

eca

ndid

ates

and

subs

eque

ntly

died

;bi

ases

resu

ltsin

favo

rof

oper

ated

grou

p.●

70%

ofop

erat

edpa

tient

sha

dav

erag

ede

crea

sein

ICP

of34

%.

No.

ofpa

tien

tsD

(%)

Pent

obar

bita

lco

ma

1782

.4

Subt

empo

ral

deco

mpr

essi

on10

40c

cP

�0.

039.

Gud

eman

etal

.(2

2)III

12G

CS

4–1

0Su

rger

yan

dno

nsur

gica

lG

OS

3m

o,1

yrPr

ospe

ctiv

est

udy

of16

2pa

tient

sw

ithse

vere

head

inju

ry,

12of

who

mde

velo

ped

DTI

CH

byC

Tsc

an.

Thes

epa

tient

sw

ere

anal

yzed

for

clin

ical

asso

ciat

ions

and

outc

omes

tobe

tter

unde

rsta

ndth

isle

sion

.

●92

%D

TIC

Hde

tect

ed�

48h

from

inju

ry.

●50

%de

velo

ped

afte

rde

com

pres

sive

surg

ery.

●D

TIC

Hha

d50

%m

orta

lity;

high

erbu

tno

tst

atis

tical

lysi

gnifi

cant

com

pare

dw

ithal

lse

vere

head

inju

ries

duri

ngth

esa

me

peri

od.

●Si

gnifi

cant

lyhi

gher

inci

denc

eof

seco

ndar

ysy

stem

icin

sults

attim

eof

adm

issi

onin

DTI

CH

patie

nts

vers

usal

lse

vere

CH

Ipa

tient

s(9

2%ve

rsus

44%

).●

No

sign

ifica

ntte

mpo

ral

rela

tions

hip

betw

een

deve

lopm

ent

ofD

TIC

H,

ICP

leve

ls,

neur

olog

ical

chan

ge.

●A

utho

rsbe

lieve

that

deve

lopm

ent

ofD

TIC

His

anep

iphe

nom

enon

ofse

cond

ary

insu

ltto

ada

mag

edbr

ain

asop

pose

dto

aca

usat

ive

fact

orfo

rne

urol

ogic

alde

teri

orat

ion—

thus

,tr

eatm

ent

shou

ldbe

aim

edat

prev

entio

nof

seco

ndar

yhy

poxi

cin

sults

.

●D

efin

ition

ofD

TIC

H:

new

pare

nchy

mal

high

dens

ityle

sion

whe

nno

lesi

onor

ane

glig

ible

abno

rmal

ityw

aspr

esen

ton

initi

alC

T.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

DTI

CH

1225

250

050

TRAUMATIC PARENCHYMAL LESIONS

NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-37

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Gue

rra

etal

.(2

3)57

IIIG

CS4

–6

Dec

ompr

essi

vecr

anie

ctom

yG

OS

1yr

Pros

pect

ive

seri

esof

57pa

tient

sw

houn

derw

ent

deco

mpr

essi

vecr

anie

ctom

yun

der

ast

anda

rdiz

edtr

eatm

ent

prot

ocol

and

stan

dard

ized

surg

ical

tech

niqu

efo

rpo

sttr

aum

atic

diffu

sebr

ain

swel

ling.

The

patie

nts

wer

edi

vide

din

toa

grou

pun

derg

oing

prim

ary

deco

mpr

essi

on(n

�39

)an

da

grou

pun

derg

oing

seco

ndar

yde

com

pres

sion

beca

use

ofth

erap

y-re

sist

ant

intr

acra

nial

hype

rten

sion

afte

rev

acua

tion

ofa

surg

ical

mas

sle

sion

(n�

18).

Surg

ical

indi

catio

nsan

dm

etho

dsar

ede

taile

d.Pa

tient

sw

ithG

CS

3an

d/or

bila

tera

lfix

ed/

dila

ted

pupi

lsw

ere

excl

uded

.A

ge�

30yr

,�

40yr

,an

d�

50yr

vari

ably

used

asex

clus

ion

crite

ria

thro

ugho

utst

udy.

●37

%G

OS

5,19

%m

orta

lity

over

all.

●G

CS

onpo

sttr

aum

ada

y1

pred

ictiv

eof

outc

ome.

●Si

gnifi

cant

lybe

tter

outc

ome

with

nolo

ssof

Bw

aves

and

pres

ence

ofpl

atea

uw

aves

onIC

Pm

onito

ring

.●

Incl

usio

nof

SEP,

ICP/

CPP

,an

dA

EPm

onito

ring

tech

niqu

eshe

lped

tode

fine

indi

catio

nsfo

rth

eau

thor

s.●

Aut

hors

conc

lude

that

deco

mpr

essi

vecr

anie

ctom

ysh

ould

be1s

tam

ong

seco

nd-t

ier

ther

apie

sfo

rre

sist

ant

intr

acra

nial

hype

rten

sion

.

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS/

D(%

)

Prim

ary

deco

mpr

essi

on38

5842

Seco

ndar

yde

com

pres

sion

1765

35P

�n.

s.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

All

patie

nts

5537

2111

919

Kat

ayam

aet

al.

(28)

21III

Unk

now

nSu

rger

yan

dno

nsur

gica

lM

orta

lity

Ret

rosp

ectiv

eca

seco

ntro

lst

udy

of21

patie

nts

with

fron

tal

lobe

cont

usio

nsan

dm

edic

ally

intr

acta

ble

intr

acra

nial

hype

rten

sion

�40

mm

Hg,

com

pari

ngm

orta

lity

betw

een

the

grou

ptr

eate

dm

edic

ally

(n�

8)an

dth

egr

oup

trea

ted

with

surg

ical

evac

uatio

nof

cont

used

brai

n(n

�13

).A

utho

rsst

ate

that

age,

sex,

GC

S,an

dIC

Ple

vels

wer

eco

mpa

rabl

ebe

twee

ngr

oups

,bu

tdo

not

prov

ide

stat

istic

s.

●M

orta

lity

was

sign

ifica

ntly

decr

ease

din

the

surg

ical

grou

p(2

2%ve

rsus

88%

).●

Aut

hors

note

that

prog

ress

ive

ICP

incr

ease

and

neur

olog

ical

dete

rior

atio

nof

ten

cont

inue

dpa

stth

etim

ing

ofm

axim

alen

larg

emen

tof

intr

acer

ebra

lle

sion

son

CT.

●A

utho

rsad

voca

tesu

rgic

alex

cisi

onof

cont

used

brai

nin

the

setti

ngof

med

ical

lyun

cont

rolla

ble

ICP

elev

atio

n.

No.

ofpa

tien

tsD

(%)

Non

oper

ativ

e8

88

Surg

ery

1322

d

dP

�0.

01

Kau

fman

etal

.(2

9)8

IIIA

llGC

SSu

rger

yan

dno

nsur

gica

lM

orta

lity

atdi

scha

rge

Ret

rosp

ectiv

ese

ries

of12

patie

nts

with

DTI

CH

orre

curr

ent

hem

atom

aaf

ter

head

inju

ryto

exam

ine

the

asso

ciat

ion

ofdi

ssem

inat

edin

trav

ascu

lar

clot

ting

and

fibri

noly

sis

with

occu

rren

ceof

thes

ele

sion

s.A

subs

etof

8pa

tient

sw

ithD

TIC

Hw

asev

alua

ted

for

this

chap

ter.

●7

of8

DTI

CH

patie

nts

had

abno

rmal

clot

ting

para

met

ers.

●In

clud

edw

ithn

�8

beca

use

ofpr

esen

tatio

nof

data

and

eval

uatio

nof

clot

ting

para

met

ers.

No.

ofpa

tien

tsD

(%)

Clo

ttin

gab

norm

alit

ies

(%)

DTI

CH

,to

tal

837

.587

.5

Kot

wic

aan

dJa

kubo

wsk

i(3

1)48

IIIA

llGC

SSu

rger

yan

dno

nsur

gica

lG

OS,

not

spec

ified

Ret

rosp

ectiv

ese

ries

of13

6pa

tient

sag

ed70

–91

yrw

ithTB

Ito

eval

uate

outc

ome

from

TBI

inan

aged

popu

latio

n.48

patie

nts

with

ICH

/con

tusi

onre

view

ed.

●O

vera

llm

orta

lity

from

ICH

/con

tusi

ons

was

50%

;8

of13

inop

erat

edca

ses,

and

16of

35in

nono

pera

ted

case

s.●

Mor

talit

yco

rrel

ated

with

adm

issi

onG

CS

(no

stat

istic

s).

●A

utho

rsfe

elth

atbe

caus

eth

em

orta

lity

rate

for

patie

nts

�70

yrw

ithG

CS

�9

isso

high

(�80

%),

limite

dat

tem

pts

shou

ldbe

mad

eat

resu

scita

tion,

inte

nsiv

eca

re,

and

surg

ery.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

ICH

�co

ntus

ion,

surg

ery

137.

77.

715

.47.

761

.5

ICH

�co

ntus

ion,

nosu

rger

y35

11.4

11.4

22.9

8.6

45.7

SURGICAL MANAGEMENT OF TBI AUTHOR GROUP

S2-38 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Kum

chev

etal

.(3

2)79

IIIG

CS

3–6

to12

–15

Surg

ery

and

nons

urgi

cal

Mor

talit

yR

etro

spec

tive

revi

ewof

79pa

tient

sw

ithin

trac

ereb

ral

hem

atom

as,

com

pari

nglo

catio

nof

hem

atom

aw

ithm

orta

lity,

and

outc

ome

ofsu

rger

yve

rsus

nons

urgi

cal

ther

apy.

Trea

tmen

tpr

otoc

olw

asno

tst

anda

rdiz

ed;

surg

ical

indi

catio

nsw

ere

not

repo

rted

.

●Th

ose

patie

nts

with

tem

pora

lIC

Hw

ere

mor

elik

ely

todi

e.●

Surg

ery

did

not

alte

rm

orta

lity.

Surg

ical

lym

anag

edpa

tient

sw

ere

mor

elik

ely

tosh

owcl

inic

alim

prov

emen

t.

Loca

tion

No.

ofpa

tien

tsD

(%)

Pva

lues

Fron

tal

166

�0.

001

Tem

pora

l36

57.6

�0.

01

Pari

eto-

occi

pita

l14

18.2

�0.

01

Mul

tiple

site

s13

18.2

�0.

01

Kun

zeet

al.

(33)

28III

All

GC

SD

ecom

pres

sive

cran

iect

omy

GO

S1

yrR

etro

spec

tive

stud

yof

28pa

tient

sun

derg

oing

uni/b

ilate

ral

deco

mpr

essi

vecr

anie

ctom

yfo

rpo

sttr

aum

atic

edem

aaf

ter

�max

imal

�m

edic

alth

erap

y.

●57

%ov

eral

lfa

vora

ble

outc

ome

(GO

S4

–5)

at1

yr.

●M

ean

ICP

decr

ease

dfr

om41

.7to

20.6

mm

Hg

afte

rde

com

pres

sion

.●

Patie

nts

with

“vas

t”pr

imar

yle

sion

s,hy

poxi

a,is

chem

icin

farc

tion,

brai

nste

min

jury

,“c

entr

al”

hern

iatio

n,an

dpr

imar

yan

isoc

oria

excl

uded

.

No.

ofpa

tien

tsG

R/M

D(%

)SD

(%)

VS

(%)

D(%

)

Dec

ompr

essi

vecr

anie

ctom

y28

5718

1411

Lee

etal

.(3

4)29

IIIG

CS

�8

Subt

empo

ral

deco

mpr

essi

on�

tem

pora

llo

bect

omy

GO

S1

yrR

etro

spec

tive

seri

esof

29pa

tient

sop

erat

edon

for

acut

eSD

Han

dse

vere

cont

usio

n/sw

ellin

gof

tem

pora

llo

bew

ithun

cal

hern

iatio

n.16

patie

nts

unde

rwen

tsu

btem

pora

lde

com

pres

sion

and

debr

idem

ent

ofco

ntus

edbr

ain

whe

reas

13su

bseq

uent

patie

nts

unde

rwen

tte

mpo

ral

lobe

ctom

yin

addi

tion.

Thes

etw

ogr

oups

wer

eco

mpa

red

with

resp

ect

toou

tcom

eat

1yr

orlo

nger

.

●A

dditi

onof

tem

pora

llo

bect

omy

tosu

btem

pora

lde

com

pres

sion

and

debr

idem

ent

ofco

ntus

edbr

ain

sign

ifica

ntly

decr

ease

dm

orta

lity

from

56%

to8%

and

sign

ifica

ntly

impr

oved

aver

age

GO

Sfr

om2.

2to

4.0.

Preo

pera

tive

GC

S,ag

e,an

dse

xw

ere

not

sign

ifica

ntly

diffe

rent

betw

een

grou

ps.

●In

cide

nce

ofm

otor

reco

very

,co

gniti

vede

ficits

,an

dse

izur

esw

ere

not

sign

ifica

ntly

diffe

rent

betw

een

grou

ps.

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS/

D(%

)D

(%)

STD

,deb

ridem

ent

1625

7556

STD

,de

brid

emen

t,TL

1377

238e

STD

,de

brid

emen

t,co

mpl

ete

TL10

100

00

STD

,de

brid

emen

t,an

teri

orTL

30

100

33

eP

�0.

01.

Loba

toet

al.

(35)

277

IIIG

CS

3–7

Surg

ery

and

nons

urgi

cal

GO

S6

mo

Pros

pect

ive

seri

esof

277

seve

rely

head

-in

jure

dpa

tient

scl

assi

fied

byC

Tsc

anin

to8

inju

ryty

pes

toex

amin

eG

OS

at6

mo

rela

ted

tole

sion

type

.IC

Pw

asm

onito

red

inal

lpa

tient

s.Pa

tient

sbr

ain

dead

onar

riva

lw

ere

excl

uded

.A

stan

dard

ized

man

agem

ent

prot

ocol

was

used

and

isde

scri

bed.

GC

S,IC

P,an

din

terv

alto

oper

atio

nva

ried

betw

een

CT

grou

ps.

●Pa

tient

sw

ithpu

reex

trac

ereb

ral

hem

atom

a,si

ngle

brai

nco

ntus

ion,

gene

ral

brai

nsw

ellin

g,an

dno

rmal

CT

scan

sha

da

sign

ifica

ntly

bette

rou

tcom

eth

anpa

tient

sw

ithex

trac

ereb

ral

hem

atom

aan

dac

ute

hem

isph

eric

swel

ling,

mul

tiple

brai

nco

ntus

ions

,an

dpa

tient

sw

ithdi

ffuse

axon

alin

jury

.●

Acu

tehe

mis

pher

icsw

ellin

gsi

gnifi

cant

lyin

crea

sed

mor

talit

y.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

Sing

leco

ntus

ion

(SC

)25

728

44

12

SC�

EDH

714

860

00

SC�

SDH

1315

4615

023

MU

C20

015

100

75

MU

C�

SDH

120

178

075

Mul

tiple

bila

tera

lco

ntus

ion

4219

265

050

GB

S25

768

40

12

GB

S�

EDH

1688

60

06

DA

I43

59

2112

53

Nor

mal

CT

2839

2918

114

TRAUMATIC PARENCHYMAL LESIONS

NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-39

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Loba

toet

al.

(36)

587

IIIG

CS

3–8

Surg

ery

and

nons

urgi

cal

GO

S6

mo

Ret

rosp

ectiv

ese

ries

of58

7pa

tient

sw

ithG

CS�

8an

dat

leas

ton

eco

ntro

lC

Tsc

an(a

vera

ge36

.7h

afte

rin

itial

CT)

toev

alua

tein

cide

nce

ofch

ange

sin

CT

clas

sific

atio

nov

ertim

ean

dto

asse

ssth

ere

lativ

epr

ogno

stic

sign

ifica

nce

ofa

seco

ndC

Tsc

anve

rsus

the

first

.

●51

.2%

deve

lope

dsi

gnifi

cant

CT

chan

ges

requ

irin

gch

ange

indi

agno

stic

cate

gory

.●

Fina

lou

tcom

ew

asm

ore

accu

rate

lypr

edic

ted

byco

ntro

lC

Tdi

agno

sis

than

byin

itial

CT

diag

nosi

s.●

19%

ofdi

ffuse

inju

ries

evol

ved

tom

ass

lesi

ons.

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS

(%)

D(%

)

Diff

use

inju

ryI

2475

8.3

16.6

Diff

use

inju

ryII

247

54.6

19.4

25.9

Diff

use

inju

ryIII

123

20.3

10.5

69.1

Diff

use

inju

ryIV

2516

480

Man

dera

etal

.(3

7)31

IIIG

CS

3–8

to13

–15

Surg

ery

and

nons

urgi

cal

GO

S,no

tsp

ecifi

edR

etro

spec

tive

stud

yof

31ch

ildre

nw

ithtr

aum

atic

ICH

toex

amin

efa

ctor

sre

late

dto

surg

ical

deci

sion

mak

ing

and

asse

ssou

tcom

e.

●O

utco

me

did

not

diffe

rbe

twee

nsu

rgic

alan

dco

nser

vativ

egr

oups

desp

iteth

efa

ctth

atm

ore

patie

nts

with

seve

rein

jury

wer

etr

eate

dsu

rgic

ally

.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

Surg

ery

2035

2030

015

Non

surg

ical

1145

1818

018

Mar

shal

l(3

9)41

4III

GC

S3–

8N

onsu

rgic

alG

OS

11d–

2yr

Pros

pect

ive

seri

esof

746

patie

nts

from

TCD

Bto

iden

tify

patie

nts

atri

skfo

rde

velo

ping

intr

acra

nial

hype

rten

sion

inth

eab

senc

eof

sign

ifica

ntm

ass

lesi

ons

onin

itial

CT.

The

auth

ors

prop

ose

ane

wcl

assi

ficat

ion

ofhe

adin

jury

base

don

CT

and

rela

teth

ene

wcl

assi

ficat

ion

cate

gori

esto

outc

ome.

Non

surg

ical

diffu

sein

jury

cate

gori

esar

ein

clud

ed.

●C

Tdi

agno

sis

was

ahi

ghly

sign

ifica

ntin

depe

nden

tpr

edic

tor

ofm

orta

lity

whe

nag

ean

dm

otor

scor

ew

ere

incl

uded

inth

em

odel

.●

InD

iffus

eIn

jury

III,

high

est

ICP

and

post

resu

scita

tion

pupi

llary

reac

tivity

wer

esi

gnifi

cant

pred

icto

rsof

outc

ome.

Mar

shal

let

al.

(40)

502

IIIG

CS

3–8

Surg

ery

(ICH

)an

dno

nsur

gica

l(D

iffus

eIn

jury

I–IV

)

GO

S11

d–2

yrPr

ospe

ctiv

ese

ries

of74

6pa

tient

sse

lect

edfr

omTC

DB

toas

sess

impo

rtan

ceof

prog

nost

icva

riab

les

inde

term

inin

gou

tcom

efr

omse

vere

head

inju

ry.

Subg

roup

sof

nono

pera

ted

patie

nts

with

Diff

use

Inju

rypa

ttern

sI–

IVan

dpa

tient

sw

ithev

acua

ted

ICH

are

incl

uded

.

●90

%of

deat

hsoc

curr

edw

ithin

2w

k.●

Intr

acra

nial

diag

nosi

sst

rong

lyco

rrel

ated

with

outc

ome;

e.g.

,hi

gher

%of

Diff

use

Inju

ryIII

/IVpa

tient

sw

ere

vege

tativ

e.●

InD

iffus

eIn

jury

IIgr

oup,

age

�40

yrst

rong

lyco

rrel

ated

with

poor

outc

ome.

●G

OS

for

evac

uate

dIC

Hpa

tient

sco

rrel

ated

nega

tivel

ywith

age

�40

yr.

●Fo

ral

lpa

tient

s,po

stre

susc

itatio

nG

CS,

pupi

llary

reac

tivity

,an

dag

eco

rrel

ated

with

outc

ome.

CT

diag

nosi

sf

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

Diff

use

Inju

ryI

5227

34.6

19.2

9.6

9.6

Diff

use

Inju

ryII

177

8.5

2640

.711

.313

.5

Diff

use

Inju

ryIII

153

3.3

13.1

26.8

22.9

34

Diff

use

Inju

ryIV

323.

13.

118

.818

.856

.2

Diff

use

Inju

ryII,

age

�40

yr15

310

28.7

41.1

11.1

9.1

Diff

use

Inju

ryII,

age

�40

yr24

08.

337

.512

.541

.7

fP

�0.

001

SURGICAL MANAGEMENT OF TBI AUTHOR GROUP

S2-40 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Mat

hies

enet

al.

(41)

218

IIIM

ean

GC

S6.

9Su

rger

yan

dno

nsur

gica

lG

OS

6m

oR

etro

spec

tive

revi

ewof

data

accu

mul

ated

inpr

ospe

ctiv

e,ra

ndom

ized

,do

uble

-blin

dH

IT-2

stud

yon

nim

odip

ine

inhe

adin

jury

.21

8pa

tient

sno

tfo

llow

ing

com

man

dsw

ithin

24h

oftr

aum

aw

ithin

trac

ereb

ral

lesi

ons

only

onC

Tw

ere

chos

enfo

ran

alys

is.

Patie

nts

with

extr

acer

ebra

lle

sion

s,no

rmal

CT,

guns

hot

wou

nds,

preg

nanc

y,bi

late

rally

fixed

/dila

ted

pupi

ls,

GC

S3

for

�2

h,an

dpr

evio

usdr

ugad

min

istr

atio

nin

terf

erin

gw

ithne

urol

ogic

alas

sess

men

tw

ere

excl

uded

.C

linic

alm

anag

emen

tw

asno

tst

anda

rdiz

ed.

Patie

nts

wer

edi

vide

din

to4

subg

roup

sba

sed

onC

Tap

pear

ance

with

in24

hof

trau

ma:

1)co

ntus

ions

;2)

frac

ture

cont

usio

ns(d

irec

tlyun

derl

ying

depr

esse

dfx

);3)

DA

I;an

d4)

ICH

(�10

cm3 ),

and

anal

yzed

with

resp

ect

toG

OS

at6

mo.

Asu

bgro

upof

patie

nts

with

GC

S�

6an

dle

sion

�20

cm3

wer

ean

alyz

edfo

rth

eef

fect

ofsu

rger

yan

dtim

ing

ofsu

rger

yon

outc

ome.

Asu

bgro

upof

patie

nts

who

�tal

ked

and

died

�w

ere

anal

yzed

tode

term

ine

the

valu

eof

earl

ysu

rger

y.

●In

itial

CT

char

acte

rist

ics

asso

ciat

edw

ithne

urol

ogic

alde

teri

orat

ion,

defin

edas

fall

inG

CS

by2,

GC

Sfr

om4

to3,

orpu

pilla

rydi

lata

tion,

wer

eSA

H,

foca

lle

sion

with

volu

me

�40

cm3 ,

and

com

pres

sed/

abse

ntci

ster

ns.

●Se

cond

ary

(�5

d)de

teri

orat

ion

corr

elat

edw

ithSA

Hon

initi

alC

T,hy

poxi

cev

ents

.●

For

the

4gr

oups

:1)

Con

tusi

ons:

outc

ome

adve

rsel

yaf

fect

edby

pres

ence

ofIV

H.

2)Fr

actu

re/c

ontu

sion

s:ou

tcom

esi

gnifi

cant

lyw

orse

than

othe

rgr

oups

;ou

tcom

ead

vers

ely

affe

cted

bypr

esen

ceof

SAH

.3)

DA

I:m

ean

adm

issi

onG

CS

sign

ifica

ntly

wor

seth

anot

her

grou

ps.N

opa

tient

sop

erat

ed.

4)IC

H:m

ean

adm

issi

onG

CS

sign

ifica

ntly

bette

rth

anot

her

grou

ps;o

utco

me

adve

rsel

yaf

fect

edby

pres

ence

ofIV

H.

●Pa

tient

sw

ithle

sion

s�

20cm

3an

dad

mis

sion

GC

S�

6:1)

Patie

nts

oper

ated

with

outp

revi

ous

dete

riora

tion

(n�

9)ha

dbe

tter

outc

ome

than

thos

eno

top

erat

edon

orop

erat

edon

afte

rde

terio

ratio

n(n

�66

).2)

Patie

nts

with

radi

olog

ical

sign

sof

mas

sef

fect

(com

pres

sion

/obl

itera

tion

ofci

ster

nan

d/or

mid

line

shift

�5

mm

)had

bette

rou

tcom

ew

ithsu

rger

yve

rsus

nosu

rger

y,an

dth

ose

oper

ated

befo

rede

terio

ratio

nha

dbe

tter

outc

ome

than

thos

eop

erat

edaf

ter

dete

riora

tion.

3)Su

rger

ydi

dno

tinf

luen

ceou

tcom

ein

patie

nts

adm

itted

with

GC

S�

5.●11

patie

nts

with

tem

pora

lcon

tusi

on,r

adio

logi

cals

igns

ofm

ass

effe

ct,a

dmis

sion

GC

S�

10:

outc

ome

sign

ifica

ntly

bette

rin

thos

eop

erat

edbe

fore

orim

med

iate

lyaf

ter

dete

riora

tion

com

pare

dw

ithde

laye

dor

nosu

rger

y.●A

utho

rspo

ints

:1)

Patie

nts

with

front

alor

tem

pora

lcon

tusi

ons

with

mid

line

shift

orci

ster

nalc

ompr

essi

onha

dst

atis

tical

lybe

tter

outc

ome

with

surg

ery.

2)Su

rgic

alou

tcom

ew

asbe

tter

the

earl

ier

itw

aspe

rfor

med

rela

ted

tode

teri

orat

ion.

3)Pa

tient

sw

ithte

mpo

ral

cont

usio

nsan

dra

diol

ogic

alsi

gns

ofm

ass

effe

ctsh

ould

beop

erat

edon

befo

rede

teri

orat

ion.

4)A

utho

rsof

fer

indi

catio

nsfo

rsu

rger

y:al

lpa

tient

sw

ithco

ntus

ions

�20

cm3

with

radi

olog

ical

sign

sof

mas

sef

fect

orw

ithan

yle

sion

�50

cm3 .

No.

ofpa

tien

tsG

R/M

D(%

)D

(%)

Mea

nG

OS

All

patie

nts

218

5627

.53.

2

Lesi

onty

peN

o.of

pati

ents

GR

(%)

MD

(%)

SD(%

)V

S(%

)D

(%)

Con

tusi

ons

122

2430

115

30

Con

tusi

ons/

depr

esse

dcr

ania

lfr

actu

reg

2412

1725

442

DA

I39

2325

305

17

ICH

3231

2816

322

No.

ofpa

tien

tsG

R/M

D/S

D(%

)V

S/D

(%)

GC

S�

6,vo

lum

e�

20cm

3

No

surg

ery

4250

50

Surg

ery

befo

rede

teri

orat

iong

610

00

Surg

ery

onda

yof

dete

rior

atio

n9

6733

Surg

ery

�1

daf

ter

dete

rior

atio

n9

5544

GC

S�

6,vo

lum

e�

20cm

3 ,C

Tm

ass

effe

ct

No

surg

ery

1926

74

Surg

ery

befo

rede

teri

orat

iong

610

00

Surg

ery

onda

yof

dete

rior

atio

n8

62.5

37.5

Surg

ery

�1

daf

ter

dete

rior

atio

n1

010

0

GC

S�

6,vo

lum

e�

50cm

3

No

surg

ery

1436

64

Surg

ery

befo

rede

teri

orat

iong

310

00

Surg

ery

onda

yof

dete

rior

atio

ng10

7030

Surg

ery

�1

daf

ter

dete

rior

atio

n1

010

0

GC

S�

10cm

3 ,te

mpo

ral

cont

usio

n,C

Tm

ass

effe

ct

Del

ayed

orno

surg

ery

80

100

Surg

ery

befo

reor

attim

eof

dete

rior

atio

ng3

100

0g

P�

0.05

.

TRAUMATIC PARENCHYMAL LESIONS

NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-41

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Mei

eret

al.

(42)

38III

All

GC

SSu

rger

yG

OS

atdi

scha

rge

Ret

rosp

ectiv

ese

ries

of93

6pa

tient

sw

houn

derw

ent

surg

ery

for

TBI,

38of

who

mw

ere

child

ren

with

ICH

/con

tusi

onas

prim

ary

path

olog

y.G

OS

isre

late

dto

adm

issi

onG

CS.

●C

hild

ren

with

adm

issi

onG

CS

6–

8ha

dbe

tter

over

all

outc

ome

than

adul

tsw

ithad

mis

sion

GC

S6

–8.

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS

(%)

D(%

)

Chi

ldre

nw

ithco

ntus

ions

3853

1037

Mei

eret

al.

(43)

19III

GC

S3–

12D

ecom

pres

sive

cran

iect

omy

GO

Sat

disc

harg

eR

etro

spec

tive

seri

esof

19pa

tient

sw

ithin

trac

tabl

ein

trac

rani

alhy

pert

ensi

onun

derg

oing

deco

mpr

essi

vecr

anie

ctom

yto

eval

uate

fact

ors

rela

ted

topr

ogno

sis.

Surg

ical

indi

catio

nsin

clud

edfa

ilure

ofco

nser

vativ

ein

terv

entio

nfo

rin

trac

rani

alhy

pert

ensi

on,

age

�50

yrw

ithou

tm

ultip

letr

aum

a,ag

e�

30yr

inpr

esen

ceof

maj

orex

trac

rani

alin

juri

es,

seve

rebr

ain

swel

ling

onC

T(o

rin

trao

pera

tivel

y).

11pa

tient

sun

derw

ent

deco

mpr

essi

vecr

anie

ctom

ybe

caus

ege

nera

lized

brai

ned

ema

was

evid

ent

duri

ngev

acua

tion

ofa

spac

e-oc

cupy

ing

lesi

on;

8pa

tient

sun

derw

ent

deco

mpr

essi

vecr

anie

ctom

yse

cond

ary

tofa

ilure

ofco

nser

vativ

etr

eatm

ent.

●2

patie

nts

�60

yrha

dG

OS

2(V

S).

●A

gean

dG

CS

rela

ted

toG

OS

(no

stat

istic

s).

●M

orta

lity

incr

ease

dw

ithth

epr

esen

ceof

extr

acra

nial

inju

ries

(no

stat

istic

s).

No.

ofpa

tien

tsG

R/M

D(%

)SD

(%)

VS

(%)

D(%

)

All

1926

526

43

Ope

rate

d63

Non

oper

ated

27

Mill

eret

al.

(44)

20III

GC

S3–

8Su

rgic

alan

dno

nsur

gica

lG

OS

3m

oPr

ospe

ctiv

ese

ries

of22

5pa

tient

sw

ithse

vere

head

inju

rym

anag

edby

stan

dard

ized

prot

ocol

toid

entif

ypr

ogno

stic

vari

able

san

dto

valid

ate

resu

ltsof

apr

evio

usst

udy.

Subg

roup

sw

ithsu

rgic

alan

dno

nsur

gica

lle

sion

sar

eid

entif

ied

and

outc

ome

issp

ecifi

edfo

rea

chle

sion

.Th

ede

finiti

onof

ICH

incl

uded

�5

mm

mid

line

shift

,an

d,th

us,

all

wer

eta

ken

tosu

rger

y.

●C

orre

latio

nbe

twee

nag

e,ab

norm

alm

otor

resp

onse

,bi

late

ral

loss

oflig

htre

flex,

impa

ired

/abs

ent

ocul

ocep

halic

refle

x,an

dou

tcom

ein

nono

pera

tivel

ym

anag

edpa

tient

s.●

Pare

nchy

mal

lesi

ons

ofin

crea

sed

dens

ityon

CT

wer

eas

soci

ated

with

seve

redi

sabi

lity/

vege

tativ

est

ate

com

pare

dw

ithot

her

lesi

ons.

●31

%in

cide

nce

ofun

cont

rolla

ble

post

oper

ativ

eel

evat

edIC

Pin

ICH

patie

nts.

Surg

ical

and

nons

urgi

cal

grou

psw

ere

not

com

para

ble.

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS

(%)

D(%

)

ICH

2026

1658

Con

tusi

on,

nosu

rger

y31

6413

23

Diff

use,

nosu

rger

y10

173

1017

Mun

chet

al.

(45)

49III

GC

S�

8to

�8

Dec

ompr

essi

vecr

anie

ctom

yG

OS

6m

oR

etro

spec

tive

seri

esof

49pa

tient

sun

derg

oing

unila

tera

lde

com

pres

sive

cran

iect

omy

for

TBI

unde

rst

anda

rdiz

edtr

eatm

ent

prot

ocol

toev

alua

tepr

eope

rativ

ean

dpo

stop

erat

ive

CT

char

acte

rist

ics,

ICP/

CPP

chan

ge,

and

toas

sess

outc

ome.

Asu

bdiv

isio

nin

tora

pid

and

dela

yed

grou

psw

asal

soan

alyz

edac

cord

ing

toou

tcom

e.Su

rgic

alin

dica

tions

deta

iled.

Patie

nts

with

bila

tera

lin

trac

rani

alle

sion

s;bi

late

rally

fixed

and

dila

ted

pupi

ls;

and

life-

thre

aten

ing

conc

omita

ntm

edic

aldi

seas

ew

ere

excl

uded

.A

llpa

tient

sun

derg

oing

rapi

dde

com

pres

sion

had

acut

eSD

H.

All

patie

nts

unde

rgoi

ngde

laye

dde

com

pres

sion

had

diffu

sebr

ain

swel

ling.

●41

%go

odou

tcom

eat

6m

o.●

Vis

ibili

tyof

mes

ence

phal

icci

ster

nsan

dm

idlin

esh

iftim

prov

edsi

gnifi

cant

lyaf

ter

cran

iect

omy;

gyra

lpa

ttern

and

visi

bilit

yof

vent

ricl

esdi

dno

t.●

No

chan

gein

mea

nth

erap

eutic

inte

nsity

leve

lbe

fore

vers

usaf

ter

deco

mpr

essi

on.

●A

ge�

50yr

,G

CS

�8

corr

elat

edsi

gnifi

cant

lyw

ithbe

tter

outc

ome.

●G

OS

at6

mo

sign

ifica

ntly

bette

rin

rapi

dve

rsus

dela

yed

deco

mpr

essi

ongr

oups

,bu

tG

OS

atdi

scha

rge

from

ICU

not

sign

ifica

ntly

diffe

rent

.●

No

sign

ifica

ntdi

ffere

nce

betw

een

befo

rean

daf

ter

deco

mpr

essi

onIC

Pan

dC

PP.

●C

hang

ein

mes

ence

phal

icci

ster

nvi

sibi

lity

corr

elat

edw

ithdi

stan

cebe

twee

nlo

wer

cran

iect

omy

bord

eran

dcr

ania

lba

se(m

ore

than

area

ofde

com

pres

sion

).

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS/

D(%

)

At

disc

harg

efr

omIC

U49

2872

At

6m

o49

4159

GC

S8

GC

S<

8R

apid

Del

ayed

Age

<50

yrA

ge50

yr

Mea

nG

OS

3.9

1.4h

3.1

1.9i

3.0

1.9i

hP

�0.

023,

iP

�0.

046.

SURGICAL MANAGEMENT OF TBI AUTHOR GROUP

S2-42 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Nag

abha

ndan

dSa

ngch

am(4

6)10

IIIU

nkno

wn

Surg

ery

Mor

talit

yR

etro

spec

tive

revi

ewof

71pa

tient

sun

derg

oing

surg

ery

for

intr

acra

nial

hem

atom

a.M

orta

lity

com

pare

dbe

twee

ndi

ffere

ntin

trac

rani

alle

sion

s,an

dbe

twee

ngr

oups

trea

ted

befo

rean

daf

ter

intr

oduc

tion

ofC

Tto

the

hosp

ital.

Asu

bset

of10

patie

nts

with

ICH

rece

ivin

gpr

eope

rativ

eC

Tis

incl

uded

No.

ofpa

tien

tsD

(%)

ICH

/con

tusi

on10

50

Nor

dstr

omet

al.

(47)

587

IIIG

CS

3–8

Surg

ery

and

nons

urgi

cal

GO

S6

mo

Ret

rosp

ectiv

ese

ries

of58

7pa

tient

sw

ithse

vere

TBI,

prim

arily

toan

alyz

eef

fect

ofin

stitu

tion

ofm

anag

emen

tpr

otoc

olin

are

gion

inSw

eden

onou

tcom

e.Pr

otoc

olin

stitu

ted

in19

83.

For

our

purp

oses

,ep

idem

iolo

gyan

dou

tcom

eof

ICH

and

seve

reTB

Iw

ithno

mas

sle

sion

are

eval

uate

d.

●Pa

tient

sw

ithIC

H(in

clud

ing

asso

ciat

edSD

H/E

DH

)ha

d64

%m

orta

lity

and

15%

good

reco

very

at6

mo.

●%

ofex

plor

ator

ycr

anio

tom

ies

and

%m

orta

lity

inlo

cal

hosp

itals

decr

ease

dfo

llow

ing

inst

itutio

nof

man

agem

ent

prot

ocol

.C

Tw

asno

tun

iver

sally

avai

labl

eat

loca

lho

spita

ls.

No.

ofpa

tien

tsG

R(%

)D

(%)

ICH

205

1564

No

mas

sle

sion

,ex

plor

ator

ycr

anio

tom

y30

73j

No

mas

sle

sion

,no

expl

orat

ion

150

61jP

�n.

s.

Nus

sbau

met

al.

(48)

10III

GC

S3–

6Te

mpo

ral

lobe

ctom

yB

arth

elin

dex,

min

imum

8m

oR

etro

spec

tive

seri

esof

10pa

tient

sw

ithG

CS

3–6

and

clin

ical

sign

sof

tran

sten

tori

alhe

rnia

tion

who

unde

rwen

tst

anda

rdiz

edte

mpo

ral

lobe

ctom

yfo

run

ilate

ral

hem

isph

eric

swel

ling.

All

patie

nts

dem

onst

rate

dfix

edpu

pilla

rydi

latio

n;un

ilate

ral

in7,

bila

tera

lin

3.A

llfa

iled

med

ical

ther

apy

and

unde

rwen

tsu

rger

yw

ithin

2h

ofsi

gns

ofhe

rnia

tion.

●O

vera

ll40

%fu

nctio

nally

inde

pend

ent

surv

ival

with

30%

mor

talit

y.

No.

ofpa

tien

tsFu

ncti

onal

inde

pend

ence

(%)

Min

imal

assi

stan

ce(%

)D

(%)

Tota

l10

4030

30

Papo

etal

.(4

9)29

IIIG

CS

4–5

to�

10Su

rger

yan

dno

nsur

gica

lM

orta

lity

atdi

scha

rge

Ret

rosp

ectiv

ese

ries

of29

patie

nts

with

trau

mat

icIC

H/b

rain

lace

ratio

nto

anal

yze

the

corr

elat

ion

betw

een

GC

S,C

T,an

dIC

Pda

taan

dou

tcom

ew

ithor

with

out

oper

ativ

etr

eatm

ent.

ICP

data

reco

rded

via

intr

aven

tric

ular

cath

eter

.

●Pa

tient

sw

ithG

CS

4–5

onad

mis

sion

trea

ted

byop

erat

ion

with

in48

hof

inju

rydi

ed(n

ost

atis

tics)

.

No.

ofpa

tien

tsD

(%)

GC

S4

–55

100

GC

S6

–10

1346

.2

GC

S�

1011

0

Pate

let

al.

(50)

38III

GC

S�

8to

�13

Non

surg

ical

Mor

talit

yR

etro

spec

tive

seri

esof

57pa

tient

sin

itial

lym

anag

edno

nope

rativ

ely

who

subs

eque

ntly

requ

ired

cran

ioto

my

toat

tem

ptto

iden

tify

fact

ors

that

led

tofa

ilure

ofno

nope

rativ

em

anag

emen

t.A

subg

roup

of38

patie

nts

with

ICH

revi

ewed

.

●54

.5%

ofpa

tient

sw

ithIC

P�

20m

mH

gfa

iled

nono

pera

tive

man

agem

ent

in�

24h.

●Fr

onta

lIC

Hw

ere

sign

ifica

ntly

mor

epr

one

toea

rly

vers

usla

tefa

ilure

.●

Mor

talit

yin

faile

dIC

Hpa

tient

sw

as10

.5%

.

No.

ofpa

tien

tsD

(%)

Faile

dIC

H38

10.5

TRAUMATIC PARENCHYMAL LESIONS

NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-43

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Polin

etal

.(5

1)35

IIIM

ean

GC

S5.

62B

ifron

tal

deco

mpr

essi

vecr

anie

ctom

y

GO

Sat

disc

harg

eR

etro

spec

tive

case

-con

trol

seri

esof

35pa

tient

sun

derg

oing

bifr

onta

lde

com

pres

sive

cran

iect

omy

for

refr

acto

rypo

sttr

aum

atic

cere

bral

edem

aco

mpa

ring

preo

pera

tive

and

post

oper

ativ

eIC

P,ag

eve

rsus

outc

ome,

and

com

pari

ngth

egr

oup

asa

who

lew

ithth

egr

oup

from

TCD

Bm

atch

edfo

rag

e,ad

mis

sion

GC

S,se

x,an

dm

axim

alIC

Pin

term

sof

outc

ome.

Onl

yTC

DB

patie

nts

with

diffu

sein

jury

,no

sign

ifica

ntm

ass

lesi

on,

nom

idlin

esh

ift(II

I)(M

arsh

all

etal

.[3

9])

wer

eel

igib

lefo

rco

nsid

erat

ion

asco

ntro

ls.

●A

dmis

sion

GC

Sre

late

dto

outc

ome.

●O

pera

tion

�48

has

soci

ated

with

favo

rabl

eou

tcom

e(4

6%)

com

pare

dw

ith�

48h

(0%

).●

Sign

ifica

ntch

ange

inIC

Pbe

fore

vers

usaf

ter

deco

mpr

essi

on.

●Si

gnifi

cant

diffe

renc

ein

post

oper

ativ

eIC

Pve

rsus

cont

rol

ICP

48–7

2h

afte

rin

jury

.●

Coa

gulo

path

ydi

dno

taf

fect

outc

ome

insu

rgic

algr

oup.

●IC

P�

40m

mH

gsu

stai

ned

and

oper

atio

n�

48h

afte

rin

jury

had

sign

ifica

ntly

less

favo

rabl

eou

tcom

es.

●A

ge�

18yr

had

high

erra

teof

favo

rabl

eou

tcom

ein

surg

ical

grou

p.●

Surg

ery

age

�18

yrha

dhi

gher

rate

offa

vora

ble

outc

ome

than

mat

ched

cont

rols

ifop

erat

ed�

48h

and

ICP

�40

mm

Hg.

●M

edic

alm

anag

emen

tal

one

carr

ied

3.86

times

rela

tive

risk

ofun

favo

rabl

eou

tcom

eco

mpa

red

with

deco

mpr

essi

vecr

anie

ctom

y.●

Max

imum

bene

fitis

achi

eved

inpa

tient

sop

erat

edon

�48

haf

ter

inju

ryan

dw

ithIC

Pel

evat

ions

sust

aine

d�

40m

mH

g(6

0%fa

vora

ble

vers

us18

%in

mat

ched

cont

rols

).

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

Surg

ery

k35

11.4

25.7

31.4

8.6

22.9

Cas

eco

ntro

l92

7.6

8.8

35.2

18.7

30.8

No.

ofpa

tien

tsG

R/M

D(%

)D

(%)

Coa

gulo

path

y18

33l

28

No

coag

ulop

athy

1741

18

ICP

�40

mm

Hg,

OR

�48

h15

6.7m

ICP

�40

,O

R�

48h

2060

Age

�18

yr18

44

Age

�18

yr17

29

OR

�48

h,IC

P�

4020

60n

ICP

�40

,co

ntro

l58

18

Age

�18

,IC

P�

40,

OR

�48

h10

80o

Age

�18

,IC

P�

40,

cont

rol

2524

kfa

vora

ble

outc

ome,

P�

0.01

4;lP

�n.

s.,

mP

�0.

0004

,n

P�

0.00

01,

oP

�0.

02.

Serv

adei

etal

.(5

4)72

4III

GC

S3–

12Su

rger

yan

dno

nsur

gica

lG

OS

6m

oPr

ospe

ctiv

est

udy

of72

4pa

tient

sw

ithm

oder

ate-

to-s

ever

eTB

Ito

dete

rmin

eth

efr

eque

ncy

ofch

ange

sin

CT

findi

ngs

and

thei

rpr

ogno

stic

impl

icat

ions

.

●16

%of

diffu

sein

juri

eson

initi

alC

Tde

mon

stra

ted

dete

rior

atio

non

subs

eque

ntC

T.●

12%

ofdi

ffuse

inju

ries

evol

ved

tom

ass

lesi

ons.

●Ev

olut

ion

from

diffu

sein

jury

with

out

swel

ling

orsh

ift(T

ype

II)to

am

ass

lesi

onw

asas

soci

ated

with

sign

ifica

ntin

crea

sein

risk

ofun

favo

rabl

eou

tcom

e.

●Tr

end

tow

ards

mor

efa

vora

ble

outc

ome

inpa

tient

sw

ithno

neva

cuat

edve

rsus

evac

uate

dm

ass

lesi

ons.

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS/

D(%

)

Diff

use

inju

ryI,

noch

ange

7587

13

Diff

use

inju

ryI,

evol

utio

n5

8020

Diff

use

Inju

ryII,

noch

ange

185

6238

Diff

use

Inju

ryII,

evol

utio

np34

3862

Diff

use

Inju

ryIII

,no

chan

ge57

3367

Diff

use

Inju

ryIII

,ev

olut

ion

757

43

Diff

use

Inju

ryIV

,no

chan

ge14

2179

Diff

use

Inju

ryIV

,ev

olut

ion

475

25

Mas

sle

sion

343

4357

pP

�0.

01.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD (%

)V

S(%

)D (%

)

Diff

use

inju

ryI

8074

129

05

Diff

use

inju

ryII

219

3622

202

21

Diff

use

inju

ryIII

6420

169

253

Diff

use

inju

ryIV

1811

2211

056

SURGICAL MANAGEMENT OF TBI AUTHOR GROUP

S2-44 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Sing

ouna

s(5

7)16

IIIG

CS

8–1

0U

nkno

wn

Mor

talit

yR

etro

spec

tive

revi

ewof

48ch

ildre

n�

14yr

with

seve

rehe

adin

jury

(ext

radu

ral

and

subd

ural

hem

atom

asex

clud

ed)

toco

mm

ent

onre

lativ

ely

good

prog

nosi

s.M

orta

lity

for

16pa

tient

sw

ithbr

ain

edem

aon

lyw

asre

port

ed.

No.

ofpa

tien

tsD

(%)

Diff

use

edem

a,no

foca

lle

sion

1612

.5

Solo

niuk

etal

.(5

8)35

IIIG

CS

�8

or�

8Su

rger

yG

OS

6m

oR

etro

spec

tive

revi

ewof

35pa

tient

sun

derg

oing

cran

ioto

my

for

evac

uatio

nof

ICH

toev

alua

tech

arac

teri

stic

sof

timin

gof

appe

aran

ceof

ICH

and

fact

ors

rela

ted

toou

tcom

e.IC

Hde

fined

asho

mog

eneo

usco

ales

cent

area

ofhi

ghat

tenu

atio

nm

easu

ring

2cm

orgr

eate

r.

●O

nly

26%

ofIC

Hre

quir

ing

evac

uatio

nar

epr

esen

ton

CT

with

in6

hof

inju

ry.

●49

%ov

eral

l1-

yrm

orta

lity;

71%

with

GC

S�

8.●

Mor

talit

yva

ries

with

loca

tion,

with

panh

emis

pher

ic,

tem

pora

l,an

dfr

onta

lra

tes

of80

%,

57%

,an

d37

%,

resp

ectiv

ely.

No.

ofpa

tien

tsD

(%)

ICH

,op

erat

ed35

49

Spri

cket

al.

(59)

34III

GC

S3

to�

7Su

rger

yan

dno

nsur

gica

lG

OS,

not

spec

ified

Ret

rosp

ectiv

ese

ries

of34

patie

nts

with

DTI

CH

ofat

leas

t2.

5-cm

diam

eter

inpr

evio

usly

norm

alar

eaon

initi

alC

Tto

eval

uate

outc

ome

and

clin

ical

char

acte

rist

ics.

●53

%D

TIC

Hde

velo

ped

with

in24

haf

ter

adm

issi

onan

d79

%w

ithin

48h

No.

ofpa

tien

tsG

R(%

)D

isab

led

(%)

D(%

)

All

3417

.655

.926

.5O

pera

ted

714

.342

.942

.9

Stat

ham

etal

.(6

0)18

IIIG

CS

5–14

Surg

ery

(n�

1)an

dno

nsur

gica

lG

OS

6m

oR

etro

spec

tive

revi

ewof

18pa

tient

sw

ithpr

imar

yC

Tdi

agno

sis

offr

onta

lco

ntus

ion,

defin

edas

regi

ons

ofm

ixed

high

and

low

orlo

wat

tenu

atio

nin

the

fron

tal

lobe

s,to

atte

mpt

tode

term

ine

fact

ors

that

may

lead

tone

urol

ogic

alde

teri

orat

ion

and

wor

seou

tcom

e.

●G

ood

outc

ome

was

achi

eved

in72

%of

patie

nts

with

fron

tal

cont

usio

n.●

Bot

hca

ses

ofde

teri

orat

ion

wer

eas

soci

ated

with

exte

nsiv

ebi

late

ral

inju

ry(n

ost

atis

tics)

.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

Uni

late

ral

cont

usio

n10

900

00

10Li

mite

dbi

late

ral

cont

usio

ns5

4040

200

0

Exte

nsiv

ebi

late

ral

cont

usio

ns3

670

00

33

Fron

tal

cont

usio

ns,

tota

l18

72.2

11.1

5.6

011

.1

Tayl

oret

al.

(61)

27II

GC

S4

–11

Dec

ompr

essi

vebi

tem

pora

lcr

anie

ctom

yan

dno

nsur

gica

l

GO

S6

mo;

Hea

lthSt

ate

Util

ityIn

dex

6m

o

Pros

pect

ive,

rand

omiz

ed,

cont

rolle

dtr

ial

of27

child

ren

with

TBI

and

sust

aine

din

trac

rani

alhy

pert

ensi

onto

eval

uate

effe

ctof

earl

yde

com

pres

sive

bite

mpo

ral

cran

iect

omy

onou

tcom

ean

don

cont

rol

ofIC

P.

●Tr

end

tow

ards

grea

ter

decr

ease

inIC

Pin

deco

mpr

essi

ongr

oup

(P�

0.05

7).

●Tr

end

tow

ards

shor

ter

ICU

stay

inde

com

pres

sion

grou

p(P

�0.

12).

●Tr

end

tow

ards

impr

oved

outc

ome

inde

com

pres

sion

grou

p(P

�0.

046

[P�

0.02

21re

quir

edfo

rsi

gnifi

canc

e]).

No.

ofpa

tien

tsFa

vora

ble

(%)

Unf

avor

able

(%)

Dec

ompr

essi

on13

53.8

q46

.1

Con

trol

1414

.385

.7q

P�

0.04

6(P

�0.

0221

requ

ired

for

sign

ifica

nce)

.Fa

vora

ble:

norm

alor

func

tiona

llyno

rmal

but

requ

irin

gm

edic

atio

nor

med

ical

supe

rvis

ion.

Unf

avor

able

:m

oder

ate

disa

bilit

y,de

pend

ent,

seve

rely

disa

bled

/veg

etat

ive,

orde

ad.

Teas

dale

etal

.(6

2)37

IIIG

CS

3–8

Non

surg

ical

GO

S6

mo

Ret

rosp

ectiv

ese

ries

of37

patie

nts

diag

nose

dw

ithse

vere

diffu

sehe

adin

jury

(with

out

mid

line

shift

of�

5m

m)

tode

term

ine

the

rela

tions

hip

betw

een

com

pres

sion

ofba

sal

cist

erns

/3rd

vent

ricl

ean

del

evat

edIC

P.

●H

ighl

ysi

gnifi

cant

rela

tions

hip

betw

een

stat

usof

basa

lci

ster

ns/II

Ive

ntri

cle

and

leve

lof

ICP.

●Pr

esen

ceve

rsus

abse

nce

ofci

ster

ns/II

Ive

ntri

cle

seem

edto

corr

elat

ew

ithou

tcom

ew

ithin

GC

Sgr

oups

(no

stat

istic

s).

No.

ofpa

tien

tsG

R/M

D(%

)SD

(%)

VS/

D(%

)

GC

S3–

5,ab

sent

cist

erns

/3rd

vent

ricl

e11

9.1

090

.9

GC

S3–

5,pr

esen

tci

ster

ns/3

rdve

ntri

cle

520

2060

GC

S6

–8,

abse

ntci

ster

ns/3

rdve

ntri

cle

837

.525

37.5

GC

S6

–8,

pres

ent

cist

erns

/3rd

vent

ricl

e13

61.5

15.4

23.1

TRAUMATIC PARENCHYMAL LESIONS

NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-45

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Tsen

g(6

3)32

IIIA

llG

CS

Surg

ery

and

nons

urgi

cal

GO

S1

yrR

etro

spec

tive

seri

esof

32pa

tient

sw

ithD

TIC

Hto

eval

uate

clin

ical

and

radi

olog

icfa

ctor

saf

fect

ing

outc

ome.

●H

emat

oma

volu

me,

cist

erna

lef

face

men

t,tim

ing

ofde

tect

ion,

occu

rren

ceof

clin

ical

dete

rior

atio

n,an

dG

CS

attim

eof

follo

w-u

pC

Tw

ere

rela

ted

sign

ifica

ntly

toou

tcom

e.●

16%

over

all

mor

talit

y.

No.

ofpa

tien

tsG

R/M

D(%

)SD

/VS/

D(%

)

GC

S3–

7at

follo

w-u

pC

Tr12

3367

GC

S8

–12

atfo

llow

-up

CT

1610

00

GC

S13

–15

atfo

llow

-up

CT

410

00

Cis

tern

effa

cem

ents

50

100

No

cist

ern

effa

cem

ent

2788

.911

.1r

P�

0.00

5,s

P�

0.00

1.

Tsen

g(6

4)32

IIIG

CS

5–7

Cra

niot

omy

�m

anua

lte

mpo

ral

lobe

redu

ctio

n

GO

S3

mo

Ret

rosp

ectiv

est

udy

of32

patie

nts

with

GC

S5–

7,C

Tev

iden

cefo

run

cal

hern

iatio

n,an

isoc

oria

,an

dhe

mip

ares

istr

eate

dei

ther

with

stan

dard

surg

ical

proc

edur

e(i.

e.,

cran

ioto

my

with

hem

atom

aev

acua

tion

and

cont

usio

nre

sect

ion)

orw

ithst

anda

rdpr

oced

ure

plus

man

ual

redu

ctio

nof

hern

iate

dte

mpo

ral

lobe

.G

OS

mea

sure

dat

�3

mo

post

opto

com

pare

outc

ome

betw

een

grou

ps.R

educ

tion

proc

edur

ede

scri

bed

asge

ntle

elev

atio

nof

tem

pora

llo

beun

tilte

ntor

ium

isvi

sual

ized

and

CSF

egre

ssis

note

d.

●A

dditi

onof

tem

pora

llo

bere

duct

ion

toth

est

anda

rdsu

rgic

alpr

oced

ure

seem

edto

resu

ltin

bette

rou

tcom

e(n

ost

atis

tics;

sele

ctio

nbi

as).

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD (%

)V

S(%

)D (%

)

Cra

niec

tom

y�

cont

usio

n�

redu

ctio

n10

2070

00

10

Cra

niec

tom

y�

cont

usio

n,no

redu

ctio

n

220

279

955

Uzz

ell

etal

.(6

5)11

7III

GC

S4

–6

Non

surg

ical

GO

S6

mo;

neur

o-ps

ycho

logi

cal

mea

n4.

8m

o(n

�30

)

Ret

rosp

ectiv

ese

ries

of11

7pa

tient

sw

ithD

AI,

diffu

sesw

ellin

g,or

foca

lin

jury

byC

Tto

char

acte

rize

diffe

rent

ial

outc

ome.

Neu

rops

ycho

logi

cal

test

ing

was

perf

orm

edin

asu

bset

of30

patie

nts

toch

arac

teri

zedi

ffere

ntia

lne

urop

sych

olog

ical

sequ

elae

base

don

lesi

onty

pe.

Patie

nts

with

SDH

,ED

H,

SAH

,or

deve

lopm

ent

ofa

seco

ndm

ajor

lesi

onw

ere

excl

uded

.D

AI

defin

edas

�mid

line

hem

orrh

ages

orm

ultip

lesm

all

hem

orrh

ages

atgr

ay-w

hite

mat

ter

inte

rfac

es�;

diffu

sesw

ellin

gde

fined

as�n

arro

win

gor

oblit

erat

ion

ofve

ntri

cles

orba

sila

rci

ster

ns�;

foca

lin

juri

esde

fined

as�u

nila

tera

lin

trac

ereb

ral

hem

orrh

ages

orco

ntus

ions

.�

●Pa

tient

sw

ithD

AI

had

sign

ifica

ntly

high

erm

orta

lity

and

sign

ifica

ntly

less

“goo

dre

cove

ry”

than

othe

rgr

oups

.●

Mem

ory

and

lear

ning

scor

ebu

tno

tin

telli

genc

eor

visu

omot

orsp

eed

scor

esi

gnifi

cant

lydi

ffere

dam

ong

CT

grou

ps.

●Le

vels

ofm

emor

y,le

arni

ng,

and

visu

omot

orsp

eed

wer

ehi

gher

afte

rdi

ffuse

swel

ling

inju

ries

,bu

tim

prov

emen

tw

asle

ssov

ertim

e.●

Patie

nts

with

DA

Iha

dgr

eate

rim

prov

emen

tov

ertim

eof

mem

ory,

lear

ning

,an

dvi

suom

otor

spee

d.●

Patie

nts

with

foca

lin

juri

esha

dim

prov

emen

tov

ertim

ein

visu

omot

orsp

eed,

but

not

reca

llor

lear

ning

.●

Dia

gnos

ticgr

oups

did

not

diffe

rsi

gnifi

cant

lyin

age,

year

sof

educ

atio

n,G

CS,

timin

gof

neur

opsy

chol

ogic

alte

stin

g,se

x,ha

nded

ness

,or

GO

Sat

6m

o.

CT

grou

ptN

o.of

pati

ents

GR

(%)

MD

(%)

SD (%)

VS

(%)

D (%)

DA

I33

1815

1512

40D

iffus

esw

ellin

g34

6217

60

15

Foca

lin

jury

5048

1514

022

tP

�0.

01.

Vol

lmer

etal

.(6

6)32

1III

All

GC

SSu

rger

yan

dno

nsur

gica

lG

OS

6m

oPr

ospe

ctiv

est

udy

from

1984

–198

7of

patie

nts

with

GC

S3–

15to

eval

uate

effe

ctof

age

onou

tcom

ein

diffe

rent

popu

latio

ns,

incl

udin

gpa

tient

sw

ithla

rge

(�15

cm3 )

ICH

requ

irin

gev

acua

tion

(n�

54)

and

patie

nts

with

�15

cm3

ICH

(n�

267)

.

●Pr

esen

ceof

ICH

and

ofla

rge

ICH

(�15

cm3 )

incr

ease

dsi

gnifi

cant

lyw

ithag

e.●

Incr

easi

ngag

ew

asin

depe

nden

tlypr

edic

tive

ofpo

orou

tcom

ein

larg

ean

dsm

all

ICH

subg

roup

s.

No.

ofpa

tien

tsV

S/D

(%)

ICH

�15

cm3u

267

Age

16–2

5yr

31.8

Age

26–3

5yr

27.7

Age

36–

45yr

42.4

Age

46–5

5yr

62.2

Age

�56

yr82

.2u

P�

0.00

1

SURGICAL MANAGEMENT OF TBI AUTHOR GROUP

S2-46 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com

TAB

LE1.

Con

tinu

ed

Aut

hors

(ref

.no

.)N

o.of

pati

ents

Cla

ssIn

clus

ion

GC

STr

eatm

ent

Out

com

eD

escr

ipti

onC

oncl

usio

n

Whi

tfiel

det

al.

(67)

26III

GC

S3–

13B

ifron

tal

deco

mpr

essi

vecr

anie

ctom

y

GO

S6

mo

Ret

rosp

ectiv

ere

view

ofou

tcom

efo

r26

patie

nts

unde

rgoi

ngbi

fron

tal

deco

mpr

essi

vecr

anie

ctom

yfo

rre

frac

tory

intr

acra

nial

hype

rten

sion

(ICP

�30

mm

Hg

with

CPP

�70

mm

Hg;

orIC

P�

35m

mH

gir

resp

ectiv

eof

CPP

)m

anag

edus

ing

ast

anda

rdiz

edIC

P/C

PPtr

eatm

ent

algo

rith

m.

Con

tinuo

usIC

P,A

BP,

and

CPP

data

wer

ean

alyz

edfo

r8

patie

nts

toex

amin

eef

fect

ofbi

fron

tal

deco

mpr

essi

vecr

anie

ctom

yon

thes

eva

riab

les.

Surg

ical

tech

niqu

ede

scri

bed.

●61

%of

seve

reTB

Isu

bgro

upha

dfa

vora

ble

outc

ome

(GO

S4

–5).

●IC

Pw

assi

gnifi

cant

lyre

duce

dfr

om37

.5to

18.1

mm

Hg

(P�

0.00

3).

●C

PPdi

ffere

nces

wer

eno

tsi

gnifi

cant

.●

Am

plitu

deof

ICP

wav

efor

m,

ampl

itude

ofsl

oww

aves

,an

dR

AP

coef

ficie

nt(r

efle

ctin

gin

crea

sed

com

pens

ator

yre

serv

e)w

ere

sign

ifica

ntly

redu

ced

bysu

rger

yin

asu

bgro

upof

eigh

tpa

tient

s.●

Tim

ing

ofsu

rger

yw

asno

tpr

edic

tive

ofou

tcom

e.N

o.of

pati

ents

GR

/MD

(%)

SD(%

)V

S(%

)D

(%)

All

2669

80

23A

ge�

166

83.3

00

16.7

GC

S3–

818

61.1

11.1

027

.8G

CS

9–1

25

100

00

0G

CS

133

66.7

00

33.3

Tim

ing

ofsu

rger

yN

o.of

pati

ents

Favo

rabl

e(%

)U

nfav

orab

le(%

)O

R�

48h

afte

rin

jury

2060

40O

R�

48h

afte

rin

jury

610

00

Wu

etal

.(6

8)35

IIIA

llG

CS

Surg

ery

GO

S6

mo

Ret

rosp

ectiv

ese

ries

of48

9pa

tient

str

eate

dsu

rgic

ally

for

intr

acra

nial

hem

atom

asto

asse

sspr

ogno

stic

fact

ors

rela

ted

toG

OS

at6

mo.

Asu

bgro

upof

35pa

tient

sw

ithIC

His

incl

uded

.

●Po

stre

susc

itatio

nG

CS,

preo

pera

tive

chan

gein

pupi

llary

size

,N

o.of

oper

atio

ns,

No.

ofhe

mat

omas

,an

dty

peof

lesi

onw

ere

sign

ifica

ntly

rela

ted

tosu

rgic

alou

tcom

e.●

Goo

dou

tcom

e:si

ngle

,ev

acua

ted

EDH

�IC

H�

SDH

.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

Acu

teIC

H,

evac

uate

d35

6022

.98.

62.

85.

7

Yam

aki

etal

.(6

9)48

IIIU

nkno

wn

Surg

ery

and

nons

urgi

cal

GO

S;tim

eof

max

imal

hem

atom

adi

amet

er

Ret

rosp

ectiv

ere

view

of48

patie

nts

with

trau

mat

icIC

H�

3-cm

diam

eter

who

sefir

stC

Toc

curr

edw

ithin

6h

ofin

jury

toev

alua

teth

etim

ing

ofhe

mat

oma

evol

utio

nan

dto

asse

ssou

tcom

e.C

Tsc

ans

of32

nono

pera

ted

patie

nts

wer

eus

edto

asse

ssna

tura

lhi

stor

yof

hem

atom

aev

olut

ion.

●A

llIC

H�

3-cm

diam

eter

deve

lope

dw

ithin

24h

ofin

jury

.●

Onl

y56

%of

ICH

�3-

cmdi

amet

erde

velo

ped

with

in6

hof

inju

ry.

●IC

Hre

ache

dm

axim

alsi

zein

84%

ofpa

tient

sw

ithin

12h.

No.

ofpa

tien

tsG

R(%

)M

D(%

)SD

(%)

VS

(%)

D(%

)

ICH

,to

tal

5853

142

328

ICH

,op

erat

ed26

358

47

46N

o.of

pati

ents

GR

(%)

Non

oper

ated

3213

Ope

rate

d26

46A

dmitt

edim

med

iate

lyaf

ter

TBI

1631

Adm

itted

�6

haf

ter

TBI

1070

You

nget

al.

(72)

15III

Gra

dyC

oma

Scal

e1–

5

Surg

ery

Mod

ified

GO

S,no

tsp

ecifi

edR

etro

spec

tive

seri

esaf

ter

intr

oduc

tion

ofC

Tof

15pa

tient

str

eate

dsu

rgic

ally

for

DTI

CH

toex

amin

ecl

inic

alan

dra

diol

ogic

corr

elat

es,

and

tore

late

clin

ical

stat

usto

outc

ome.

●M

orbi

dity

/mor

talit

yas

soci

ated

with

com

asc

ore

onad

mis

sion

(no

stat

istic

s).

●80

%oc

cipi

tal/p

arie

tooc

cipi

tal

impa

ct;

cont

reco

upfr

onto

tem

pora

lle

sion

s.●

Def

initi

onof

DTI

CH

:de

velo

psin

area

ofpr

evio

usco

ntus

ion.

No.

ofpa

tien

tsIn

tact

(%)

Mild

disa

bilit

y(%

)

Sign

ifica

ntdi

sabi

lity

(%)

D(%

)

Gra

dy1–

26

83.3

16.7

00

Gra

dy3–

49

00

22.2

77.8

DTI

CH

,to

tal

1533

.36.

713

.346

.7

Zum

kelle

ret

al.

(73)

53III

GC

S�

5to

11–1

5Su

rger

yan

dno

nsur

gica

lPo

orve

rsus

good

,no

tsp

ecifi

ed

Ret

rosp

ectiv

ese

ries

of10

4pa

tient

sw

ithIC

H,

53of

who

mpr

esen

ted

with

trau

mat

icIC

H,

com

pari

ngop

erat

ive

vers

usno

nope

rativ

etr

eatm

ent

with

outc

ome.

●N

ost

atis

tical

diffe

renc

ein

outc

ome

was

foun

dbe

twee

nop

erat

edan

dno

nope

rate

dgr

oups

.

No.

ofpa

tien

tsG

ood

(%)

Poor

(%)

Ope

rate

d31

7129

Non

oper

ated

2240

.959

.1Si

ngle

lobe

,op

erat

ed17

70.6

29.4

Sing

lelo

be,

non-

oper

ated

875

25P

�n.

s.

aG

CS,

Gla

sgow

Com

aSc

ale;

GO

S,G

lasg

owou

tcom

esc

ore;

ICH

,int

race

rebr

alhe

mor

rhag

e;IC

P,in

trac

rani

alpr

essu

re;C

T,co

mpu

ted

tom

ogra

phic

;GR

,goo

dre

cove

ry;M

D,m

oder

ate

disa

bilit

y;V

S,ve

geta

tive

stat

e;D

,dea

th;S

D,s

ever

edi

sabi

lity;

DTI

CH

,del

ayed

trau

mat

icin

trac

ereb

ralh

emat

oma;

SDH

,sub

dura

lhem

atom

a;n.

s.,n

otsi

gnifi

cant

;FIM

,fun

ctio

nali

ndep

ende

nce

mea

sure

;ED

H,

epid

ural

hem

atom

a;LO

C,l

oss

ofco

nsci

ousn

ess;

TCD

B,T

raum

atic

Com

aD

ata

Ban

k;SE

P,so

mat

osen

sory

evok

edpo

tent

ial;

CPP

,cer

ebra

lper

fusi

onpr

essu

re;A

EP,a

cous

ticev

oked

pote

ntia

l;ST

D,

subt

empo

ral

deco

mpr

essi

on;

TL,

tem

pora

llo

bect

omy;

MU

C,

mul

tiple

unila

tera

lco

ntus

ion;

GB

S,ge

nera

lized

brai

nsw

ellin

g;D

AI,

diffu

seax

onal

inju

ry;

TBI,

trau

mat

icbr

ain

inju

ry;

SAH

,su

bara

chno

idhe

mor

rhag

e;IV

H,

intr

aven

tric

ular

hem

orrh

age;

AB

P,ar

teri

albl

ood

pres

sure

;R

AP,

rena

lar

tery

pres

sure

;IC

U,

inte

nsiv

eca

reun

it;O

R,

oper

atio

n.