Korean J Neurotrauma.  2018 Apr;14(1):6-13. 10.13004/kjnt.2018.14.1.6.

Efficacy of the All-in-One Therapeutic Strategy for Severe Traumatic Brain Injury: Preliminary Outcome and Limitation

• Park YS
• Kogeichi Y
• Shida Y
• Nakase H

• KMID: 2410914
• DOI: http://doi.org/10.13004/kjnt.2018.14.1.6

Abstract

OBJECTIVE
Despite recent advances in medicine, no significant improvement has been achieved in therapeutic outcomes for severe traumatic brain injury (TBI). In the treatment of severe multiple traumas, accurate judgment and prompt action corresponding to rapid pathophysiological changes are required. Therefore, we developed the "All-in-One" therapeutic strategy for severe TBI. In this report, we present the therapeutic concept and discuss its efficacy and limitations.
METHODS
From April 2007 to December 2015, 439 patients diagnosed as having traumatic intracranial injuries were treated at our institution. Among them, 158 patients were treated surgically. The "All-in-One" therapeutic strategy was adopted to enforce all selectable treatments for these patients at the initial stages. The outline of this strategy is as follows: first, prompt trepanation surgery in the emergency room (ER); second, extensive decompression craniotomy (DC) in the operating room (OR); and finally, combined mild hypothermia and moderate barbiturate (H-B) therapy for 3 to 5 days. We performed these approaches on a regular basis rather than stepwise rule. If necessary, internal ecompression surgery and external ventricular drainage were performed in cases in which intracranial pressure could not be controlled.
RESULTS
Trepanation surgery in the ER was performed in 97 cases; among these cases, 46 had hematoma removal surgery and also underwent DC in the OR. Craniotomy was not enforced unless the consciousness level and pupil findings did not improve after previous treatments. H-B therapy was administered in 56 cases. Internal decompression surgery, including evacuation of traumatic intracerebral hematoma, was additionally performed in 12 cases. Three months after injury, the Glasgow Outcome Scale (GOS) score yielded the following results: good recovery in 25 cases (16%), mild disability in 28 (18%), severe disability in 33 (21%), persistent vegetative state in 9 (6%), and death in 63 (40%). Furthermore, 27 (36%) of the 76 most severe patients who had an abnormal response of bilateral eye pupils were life-saving. Because many cases of a GOS score of ≤5 are included in this study, this result must be satisfactory.
CONCLUSION
This therapeutic strategy without any lose in the appropriate treatment timing can improve the outcomes of the most severe TBI cases. We think that the breakthrough in the treatment of severe TBI will depend on the shift in the treatment policy.

Keyword

All-in-One therapeutic strategy; Barbiturate therapy; Hypothermia therapy; Severe traumatic brain injury

MeSH Terms

Brain Injuries*
Consciousness
Craniotomy
Decompression
Drainage
Emergency Service, Hospital
Glasgow Outcome Scale
Hematoma
Humans
Hypothermia
Intracranial Pressure
Judgment
Multiple Trauma
Operating Rooms
Persistent Vegetative State
Pupil
Trephining

Figure

• 

  FIGURE 1 Outline of the “All-in-One” therapeutic strategy. IVR: interventional radiology, ER: emergency room, EVD: external ventricular drainage, ICP: intracranial pressure.

• 

  FIGURE 2 (A) Initial computed tomography (CT) showed no obvious intracranial hemorrhage. (B) After transarterial embolization therapy, CT revealed the left subdural hematoma and diminished ambient cistern. (C) CT just after decompressive craniotomy surgery revealed traumatic intracerebral hematoma (ICH) and severe brain bulging. (D) CT after the second surgery showed removal of traumatic ICH and left temporal lobectomy as internal decompression surgery. (E) Two months later, cranioplasty was performed. (F) In spite of severe left cerebral damage, she recovered dramatically. Now she can talk freely and play the piano.

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