Evolution and Impact of the Brain Trauma Foundation Guidelines

Neurosurgery 89:1148–1156, 2021

The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Head Injury were the first clinical practice guidelines published by any surgical specialty. These guidelines have earned a reputation for rigor and have been widely adopted around the world. Implementation of these guidelines has been associated with a 50% reduction in mortality and reduced costs of patient care.

Over their 25-yr history the traumatic brain injury (TBI) guidelines have been expanded, refined, and made increasingly more rigorous in conjunction with new clinical evidence and evolving methodologic standards.

Here, we discuss the history and accomplishments of BTF guidelines for TBI as well as their limitations. We also discuss planned changes to future TBI guidelines intended to increase their utility and positive impact in an evolving medical landscape. Perhaps the greatest limitation of TBI guidelines now is the lack of high-quality clinical research as well as novel diagnostics and treatments with which to generate substantially new recommendations.

External Lumbar Drainage following Traumatic Intracranial Hypertension

Neurosurgery 89:395–405, 2021

Traumatic brain injury (TBI) often results in elevations in intracranial pressure (ICP) that are refractory to standard therapies. Several studies have investigated the utility of external lumbar drainage (ELD) in this setting.

OBJECTIVE: To evaluate the safety and efficacy of ELD or lumbar puncture with regard to immediate effect on ICP, durability of the effect on ICP, complications, and neurological outcomes in adults with refractory traumatic intracranial hypertension.

METHODS: A systematic review and meta-analysis were conducted beginning with a comprehensive search of PubMed/EMBASE. Two investigators reviewed studies for eligibility and extracted data. The strength of evidence was evaluated using GRADE methodology. Random-effects meta-analyses were performed to calculate pooled estimates.

RESULTS: Nine articles detailing 6 studies (N = 110) were included. There was moderate evidence that ELD has a significant immediate effect on ICP; the pooled effect size was –19.5 mmHg (95% CI –21.0 to –17.9 mmHg). There was low evidence to indicate a durable effect of ELD on ICP up to at least 24 h following ELD. There was low evidence to indicate that ELD was safe and associated with a low rate of clinical cerebral herniation or meningitis. There was very low evidence pertaining to neurological outcomes.

CONCLUSION: Given preliminary data indicating potential safety and feasibility in highly selected cases, the use of ELD in adults with severe TBI and refractory intracranial hypertension in the presence of open basal cisterns and absence of large focal hematoma merits further high-quality investigation; the ideal conditions for potential application remain to be determined.

Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations

Neurosurgery 87:427–434, 2020

When the fourth edition of the Brain Trauma Foundation’s Guidelines for theManagement of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released.

The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of “living guidelines,” whereby topics are updated more frequently, and between new editions, when important new evidence is published.

The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice.

This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline canbe found at: https://braintrauma.org/guidelines/guidelines-for-themanagement- of-severe-tbi-4th-ed#/.

Interhemispheric hygroma after decompressive craniectomy: does it predict posttraumatic hydrocephalus?

Journal of Neurosurgery, June 2010. DOI: 10.3171/2010.4.JNS10132

The aim of this study was to determine the incidence of posttraumatic hydrocephalus in severely head-injured patients who required decompressive craniectomy (DC). Additional objectives were to determine the relationship between hydrocephalus and several clinical and radiological features, with special attention to subdural hygromas as a sign of distortion of the CSF circulation.

Methods The authors conducted a retrospective study of 73 patients with severe head injury who required DC. The patients were admitted to the authors’ department between January 2000 and January 2006. Posttraumatic hydrocephalus was defined as: 1) modified frontal horn index greater than 33%, and 2) the presence of Gudeman CT criteria. Hygromas were diagnosed based on subdural fluid collection and classified according to location of the craniectomy.

Results Hydrocephalus was diagnosed in 20 patients (27.4%). After uni- and multivariate analysis, the presence of interhemispheric hygromas (IHHs) was the only independent prognostic factor for development of posttraumatic hydrocephalus (p < 0.0001). More than 80% of patients with IHHs developed hydrocephalus within the first 50 days of undergoing DC. In all cases the presence of hygromas preceded the diagnosis of hydrocephalus. The IHH predicts the development of hydrocephalus after DC with 94% sensitivity and 96% specificity. The presence of an IHH showed an area under the receiver-operator characteristic of 0.951 (95% CI 0.87–1.00; p < 0.0001).

Conclusions Hydrocephalus was observed in 27.4% of the patients with severe traumatic brain injury who required DC. The presence of IHHs was a predictive radiological sign of hydrocephalus development within the first 6 months of DC in patients with severe head injury.

Indications for Brain Computed Tomography and Hospital Admission in Pediatric Patients with Minor Head Injury

Pediatr Neurosurg 2009;45:262–270. DOI: 10.1159/000228984

Objectives: The aim of this study was to describe the characteristics of patients with a minor head injury (MHI) who were admitted to a pediatric emergency unit and to identify the clinical signs and symptoms that most reliably predict the need for cranial computed tomography (CCT) and hospital admission following MHI.

Methods: All patients were retrospectively evaluated according to age, gender, details of injury, presenting symptoms, physical examination findings, radiological investigations ordered and results, length of stay, outcome of the injury and hospitalization rates.

Results:The factors affecting indications for computed tomography and hospitalization were retrospectively analyzed in 916 patients – 585 males and 331 females, aged between 1month and 15 years (mean: 5.01 8 3.58 years), with MHI. A multivariate analysis revealed significant correlations between CCT abnormalities and Glasgow Coma Scale scores of 13 or 14, headache, posttraumatic amnesia, blurred vision, cephalohematomas, periorbital ecchymoses, otorrhea and abnormal neurological findings. CCT abnormalities were identified in 67 (19.8%) of the 338 CCT scans. Twenty of the 67 patients (29.9%) with CCT scan abnormality had no clinical signs. Of all cases, 125 (13.6%) were hospitalized, 617 (67.4%) were treated as outpatients, and 174 (19.0%) left the emergency department based on a personal decision.

Conclusion: Some clinical risk factors can be used as predictors of abnormalities in CCT scans following MHI, but the absence of such clinical findings does not exclude the possibility of intracranial injuries.