Induced hypothermia for traumatic brain injury: A systematic review

Introduction: Traumatic Brain Injury (TBI) is one of major causes of morbidity and mortality, which requires efficacious treatment strategy. Hypothermia has long been used for TBI, but evidences regarding this treatment remain inconclusive. This study aims to review the existing evidence of induced hypothermia on functional outcome, mortality, and the rate of pneumonia acquired during hospitalization among TBI patients.

Methods: This study is a systematic review. Major online databases (Cochrane Library, PubMed, Science Direct, and EBSCO host) was searched using the following keywords: Traumatic Brain Injury AND Hypothermia OR Normothermia, and narrowed down further to journals published within the last 5 years. Only Randomized Controlled Trials (RCTs) which met the predefined inclusion criteria were included. Relevant journals were then reviewed using Study Appraisal Tool from CEBM.

Results: There were no statistically significant differences between hypothermia group and normothermia group in the two included studies in terms of functional outcome, mortality, and pneumonia. Concerning functional outcome, one of the studies yield relative risk reduction (RRR) of -0.4, while the other one had an alarming number needed to treat (NNT) of 92.62 despite positive RRR. Both studies had negative RRR for mortality and pneumonia, indicating the harm of hypothermia for TBI patients.

Conclusions: There is no evidence that TBI patients would benefit from hypothermia in terms of functional outcome, mortality, and pneumonia incident.

Keywords: Hypothermia, systematic review, traumatic brain injury

Bilateral decompressive craniectomy for traumatic brain injury: A case report

Introduction: Decompressive craniectomy is a controversial method of managing increased intracranial pressure, most commonly performed in the setting of major ischemic stroke, traumatic brain injury, and subarachnoid hemorrhage due to vascular abnormality. However, there is little literature regarding its use in the management of Intra Cerebral Hemorrhage (ICH). Decompressive craniectomy has been proven to reduce mortality significantly in the setting of ischemic infarction, most dramatically via the results of the Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery II (DESTINY II) study. The incidence of traumatic brain injury (TBI), regardless of severity, is difficult to evaluate. North American data indicate an estimated incidence of about 500/100.000 inhabitants, requiring hospitalisation in 20% of cases and leading to death in 3% of cases.¹⁶
However, the indications for decompression craniectomy remain difficult to define for the surgeon in the emergency setting, as this technique remains a controversial issue in the literature.

Case presentation: A 44-year-old female patient was admitted to our hospital due to loss of consciousness 8 hours because of a traffic accident, where the patient rode a motorcycle and then crashed into a car from behind. The neurological examination was Glasgow Coma Scale (GCS) E2M4V2, pupil anisocoria left eye > right eye, decrease light reflex both of eyes.  The patient’s CT Scan imaging showed left acute subdural hemorrhage sized> 1cm with burstlobe frontal lesion and right temporal epidural hemorrhage with a volume of 30ml and no midline shift. The patient underwent bilateral decompression craniectomy.The patient was operated on, following this, bicoronal incision, firstly right side craniotomy to evacuated epidural hemorrhage and second left side decompression craniectomy to evacuated acute subdural hemorrhage with duraplasty temporal muscle fascia. After surgery the haemodinamic was stable. Until fourth day after surgery, the GCS was E3M5Vt and the haemodinamic stable as well. The fifth day the GCS was decreased (GCS E2M2Vt), and she was died in the sixth day after surgery.

Conclusion: Patient of left acute subdural hemorrhage with burstlobe frontal lesion and right temporal epidural hemorrhage and no midline shift did early bilateral decompression craniectomy. This patient had high risk for poor neurological outcome because severe traumatic brain injury (GCS E2M4V2). After surgery her haemodinamic was stable, reduction in intracranial hypertension and undercontrol in intensive care unit. In the fifth day her condition getting worse and the sixth day was died.

Keywords: traumatic brain injury, acute subdural hemorrhage, epidural hemorrhage, decompression craniectomy

Coagulopathy as a preventive factor of mortality in pediatric severe traumatic brain injury: A systematic review and meta-analysis

Introduction: Coagulopathy is one of the most frequent but anticipated potential event in traumatic brain injury (TBI). Severe TBI in children is still a devastating problem because of its mortality. The objective of this meta-analysis was to evaluate the mortality rate following coagulopathy abnormality in severe TBI in children.

Method: Studies were searched in the Pubmed, Cochrane, JNS, and EMBASE databases. The keywords were "coagulation" OR "coagulopathy" AND "severe traumatic brain injury" AND "children" AND "death". The inclusion criteria were full-text observational study or randomized control trial, subjects in study were < 18 years old and were proven of having coagulopathy (thrombocytopenia (platelet count <100,000 per mm³)) or international normalized ratio (INR) > 1.2, and/or aPTT > 36 seconds), and GCS < 9.

Results: A total of two studies were eligible for this study - studies with subjects who had coagulation disorder before the accident or routinely consumed anti-coagulant drugs were excluded. Mortality appeared significantly more frequent in children with severe TBI and coagulopathy.

Conclusion: Based on the findings, it was concluded that coagulopathy and trauma itself have a strong correlation. TBI introduces a coagulation anomaly in which this process involves the activation of platelets and pro-coagulant molecules, but this pathology process has not yet been explored further. This still leaves research space for exploration as an attempt to prevent mortality in severe pediatric TBI in the future.

Keywords: coagulopathy, severe traumatic brain injury, children, mortality