Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Lifting the lid on decompressive craniectomy by Associate Professor Lindy Jeffree

52 views

Published on

Associate Professor Lindy Jeffree: Lifting the lid on decompressive craniectomy.
From CICM ASM PROGRAM 2019.

Published in: Health & Medicine
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Be the first to like this

Lifting the lid on decompressive craniectomy by Associate Professor Lindy Jeffree

  1. 1. Lifting the Lid on Decompressive Craniectomy Associate Professor Lindy Jeffree Royal Brisbane Hospital University of Queensland
  2. 2. Decompressive craniectomy Huh J 2018 J Korean Neurosurgical Society Ragel BT 2010 JNS Hieu PD 1996 Childs Nerv. Syst. Unilateral Bifrontal …sinus strip• Stroke • Trauma • RBWH practice • Cranioplasty • Decisions
  3. 3. Craniectomy for MCA stroke DECIMAL DESTINY HAMLET Stroke size >50% MCA >2/3 MCA territory >145cms DWI basal ganglia mass effect Age 18-55 yrs 18-60 yrs NIHSS ≥16 ≥18, ≥ 20 ≥16, ≥21, GCS <14 Timing <30 hrs <42 hrs <99 hrs Craniectomy ‘large’ > 12 cms Outcome MRS 0-3 vs 4-6 Vahedi K 2007 Stroke Juttler E 2007 Stroke Hofmeijer J 2006 BMC
  4. 4. Decompression for MCA stroke MRS >4 12 months MRS >3 12 months Death at 12 months DECIMAL DESTINY HAMLET Total Vahedi K et al 2007 Lancet Neurol 2007; 6: 215–22 Modified Rankin Scale 0 No symptoms 1 No significant disability 2 Slight disability, 3 Moderate disability 4 Moderately severe disability 5 Severe disability 6 Death Favours conservative Favours surgery
  5. 5. Decompression for MCA stroke: Pooled results Vahedi K et al 2007 Lancet Neurol 2007; 6: 215–22 NNT 2 to prevent death, 8.3 to achieve slight disability NNH 3.6 => mod-severe disability, 55% aphasia Good Death Conservative treatment Surgery Bedridden Help with ADLs & walking
  6. 6. DECRA trauma trial: Methods • 15 hospitals: Australia, NZ, Saudi Arabia • 15-59 years, • GCS 3-8 or Marshall class III • EVD • ICP > 25mmHg for >5 mins x2 in 30 mins • Randomised in first 48 hours • Bifrontotemporal craniectomy Cooper DJ et al (2011) NEJM 364:1493-1502
  7. 7. Protocol modifications Randomization < 3 days ICP >20 for 15 mins EVD not required (~70%) DECRA trial: Recruitment Cooper DJ et al (2011) NEJM 364:1493-1502 Dec 2002 – April 2010 Follow up 100% Follow up 100% 5%
  8. 8. Cooper DJ et al (2011) NEJM 364:1493-1502 Death Good recovery DECRA trial: Outcomes
  9. 9. RESCUEicp: Methods • Aimed for 400 patients over 4 years • 10-65 years old • ICP >25 for 1 hour • Unilateral or bifrontal craniectomy • Crossover permitted if Stage 3 failed Hutchinson N Engl J Med 2016; 375:1119-1130
  10. 10. RESCUEicp: Results • 408 patients • 15 hospitals • UK, Europe • 2004-2014 • NNT GOS >3 =12 Hutchinson N Engl J Med 2016; 375:1119-1130 Death Good recovery
  11. 11. What is a ‘good outcome’. https://lifeinthefastlane.com/rescueicp-and-the-eye-of-the-beholder/ Dr Alistair Nichol
  12. 12. Audit of RBWH practice • Ethics exemption • Bone Flap Register • 2012-2018 • Diagnosis • Reason for surgery • Outcome • Cranioplasty timing & complications
  13. 13. RBWH Craniectomies: Reasons for surgery Pure decompressionCraniectomy en passant
  14. 14. RBWH outcomes: Craniectomy for MCA stroke RBWH n=25 Pooled trials n=93 HomeRehabN/HDeath
  15. 15. RBWH outcomes: Craniectomy for MCA stroke Time to surgery (hours) From presentation From RBWH admission Mean (hours) 51 32 Range 2-117 22-118 Length of stay post op (days) RBWH all RBWH survivors Total QHealth Mean 45 62 122 Range 8-421 22-421 Hours Glasgowoutcomescale Low disability Death
  16. 16. RBWH outcomes: Decompression in Trauma Time to surgery 68 hours (5-230) QHealth admission 111 days (39-243) RBWH n=10 RESCUEicp n=408
  17. 17. RBWH Craniectomies: Diagnosis Pure decompressionCraniectomy en passant
  18. 18. Fraioli, M 2016 Open Access Library Journal International Business Times Hempenstall J 2012 JICS neurowhoa.blogspot.comhttps://www.bbc.com/....-23195940
  19. 19. Cranioplasty at RBWH • Time to cranioplasty 117 days (14 – 799) • 41 during index admission • Length of stay 6 days Complications Return to theatre for haemorrhage 15 Symptomatic haemorrhage 1 Imaging haemorrhage 6 Infected & removed 1 CSF circulation problem 7 Infection 3 Post op neuro deficit 4 Bone resorbed 1 Bone loose 1 39 = 33% Cranioplasty material (n=119) Pre-formed Ti AcrylicOwn bone
  20. 20. PRECIS Prospective Randomized Evaluation of therapeutic decompressive Craniectomy In Severe traumatic brain injury with mass lesions • Mass lesion • Replace if possible vs leave out anyway • +- Salvage decompression • 15 x 12 cms craniotomy • ICP <25, CPP >60 • Salvage if ICP >30 or ICP >25 for 1hr & midline shift etc on scan. • Acute SDH • 990 patients >16 yo • >11cm craniotomy • Randomised intra-op • Outcomes include Return to OT • May 2019: Enrolment “officially over” - 463 patients randomised Zhao H-X (2016) BMC Neurology 16:1http://www.rescueasdh.org/home
  21. 21. When to consider decompressive craniectomy • Large volume MCA stroke & patient who is drowsy: => doubles survival, patient disabled. • Severe closed head injury and ICP >25 mmHg for 1 hour: => reduced mortality, survivors severely disabled. Whether to do one depends on what the patient would consider an acceptable outcome.
  22. 22. Talking to the family 1. Listen about the – Event - Person 2. Explain - Extent of injury - Range of outcomes - Best outcome 3. Offer Care options: Shared decision https://www.news-mail.com.au/news/the-life-of-a-trauma-patient/3231785/.

×