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A Journal on Neurosurgery

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Journal of Neurosurgical Sciences 2018 April;62(2):153-77

DOI: 10.23736/S0390-5616.17.04255-2


language: English

Decision making in very severe traumatic brain injury (Glasgow Coma Scale 3-5): a literature review of acute neurosurgical management

Jeroen T. van DIJCK 1, 2 , Florence C. REITH 3, Inge A. van ERP 1, 2, Thomas A. van ESSEN 1, 2, Andrew I. MAAS 3, Wilco C. PEUL 1, 2, Godard C. de RUITER 1, 2

1 Neurosurgical Cooperative Holland, Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands; 2 Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands; 3 Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium


INTRODUCTION: Patients presenting with an early Glasgow Coma Scale (GCS) Score of 3-5 after blunt or penetrating skull-brain assaults are categorized as having sustained a very severe traumatic brain injury (vs-TBI). This category is often overlooked in literature. Impact on patients and families lives however is huge and the question “whether to surgically treat or not” frequently poses a dilemma to treating physicians. Little is known about mortality and outcome, compared to what is known for the group of severe TBI patients (s-TBI) (GCS 3-8). The main goal of this review was creating more awareness for the neurosurgical treatment of this patient group.
EVIDENCE ACQUISITION: A literature search (2000-2017) was conducted discussing “severe TBI (GCS 3-8)”, “(neuro)surgical management” and “outcome”. Ultimately 45 out of 2568 articles were included for further analysis.
EVIDENCE SYNTHESIS: Mortality rates and unfavorable outcome are high for s-TBI patients and as expected higher for vs-TBI patients. Mortality rates reach up to 100% for specific subgroups with GCS=3 and bilaterally fixed dilated pupils. Functional outcome was generally poor, but sometimes, although seldom, favorable in specific groups of vs-TBI patients after neurosurgical intervention. Factors like initial GCS, pupillary abnormalities and age seem to be associated with worse outcome.
CONCLUSIONS: Overall this literature review showed high rates of unfavorable outcome and mortality for vs-TBI patients. However, some studies, reporting relatively low mortality rates, reported “good” outcome for specific groups of vs-TBI patients. It is concluded that clinical decision making, in particular those on treatment limitations, should never be taken based on the GCS alone.

KEY WORDS: Brain injuries, traumatic - Head injuries, penetrating - Clinical decision-making - Surgical procedures, operative - Outcome assessment (health care)

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Publication History

Issue published online: March 14, 2018
Article first published online: November 10, 2017
Manuscript accepted: November 7, 2017
Manuscript received: October 31, 2017

Cite this article as

van Dijck JT, Reith FC, van Erp IA, van Essen TA, Maas AI, Peul WC, et al. Decision making in very severe traumatic brain injury (Glasgow Coma Scale 3-5): a literature review of acute neurosurgical management. J Neurosurg Sci 2018;62:153-77. DOI: 10.23736/S0390-5616.17.04255-2

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