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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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