Background and purpose: Trend of trepanation as an optional surgical procedure was investigated in cases with severe traumatic brain injury (TBI), by comparing data from Japan Neurotrauma Data Bank (JNTDB) Project 2015 with those from Project 2009.
Materials and Methods: Two–hundred and thirty cases with severe TBI, who were initially treated by trepanation, were involved in this study (M:F = 133:97, Age 67±20 y.o.). In these cases, following parameters were summarized from JNTDB Project 2015 database, to compare with those of 2009; age, gender, cause of trauma, Glasgow Coma Scale (GCS) scores on admission, worst GCS scores, presence of mydriasis, CT findings (intracranial hematoma thickness, width of midline shift, and appearance of ambient cistern), Glasgow Outcome Scale (GOS) scores on discharge. Correlation between preoperative clinical parameters and GOS scores were also examined in cases with acute subdural hematoma (ASDH), in particular.
Results: There was no significant difference in gender, age, cause of TBI, distribution of targeted intracranial hematoma, and GCS scores between Project 2015 and 2009. Mydriasis were presented bilaterally in 66 (29%), unilaterally in 37 (16%), and not in 125 (54%) in Project 2015. Compared to Project 2009, bilateral mydriasis was significantly decreased in Project 2015, as normal pupil reaction was significantly increased. In appearance on CT, ambient cistern appeared normal in 44 (19%), unilaterally compressed in 110 (48%), and disappeared in 76 (33%) in Project 2015. Compared to Project 2009, disappeared ambient cistern was significantly decreased, as normal and unilateral compression was significantly increased in Project 2015. Thickness of midline shift was significantly decreased in Project 2015 than 2009. Intracranial hematoma thickness was significantly larger in Project 2015 than 2009, in contrast. GOS scores were GR in 8 (3%), MD in 31 (14%), SD in 57 (25%), VS in 30 (13%), and D in 103 (45%). Mortality was significantly decreased in Project 2015 than 2009, although favorable outcome (GR+MD) was not significantly different between them. In Project 2015, a combination of GCS score 3 and bilateral mydriasis, or disappearance of ambient cistern on CT could correctly expect mortality in cases with ASDH, as well as Project 2009.
Conclusion: Emergency trepanation is widely used in cases with severe TBI in Japan. Recent decrease in mortality may be brought by avoiding trepanation in cases who presented with a couple or more of brain herniation signs.
