Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept

Nathan Beucler; Aurore Sellier; Christophe Joubert; Henri De Lesquen; Ghislain Schlienger; Alexandre Caubere; Quentin Holay; Nicolas Desse; Pierre Esnault; Arnaud Dagain

doi:10.25259/JNRP-2022-1-38-R1-(2348)

Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept

J Neurosci Rural Pract. 2022 Oct-Dec;13(4):585-607. doi: 10.25259/JNRP-2022-1-38-R1-(2348). Epub 2022 Dec 2.

Authors

Nathan Beucler^{1

2}, Aurore Sellier¹, Christophe Joubert¹, Henri De Lesquen³, Ghislain Schlienger⁴, Alexandre Caubere⁵, Quentin Holay^{2

6}, Nicolas Desse¹, Pierre Esnault⁷, Arnaud Dagain^{1

8}

Affiliations

¹ Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France.
² Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France.
³ Department of Thoracic and Vascular Surgery, Sainte-Anne Military Teaching Hospital, Paris, France.
⁴ Department of Visceral Surgery, Sainte-Anne Military Teaching Hospital, Paris, France.
⁵ Department of Orthopaedic Surgery, Sainte-Anne Military Teaching Hospital, Paris, France.
⁶ Department of Diagnostic and Interventional Radiology, Sainte-Anne Military Teaching Hospital, Paris, France.
⁷ Department of Intensive care unit, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France.
⁸ Department of Val-de-Grâce Military Academy, Paris, France.

Abstract

Objectives: Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH).

Materials and methods: A scoping review was conducted on Medline database from inception to September 2021.

Results: The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D).

Conclusion: This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.

Keywords: Combined surgery; Damage control; Intracranial hematoma; Non-compressible hemorrhage; Severe trauma patient; Traumatic brain injury.

Publication types

Review