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. 2019 Mar;161(3):435-449.
doi: 10.1007/s00701-018-3761-z. Epub 2018 Dec 19.

Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study

Thomas A van Essen  1   2 , Hugo F den Boogert  3 , Maryse C Cnossen  4 , Godard C W de Ruiter  5 , Iain Haitsma  6 , Suzanne Polinder  4 , Ewout W Steyerberg  4   7 , David Menon  8 , Andrew I R Maas  9 , Hester F Lingsma  4 , Wilco C Peul  10   5 ; CENTER-TBI Investigators and Participants
Collaborators, Affiliations

Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study

Thomas A van Essen et al. Acta Neurochir (Wien). 2019 Mar.

Erratum in

Abstract

Background: Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe.

Methods: A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP).

Results: The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions.

Conclusion: Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care.

Keywords: Acute subdural hematoma; Neurosurgery; Practice variation; Traumatic brain injury.

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Conflict of interest statement

The authors declare that they have no conflicts of interest.

All procedures performed in studies involving human participants were in accordance with ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments.

Figures

Fig. 1
Fig. 1
Centers and countries included in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Reprinted and updated from Cnossen et al. (2016) with permission from Dr. Cnossen and Maas et al. (2015). Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury: a prospective longitudinal observational study. Neurosurgery, 76:67–80, under a CC BY license, with permission from professor A.I. Maas
Fig. 2
Fig. 2
Factors of influence on neurosurgical decision-making. Shown are the percentages of centers that would be never/rarely, sometimes or frequently/always influenced by the described factors in the decision to perform neurosurgical procedures. Question was completed by all 68 centers. ICP: intracranial pressure; ED: Emergency Department B Other factors were not predetermined but were specified by responders
Fig. 3
Fig. 3
Treatment indications for neurosurgical interventions. Shown are the proportions of centers that generally have these specific preferences with regard to operating or not in ASDH, ICH, and raised intracranial pressure, respectively. ASDH: acute subdural hematoma; DC: decompressive craniectomy; ICH: intracerebral hematoma; ICP: intracranial pressure
Fig. 4
Fig. 4
BTF guideline adherence. Shown are the percentages of centers that reported to never/rarely, sometimes or frequently/always follow the Brain Trauma Foundation guidelines for the management of SDH, EDH, or contusions. Question was completed by 68 of the 68 centers. TBI: traumatic brain injury; SDH: subdural hematoma; EDH: epidural hematoma
See this image and copyright information in PMC

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