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

Database and bibliographic research

We conducted a scoping literature review focused on STP requiring both a cranial and an extracranial procedure, using two different sources.

First, Medline database (ncbi.nlm.nih.gov/pubmed/) was screened from inception until September 2021. We used the advanced research mode with the following associations of terms in the title: (Brain injury OR Head trauma OR Epidural OR Acute subdural OR Subdural OR Cranial OR Neurosurgery OR Cranial surgery) AND (Polytrauma OR Femur OR Pelvis OR Pelvis OR orthopedic OR visceral OR abdominal OR abdomen OR spleen OR endovascular OR thorax).

Second, we searched potentially eligible works directly in the reference list of relevant articles.

Inclusion and exclusion criteria

All the English language patient original series or case reports reporting cranial procedures and extracranial procedures carried out during the first 24 h following trauma were included in the study, regardless of the objectives of the study or the length of the follow-up. Given the paucity of the literature on the subject, the original patient series concerning STP with a cranial procedure without extracranial procedure during the first 24 h following trauma was also retained. Review articles, abstracts, expert opinions, and editorials relevant to the subject were included in the discussion.

The exclusion criteria were articles written in foreign language, articles not found on the internet despite being indexed in Medline, STP series with no cranial procedure carried out, pediatric series, and articles not directly relevant to the subject.

Data extraction

All the articles included in the quantitative analysis were screened in a systematic manner and the following information were extracted: Author and year of publication; study type, inclusion criteria and study goal; age and sex of the patients; cause of polytrauma; mean ISS, head AIS, and peripheric AIS; GCS; pupil examination; presence of an open fracture; hemorrhagic shock; tracheal intubation and tracheotomy; intracranial pressure (ICP) monitoring; neurosurgical procedures; peripheral procedures performed early (≤24 h) or late (>24 h); whether the cranial and peripheric procedure was performed concomitantly; secondary brain insults; Glasgow Outcome Scale (GOS); and mortality. This work was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.^[27]

Primary and secondary endpoints

The first aim of this work was to synthetize current knowledge concerning STP requiring undelayable concomitant cranial and extracranial surgery. The other objective of this study was to evaluate the feasibility of combining an extracranial procedure for non-compressible hemorrhage and a cranial procedure for hematoma evacuation, to reduce the time spent with intracranial hypertension.

Statistical analysis and level of evidence

Given the heterogeneity of the articles included in this review, the original statistical analyses were retained if they were deemed relevant. No further statistical analysis was carried out. A two-sided P ≤ 0.5 was considered to indicate statistical significance.

The level of evidence of each statement was reported using the Levels of Evidence of Oxford Centre for Evidence-Based Medicine and also according to the Grading of Recommendations, Assessment, Development, and Evaluation methodology.^[28,29]

Database and bibliographic research

The Medline search yielded 138 articles after removal of duplicates. One hundred and twenty-two articles met one of the exclusion criteria after reading the abstract. After reading the text entirely, the remaining 16 articles were also excluded from the study [Figure 1].

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Figure 1:

Preferred reporting items for systematic reviews and meta-analyses flowchart.

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The bibliographic research yielded 44 articles. Nineteen articles met the exclusion criteria after reading the abstract. After reading the text entirely, 13 articles also met the exclusion criteria. Hence, 12 articles were finally retrained in the qualitative analysis and 10 articles in the quantitative analysis.^[30-39] Seven articles were published before 2002, and the remaining three articles were published since 2018.

The articles included displayed an important heterogeneity regarding both the study goal and the inclusion criteria. Five articles (42%%) were focused on the optimal timing of extracranial surgery in the context of sTBI,^{[30-32,34,35]} 4 articles (33%) dealt with neurological outcome in sTBI patients depending on the presence of extracranial injury,^[33,36-38] and 1 article (8%) was focused on defining clinical and biological characteristics associated with neurological outcome in STP with sTBI.^[39] The last 2 articles (17%) included in the qualitative analysis were an expert opinion and a recommendation article.^[13,26]

Epidemiology

A total of 2086 patients were included, among which 787 patients (38%) suffered from severe trauma associated with sTBI. The mean age was 38.2 years old; it was 31.8 years old in the articles published before 2002 and 50.2 years old in the articles published since 2018. The male-to-female sex ratio was 2.8/1. The main reported causes of polytrauma were traffic accident in 52% of the cases, fall from height in 13% of the cases, and assault in 9% of the cases.

Clinical presentation

Considering only STP with concomitant sTBI, the mean ISS was 32.1. The mean head AIS was 4.0, and the mean peripheric AIS was 3.3 for the thorax, 2.9 for the abdomen, and 2.7 for extremity/orthopedics. The mean GCS score was 9.6 out of 15. About 23% of these patients presented with hemodynamic shock compared with 4% of the patients with TBI only. It is noteworthy that two authors reported a significantly higher rate of shock among STP with TBI and extracranial injuries compared with patients with isolated TBI (P < 0.001)^[37] and among patients with an unfavorable outcome (P < 0.001).^[39] In the three studies which mentioned it, the coagulation parameters were significantly altered with a diminution of the platelet count, a rise of the prothrombin time, and a rise of D-dimers and fibrin degradation products [Tables 1 and 2].^[37-39]

TBI patterns

Considering only STP with concomitant sTBI, there were 12% (n = 195) of skull fractures reported. There were 2% (n = 27) of depressed fractures which were operated on. There were 10% (n = 161) of EDH, 13% (n = 212) of ASH, and 3% (n = 56) of unspecified extra-axial lesions. There were 12% (n = 202) of traumatic subarachnoid hemorrhage, 17% (n = 281) of brain contusion, and finally 2% (n = 36) of diffuse axonal injury reported [Supplementary Table 1].

Surgical management

Considering only STP with concomitant sTBI (n = 1587), 20% (n = 316) underwent a cranial procedure. It was a craniotomy in 90% of the cases (n = 284), and in 10% of the cases (n = 32), the procedure was not specified between craniotomy and craniectomy. In 1.6% of the cases (n = 27), the cranial and the extracranial surgeries were performed <24 h after the trauma. Among these 27 cases, 3 patients (0.2%) underwent a combined cranial and abdominal procedure [Table 3].

In the articles focused on the timing of peripheric osteosynthesis in the context of concomitant TBI, the mean extremity/orthopedic AIS was significantly higher (P ≤ 0.01) and there was a significantly higher rate of open fractures (P ≤ 0.02) in early peripheric osteosynthesis (EPO) groups compared with delayed peripheric osteosynthesis (DPO) groups.^[34,35] 3/4 articles were in favor of EPO within the first 24 h following trauma. In two of them, no difference in the outcome between EPO and DPO groups was found (P=0.23 and P = not significant).^[34,35] However, the patients who underwent EPO presented higher need of blood transfusion (P = 0.01)^[34,35] and fluid resuscitation (P = 0.01)^[34] compared with DPO groups. Three articles reported early thoracotomy and laparotomy within the first 24 h following trauma, although no subgroup analysis was carried out.^[32,35,36]

Perioperative management

Six articles mentioned the use of invasive ICP monitoring devices.^[32-36,38] About 14% (n = 295) of the patients benefited from invasive ICP monitoring, among which there were 53% (n = 157) of intraparenchymal monitors, 20% (n = 58) of external ventricular drains (EVD), and 27% (n = 80) of unspecified devices. No difference in the occurrence of episodes of ICH was observed between the groups of EPO and the groups of DPO.^[34,35] On the same way, no difference was observed between the groups of isolated sTBI and the groups of STP with sTBI.^[33,36] Thus, 4/4 articles were in favor of invasive ICP monitoring during peripheric procedures.^[34-36]

Four articles reported the secondary brain insults that occurred perioperatively or during the intensive care unit stay. Regarding hypotension (generally defined as a SBP ≤90 mmHg or a mean arterial pressure ≤ 65 mmHg) and hypoxia, two articles reported a comparable occurrence rate between polytrauma patients with TBI undergoing EPO or DPO (P = not significant),^[34,35] and one article reported inhospital comparable rates between TBI patients without or with peripheric injuries (P = 0.959 and P = 0.333).^[36]

Complications

Complications were only mentioned in six articles. Neurological complications were not only reporteds in one article which mentioned infection of ICP monitor, meningitis, and encephalitis but also post-operative seizures after peripheric osteosynthesis whether they were in the EPO or the DPO group [Supplementary Table 2].^[34]

Concerning extracranial complications, the series exhibited high rates of nosocomial infection (30 up to 34%) and septic shock (up to 14%) in polytraumatized patients with sTBI but also deep venous thrombosis and pulmonary embolism (4 up to 10%). The important number of other rarely reported complications, such as fat embolism, acute respiratory distress syndrome, acute pancreatitis, acute cholecystitis, acute renal failure, stress ulcer or gastrointestinal bleeding, and decubitus ulcer, reflects the seriousness of STP with sTBI in this review.

Outcome

In this review, considering only STP with concomitant sTBI, 67% of the patients presented a favorable outcome defined as a GOS ≥4 (4 being considered “moderate severe disability”). The mortality rate for these patients was 18% [Table 4]. 3/3 articles showed that sTBI predicted neurological outcome independently from the presence of extracranial lesions (P < 0.05), and one article showed no difference in the outcome between patients without and with extracranial injuries (P = 0.301) [Table 4].^[33,36-39]

One article showed that extracranial injuries were not predictive of the mortality rate in STP with associated severe (P = 0.08).^[38] Another article showed that additional extracranial injuries were predictive of mortality (P = 0.042).^[37]

Context

As great progress has been made in patient triage,^[40] pre-hospital emergency care,^[41] and neuroresuscitation over the past 30 years,^[6,42] the concept of STP has simultaneously evolved toward more serious and somewhat older patients with greater ISS and higher in-hospital mortality^[2,3,43] In the same time, the profile of sTBI patients has also moved to older male patients suffering fall from a height.^[16,44] These epidemiologic changes, combined with the reduction of early mortality caused by exsanguination thanks to the implementation of massive blood transfusion protocols,^[4,45,46] have opened the door to hospital admission of severely injured patients with simultaneous life-threatening intracranial hematoma and extracranial bleeding. Because such patients are rarely encountered, there is no scientific evidence to guide their emergency surgical management and recommendations are based on studies concerning isolated organ traumatism.

Definition of undelayable traumatic cranial surgical emergencies

ASH is the most frequently encountered traumatic extra-axial lesion. A patient meeting ASH surgical criteria such as hematoma thickness >10 mm or midline shift >5 mm, a drop ≥2 point on the GCS score, abnormal pupil examination, or ICH >20 mmHg should undergo urgent surgical evacuation within 4 h following trauma.^[23,25]

EDH is rarely encountered but seems to be more frequent in polytrauma patients with sTBI.^{[30,32,33,35]} A patient meeting EDH surgical criteria such as a volume >30 mL or a thickness >15 mm, a midline shift >5 mm, and a GCS score ≤8 or focal symptoms should undergo immediate surgical evacuation.^[22]

More diffuse TBI first requires aggressive neuroresuscitation measures guided by an invasive ICP monitor, such as an EVD which allows cerebrospinal fluid (CSF) drainage.^[47] Decompressive craniectomy (DC) should be considered in a 2^nd time in case of traumatic ICH refractory to maximal medical treatment. Hence, diffuse TBI rarely requires urgent cranial surgery on admission.^[24] Consequently, ASH and EDH constitute the majority of traumatic intracranial lesions requiring undelayable surgical evacuation in STP.

Definition of undelayable extracranial surgical emergencies

In contrary to hemorrhages of the limbs which can be controlled with a tourniquet, non-compressible thoracic, abdominal, and pelvic hemorrhages constitute most of the extracranial undelayable life-threatening lesions. Resuscitation thoracotomy for cross-clamping of the descending aorta is a last resort option that can be performed in the emergency room by general surgeons for STP with <15 min of cardiopulmonary resuscitation. The other undelayable thoracic emergencies include exsufflation and drainage of tension pneumothorax and thoracotomy for massive hemothorax with chest tube blood output >1500 mL.^[48,49]

Life-threatening abdominal trauma emergencies are managed by “abbreviated” damage control laparotomy and include bleeding from solid organ (spleen, liver, or kidney) or from mesenteric rupture in hemodynamically unstable patients or which are not accessible to endovascular treatment and hollow organ perforation at high septic risk.^[8,50] During the same procedure, pre-peritoneal packing for pelvic fracture-associated hemorrhage can be achieved if necessary.^[51] Open Tile C pelvic fracture requires urgent closure with an external fixator given the immediate risk of massive exsanguination in the pelvis.^[52]

Damage control principles facing two concomitant surgical emergencies

In face with STP suffering from combined life-threatening intracranial and extracranial lesions, the resuscitation objectives are to maintain a proper cerebral perfusion pressure and, in the same time, to limit exsanguination as much as possible. In such case, neuroresuscitation guidelines recommend to maintain the SBP >110 mmHg even if it may sustain extracranial bleeding,^[53] the SpO₂ ≥96, the PaCO₂ between 30 and 35 mmHg, the body temperature between 35 and 37 Celsius degrees, and blood sugar level between 8 and 10 mmol/L to limit the occurrence of secondary brain insults.^[54] On the same way, the platelet count should be maintained >50 G/L in STP, and >100 G/L in case of life-threatening hemorrhage or sTBI, and the fibrinogen level >1.5–2 g/L.^[55]

Aside from the fact that exsanguination eventually leads to hypovolemic shock, the ongoing extracranial bleeding must be stopped as soon as possible because it participates in trauma-induced coagulopathy caused by direct loss of coagulation factors.^[56] What is more, TBI is responsible for a brain-induced coagulopathy with releasing of tissue factor and activation of the extrinsic coagulation pathway, with increased consumption of platelets and coagulation factors.^[57] These trauma-induced coagulopathies, along with the lethal triad in a hypovolemic STP,^[58] sustain the ongoing bleeding. This vicious hemorrhagic circle is the rationale for damage control thoracic or visceral surgery designed to “prioritize short-term physiological recovery over anatomical reconstruction.”^[59] These procedures’ aim is to perform a fast and reproducible exploration of the major sources of bleeding and to achieve temporary hemostasis using drainage, packing, splenectomy, and shunt but also sometimes to perform intestine repair or excision in face with hollow organ perforation.^[8,49]

Rotational thromboelastometry is of great support to optimize massive transfusion protocols in such context.^[60] What is more, SBP targets are very difficult to reach in face with a persistent uncontrolled hemorrhage, which directly contributes to secondary injuries to the brain, also known as cerebral “second hits.”^[61] The trauma leader should be aware of the need for early massive transfusion protocol for these patients. Indeed, greater transfusion requirements were clearly highlighted in the present review for patients undergoing EPO.^[34,35]

In our opinion, damage control neurosurgery for any compressive ICH can be performed concomitantly to almost any other hemostatic surgery.^[14,26] DC represents the fast, standardized, and reproducible damage control neurosurgical procedure to alleviate ICH in this emergency setting.^[14,62] Indeed, DC allows both the evacuation of any extra-axial or intraparenchymal hematoma and the optimal control of ICH by allowing brain expansion directly under the skin. Guidelines recommend the use of an invasive ICP monitor in case of sTBI (GCS ≤8) with non-operative brain lesions on the CT scan or after cranial surgery in STP and to maintain a CPP between 60 and 70 mmHg.^[19,54,63] For this purpose, an EVD should be preferred because it allows both the surveillance of ICP and CSF drainage in case of ICH.^[47,63]

Place for concomitant endovascular embolization (EE)

Nowadays, EE can be considered for any active bleeding in STP. Although the current guidelines and hospital practice still recommend open surgery in case of hemodynamically unstable patients,^[64,65] a combined intervention with cranial procedure and EE could theoretically be possible depending on the ability of the resuscitation team to stabilize hemodynamic status, and with the agreement between the surgical and the interventional team before the procedure. As an example, Kataoka et al. reported the case of a 24-year-old male patient with an ISS of 57, who successfully underwent DC combined with perihepatic packing closely followed by intraoperative EE of the right renal artery. Finally, the patient underwent embolization of the right portal vein for venous bleeding.^[66]

Practical implementation of a combined surgical or interventional treatment

The present review highlights a few concepts [Table 6]:

• Emergency peripheric osteosynthesis can be performed in polytrauma patients with concomitant sTBI.^[34,35]

• Invasive ICP monitoring is mandatory during peripheric surgeries in case of concomitant intracranial lesions.^[34-36]

• The outcome of polytrauma patients essentially depends on the seriousness of TBI, independently from the presence of extracranial injuries.^{[33,36,37,39]}

• After exclusion of early in-hospital deaths, the impact of extracranial injuries on mortality in patients with concomitant sTBI is uncertain.^[37,38]

This review also depicts the typical polytraumatized population from which patients with concomitant life-threatening intracranial and extracranial lesions can be encountered. Nevertheless, it does not provide any concrete evidence concerning the management of patients requiring concomitant life-saving cranial and extracranial surgeries, as the only relevant information available in the literature since 2003 are expert opinions.^[13,26]

The main theoretical objectives of combined cranial and extracranial surgery are to reduce the time spent with ICH to optimize neurological outcome and also to hasten the admission in the intensive care unit to facilitate resuscitation. Nevertheless, combining two different procedures in STP can lead to important blood loss exceeding the coagulation capacities of the patient and the supporting capacities of the resuscitation team. Hence, the timing of the beginning of the cranial procedure should be a joint decision between the neurosurgical and the resuscitation team, depending on the necessity of stopping the extracranial source of bleeding before the cranial incision and taking into account the hemorrhagic risk of the cranial surgery itself [Figure 2].

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Figure 2:

Emergency surgical management of patients with concomitant life-threatening intracranial hematoma and extracranial non-compressible hemorrhage. (Upper diagram) The current guidelines with extracranial procedure first, closely followed by cranial damage-control surgery. (Lower diagram) proposition for a combined cranial and extracranial procedure which allows to reduce the time spent with intracranial hypertension and to hasten admission in the intensive care unit.

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What is more, combining two different procedures in an extreme emergency context imply high adaptation capacities from all the caregivers involved. At least one team must work outside of its usual operating room, and the main operators must have proper access to the patient. That being said, a damage control thoracotomy, a laparotomy, or a femoral endovascular access are usually performed in supine position, which is perfectly suited for DC.^[62] As military surgeons, we are specifically trained to stick to damage control procedures and to perform surgery in a low-resource setting, thus making it somewhat easier to orchestrate combined procedures in an acute trauma setting [Figure 3].^[67,68]

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Figure 3:

Combined cranial and extracranial surgery in a 24-year-old severe trauma male patient. On the left side, splenectomy performed by the visceral team wearing green gowns. On the right side, epidural hematoma evacuation performed by the neurosurgical team wearing blue gowns.

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Particular case of low- and middle-income countries

The management of STP in low- and middle-income countries poses two specific issues. First, in low-income countries, isolated depressed skull fracture from physical assault constitutes most of the sTBI requiring neurosurgical procedure (45%). Indeed, the epidemiology of the mechanism of trauma differs from that of high-income countries, and so do the most serious trauma lesions.^[69] Given that fall from high and high-velocity traffic accidents are less frequent compared to high-income countries, STP with combined cranial and extracranial lesions is less likely to be encountered.

Second, the median time from injury to admission is much longer in low-income (15 h, 5–46) and middle-income countries (8 h, 4–20) compared to high (4, 2–12) and very high-income countries (2, 1–7).^[69] This is related to the lack of efficient emergency pre-hospital care in low-income countries, where trauma patients are brought to the hospital directly by private vehicles or by ambulance without medical or paramedical staff. Given these elements, and considering the fact that STP suffering from combined cranial and extracranial life-threatening injuries can only survive massive exsanguination on the trauma scene with the support of exceptional pre-hospital care, it seems very unlikely that such type of very serious trauma patient could reach a Level 1 trauma center alive in low- and middle-income countries. In other words, in low- and middle-income countries, STP with combined cranial and extracranial lesions is more rarely encountered compared to high-income countries, and they usually do not make it to the hospital alive.

Limitations

This review presents a few limitations that include a risk for incomplete retrieval of identified research. Indeed, we conducted a review on Medline database looking for specific terms in the title of the articles, which restricted the number of potentially eligible articles for screening compared to a genuine systematic review using Mesh terms. Besides, the heterogeneity of the subject renders any attempt of systematic review unrealistic. Given the retrospective nature of this work, there was a measurement bias from the authors at the time of writing of the articles retained and a bias during our own collection of data. There was also an attrition bias considering the proportion of missing data.

On the other side, to the best of our knowledge, this review is the first aiming to define a rarely encountered type of SVT requiring undelayable combined cranial and extracranial procedures.