Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury.

BACKGROUND: Decompressive craniectomy has historically served as a salvage procedure to control intracranial pressure after severe traumatic brain injury. We assessed the safety and feasibility of performing craniectomy as the initial surgical intervention. METHODS: Of 29 consecutive patients undergoing emergent decompression for severe traumatic brain injury with horizontal midline shift greater than explained by a removable hematoma, 17 had traditional craniotomy with or without brain resection and 12 underwent craniectomy. RESULTS: The craniectomy group had lower Glasgow Coma Scale scores at surgery (median, 4 vs. 7; p = 0.04) and more severe radiographic injuries (using specific measures). Mortality, Glasgow Outcome Scale scores, Functional Independence Measures, and length of stay in both the acute care setting and the rehabilitation phase were similar between the surgical groups. CONCLUSION: Despite more severe injury severity, patients undergoing initial craniectomy had outcomes similar to those undergoing traditional surgery. A randomized evaluation of the effect of early craniectomy on outcome is warranted.

Cerebral angiography practices at US teaching hospitals. Implications for carotid endarterectomy.

BACKGROUND AND PURPOSE: Although several clinical trials of carotid endarterectomy (CE) have been carried out in the last decade, the methods for angiographic measurement of carotid stenosis have not been standardized. How one measures carotid stenosis may affect the applicability of clinical trial results. We sought to obtain information on cerebral angiography practices at teaching hospitals in the United States. METHODS: We surveyed hospitals with an accredited radiology residency program. RESULTS: Of the 200 radiology program directors who were sent the survey, 97 responded. The angiographic complication rate was known in 68 of 97 medical centers and averaged 0.6%. The most common method being used for measurement of carotid stenosis is the NASCET method (70%). Forty-two of 97 program directors reported a decrease in the volume of angiography being performed. Of these 42, one third reported that CE was commonly being performed on the basis of noninvasive tests alone. CONCLUSIONS: The angiographic complication rate at American teaching hospitals is within the "acceptable" range. The NASCET method of stenosis measurement is the most popular among academic radiologists. The volume of cerebral angiography appears to be decreasing. How these data compare with community hospitals without an accredited radiology residency program warrants further study.