Outcome of Early Surgical Interventions for Cerebral Contusions

Abstract

The bruising of brain tissue is cerebral contusion. It can be compared to bruises in other parts of the body only after microscopic examination. Cerebral contusions consist of areas of injured or swollen brain mixed with blood that has leaked from arteries, veins, or capillaries. Mostly contusions occur at the base of the front parts of the brain, but may occur anywhere. An intracerebral hemorrhage (ICH) describes bleeding within the brain tissue; it may be related to other brain injuries, especially contusions. The size and location of the hemorrhage helps determine whether it can be removed surgically or not.

Objectives: The main purpose of early surgical intervention for cerebral contusion is to prevent secondary brain injury. Extravagated blood is believed to be neurotoxic, leading to secondary injury that may be avoided by early surgical removal. Cerebral contusion of brain does not seem to recover and appears later as encephalomalacic brain tissue loss on convalescent phase imaging. Tissue loss is not increased by removal of irreversibly damaged brain contusion. Patients can deteriorate clinically after intracerebral hemorrhage arising   and the question of early surgery to anticipate such secondary damage.

Methods & Materials: Early management of patients with TICH requires evaluation to determine whether early surgery should become part of the standard of care. This randomized patient group trial compared early surgery (within 12 h of randomization) with initial conservative treatment (subsequent surgery allowed if deemed necessary). Patients were randomized using an independent randomization service within 48 h of TBI. Patients were eligible if they had no more than two intra-parenchymal hemorrhages of 10 ml or more and did not have an extradural or subdural hematoma that required surgery.

Results: The primary outcome measure at 6 month was the traditional dichotomous split of the Glasgow Outcome Scale. Total of 170 patients were registered for this trial. From 82 patients randomized to early surgery with complete follow-up, 30 (37%) had an unfavorable outcome. Of 85 patients randomized to initial conservative treatment with complete follow-up, 40 (47%) had an unfavorable outcome (odds ratio, 0.65; 95% confidence interval, CI 0.35, 1.21; p=0.17), with an absolute benefit of 10.5% (CI, −4.4–25.3%). There were significantly more deaths in the first 6 months in the initial conservative treatment group (33% vs. 15%; p=0.006). The 10.5% absolute benefit with early surgery was consistent with the initial power calculation.

Conclusions: Use of surgical intervention for treatment of cerebral contusion varies around the world. In Asia surgical interventions are more frequent than in Europe or North America. Implementation of early referral and diagnosis with immediate treatment may reduce incidence of death and disability in this specific group of TBI patients. The occurrence of cerebral contusion is a definitive risk for higher mortality and prolonged disability. Surgical intervention at the right moment can however, change the course of this fatal condition and lead to improved outcomes in cohorts of severe traumatic brain injury.