Our next speaker is joining us from Egypt, Dr. El-Fikhi. Welcome. And he will be discussing the threshold of postoperative ICP necessary for better than vegetative outcome after decompressive craniectomy. Good afternoon. Thank you very much for the introduction. It looks like we are in a dilemma, and we are trying to get a threshold where we can continue managing our patient. First, I have nothing to declare. And severe TBI is extensive, quite expensive, whether it's primary management or in the management of its disability. That's why it's important to try to reduce people with a postoperative or a post-trauma disability. That's a WHO report on RTA. And in Egypt, we have high incidence of patients who are pedestrians rather than hit in the car and others that are cyclists. The current status has been shown. There is no specific drug treatment. Promising agents did not work in clinical trials. The evidence-based and the benefit of transferring patients to a tertiary care center, if available, and the importance of using multimodal monitoring. And that's what I would like to stress. That's very, very important. We had several talks today, and I don't want to repeat it, but it looks like refractory ICP is essential for brain herniation. But it's not the only factor. We need an individualized treatment based on physiological parameters. That's the rationale that you all know. And the questions that need to be answered, which patients may benefit from a decreased ICP and consequently a decompressive craniotomy? And that has been answered. And what is the target level of the postoperative ICP that we should try to maintain in order to improve the number of patients who are not dead or vegetative? If you have a wrong assumption, you reach a wrong conclusion. Not all patients with severe TBI are a homogeneous group. That's wrong. Not all patients with the same Glasgow Coma score are a homogeneous group. And not all patients with the same picture on the CT scan are a homogeneous group. And not all patients in which we will succeed to decrease their ICP by decompressive craniotomy are a homogeneous group. I'll skip the guidelines, and the limitations have been discussed before. And there are several trials. We did a trial in Alexandria for a prospective study of the immediate outcome. This is the DECRA study, and you all are quite aware of it. And here, if you look at this, this is the BESTRIP study of South America, where, look here, you see a difference in here. There is a shift, although the difference is not statistically different, but there is a shift towards a better outcome in patients in which ICP was monitored. The status afterwards showed that ICP-based monitoring and treatment alone may not be enough to enhance outcome. The consensus was shared by many, and these are the guidelines that we were talking about. That's the fourth edition. And it says that bifrontal decompressive craniotomy is recommended. However, it has to be large enough, and the final results will be announced later. The monitoring, it's important to manage severe TBI. Reducing information from ICP monitoring and to reduce in-hospital and two weeks, as it was discussed. The rescue, final conclusion was use decompressive craniotomy in order to reduce ICP. The center TBI, there is a need that exists for a new precision medicine and a stratified management approach that will incorporate emerging technologies, including, as has been shown, most of monitoring. We are trying to use some of these monitoring studies. So it's medical and surgical indications should be based on a combination of clinical, radiological, neurophysiological, and not only on ICP. And that's like, if you have, that's why you have this dilemma in understanding and in clinical trials, whether they are controlled or not controlled. The statements, which patients may benefit from continued ICP monitoring? That's a very important question. There is ongoing uncertainty, and there was a report of the group who met in Cambridge. So the remaining question is target level of the postoperative ICP. Now, who should be monitored, for how long, and what is the ICP salvage threshold? The queries has been answered. Which patients may benefit, and the ICP value that should be individualized based on multimodal monitoring? This has been discussed before, and really nicely. And it looks like we are now like David and Goliath, fighting. The size of the decompressive carinectomy must be large enough, and thus we emphasize very much, as was displayed before. This is the final conclusion of the ICP, and there is a lower mortality, higher rate of vegetative state, higher independent disability, and home independence, and the rates of moderate disability and good recovery were similar in the two groups. So we have to work on the group who are vegetative, severely disabled, or mildly disabled, trying to move some of them into a better outcome. We had to evaluate the immediate role in one week of the decompressive carinectomy, and lowering increased ICP, improvement of one-week outcome, and the rate of complication. We studied 80 patients with a Glasgow Coma score of 5.83, which is much lower than what was in the rescue ICP or the DICRA study. And we used the ICP monitoring, and refractory cases of raised ICP showed failure of best conservative measures to lower increased ICP. We do not have an extremely good evacuation system where we can interfere within the first six hours. Sometimes we do interfere after that period of time. So 43 patients were randomized to primary decompressive carinectomy when they first presented to a tertiary care trauma center, and 37 patients crossed over when they deteriorated during the period they were monitored for the follow-up. And we performed a uni or a bilateral large frontal and proparietal flap with an augmentation uroplasty. This is the DICRA. This is the rescue ICP, and that's what we tried to add. Usually when we have to do it bilaterally, we leave part of bone on the superior sectional sinus because we do believe that increasing venous pressure and exposing the dural sinuses to the atmospheric pressure might alter the consequences of our patients. That's too small. And based on the initial data, we noted an ICP value favoring survival in a subgroup of the studied patients. We tried to analyze some of the same data further in order to detect some of these patients who did improve. An ICP postoperative threshold favoring a better outcome was found. This is the distribution of the studied patients, and that's their age distribution. And that's the Glasgow Coma score on starting the study. Thirty-eight patients were four nearly, and of course we encountered a lot of complications, whether surgical or non-surgical. Surgical complications were found in 52% of our patients, and we had a lot of other complications accompanying that. Patients who presented with extracranial injuries were very common. Two-thirds of patients have associated extracranial injuries. Hypoxic episodes within the first 24 hours occurred in about two-thirds of our patients. Hypotensive episodes were encountered in slightly less than 50% of the patients. Decompressive craniotomy was successful in decreasing ICP with a mean of 32-millimeter water to 19.2-millimeter water. The one-week Glasgow outcome score, this is ours, and this is the rescue ICP result. Hypoxia and hypotension worsened the outcome with a great significance. Associated extracranial injuries also worsened the outcome greatly and significantly. And when we tried to plot the relationship between ICP and the outcome, we found that when ICP one week post-operatively remained low, look at this yellow. These are all above, and these are the patients who died or became vegetative. These patients who survived, moderately disabled, good recovery, or severe disability, that range was about 20-millimeter water, and that difference was significant. The outcome summary, post-operative decrease, the ICP was not reflected as an improved outcome, except in the patients in whom sustained decrease, the ICP was maintained for more than one week. This is the morbidity and mortality. Bad prognosis was found in patients who were exposed to hypotension or hypoxia, and in those associated with extracranial injuries in a high significance of patients, a very high preoperative ICP. We were not able to salvage any of them, and recurrence of an increased ICP within one week was a bad prognosis. In all patients, we succeeded to decrease ICP below 20-centimeter of water in the immediate post-operative period. When it was maintained below that level, most of the patients improved, while an increased ICP to above 20-centimeter water within one week was noted in those who died or became vegetative, as you see in this graph. Severe TBI patients are a heterogeneous group, and they do respond differently to decompressive craniotomy. A refractory traumatic high ICP benefits from wide decompressive craniotomy. Better outcome is assured if the ICP is maintained below 20- millimeter of water, and ICP monitoring could guide therapeutic decision-making process in some cases of increased ICP. We have to define the parameter that interfere with the recovery of patients with STBI in whom ICP was reduced by decompressive craniotomy that later increased. And we are trying to study these patients now, some of them retrospectively. And we have problems with the registry where sometimes we cannot get to their files. So the major conclusion is that after decompressive craniotomy, a survival threshold of postoperative ICP must be maintained for at least one week after successful craniotomy, and only patients who maintain or lower the ICP below a certain level should clinical recover. Thank you very much for your attention. I have a question for the audience, a show of hands. How many people here routinely monitor ICP after they've done a decompressive craniotomy? Show of hands. Okay. Hands down. How many people never monitor ICP after you do a decompressive craniotomy? Show of hands. Okay. So a couple. How many people take it case by case and decide at the time of surgery? All right. I think this is outstanding research. I really think it's an important question and useful information that you're providing. I'd like to see this expanded, but you're to be congratulated. Very good. Thank you. Any other questions from the audience? So thanks very much. I was just wondering, how do you manage patients after decompressive craniotomy whose ICP remains high? We try to use barbiturate coma. We try to use hypertonic saline. We try to use whatever means suggested by our ICU personnel. We are measuring sometimes. We sometimes measure S100 and glial fibrillary acidic protein. We try to correct all metabolic disturbances that might occur during that period. We try to keep the patients as normal as possible. Thank you so much. Thank you.

postoperative intracranial pressure

decompressive craniectomy

traumatic brain injury

multimodal monitoring

refractory ICP