"Degrees of Certainty" [Standards, Guidelines, Options] and "Classification of Evidence" [Class I to III] are defined at the end of the "Major Recommendations" field.
Note: All of the following recommendations are at the Options level, supported only by Class III scientific evidence.
Recommendations
Indications
- Patients with parenchymal mass lesions and signs of progressive neurological deterioration referable to the lesion, medically refractory intracranial hypertension, or signs of mass effect on computed tomographic (CT) scan should be treated operatively.
- Patients with Glasgow Coma Scale (GCS) scores of 6 to 8 with frontal or temporal contusions greater than 20 cm3 in volume with midline shift of at least 5 mm and/or cisternal compression on CT scan, and patients with any lesion greater than 50 cm3 in volume should be treated operatively.
- Patients with parenchymal mass lesions who do not show evidence for neurological compromise, have controlled intracranial pressure (ICP), and no significant signs of mass effect on CT scan may be managed nonoperatively with intensive monitoring and serial imaging.
Timing and Methods
- Craniotomy with evacuation of mass lesion is recommended for those patients with focal lesions and the surgical indications listed above, under Indications.
- Bifrontal decompressive craniectomy within 48 hours of injury is a treatment option for patients with diffuse, medically refractory posttraumatic cerebral edema and resultant intracranial hypertension.
- Decompressive procedures, including subtemporal decompression, temporal lobectomy, and hemispheric decompressive craniectomy, are treatment options for patients with refractory intracranial hypertension and diffuse parenchymal injury with clinical and radiographic evidence for impending transtentorial herniation.
Summary
The majority of studies regarding surgical treatment of parenchymal lesions are case series. Only one prospective clinical trial of treatment using surgical versus nonsurgical management has been published. The majority of evidence indicates that the development of parenchymal mass lesions, which are associated with progressive neurological dysfunction, medically refractory intracranial hypertension, or radiological signs of mass effect, are associated with a poor outcome if treated nonsurgically. Specific surgical criteria, however, have not been firmly established.
Evidence also suggests that decompressive craniectomy may be the procedure of choice in patients with posttraumatic edema, hemispheric swelling, or diffuse injury, given the appropriate clinical context. This context has yet to be defined.
Definitions:
Degrees of Certainty
Standards: Represent accepted principles of patient management that reflect a high degree of clinical certainty.
Guidelines: Represent a particular strategy or range of management strategies that reflect a moderate degree of clinical certainty.
Options: Are the remaining strategies for patient management for which there is unclear clinical certainty.
Classification of Evidence on Therapeutic Effectiveness
Class I: Evidence from one or more well-designed, randomized, controlled clinical trials, including overviews of such trials
Class II: Evidence from one or more well-designed comparative clinical studies, such as nonrandomized cohort studies, case-control studies, and other comparable studies
Class III: Evidence from case series, comparative studies with historical controls, case reports, and expert opinion