Abstract
Craniotomy or decompressive craniectomy are among the therapeutic options to prevent or treat secondary damage after severe brain injury. The choice of procedure depends, among other things, on the type and severity of the initial injury. It remains controversial whether both procedures influence the neurological outcome differently. Thus, estimating the risk of brain herniation and death and consequently potential organ donation remains difficult. All patients at the University Hospital Münster for whom an isolated craniotomy or decompressive craniectomy was performed as a treatment after severe brain injury between 2013 and 2022 were retrospectively included. Proportion of survivors and deceased were evaluated. Deceased were further analyzed regarding anticoagulants, comorbidities, type of brain injury, potential and utilized donation after brain death. 595 patients were identified, 296 patients survived, and 299 deceased. Proportion of decompressive craniectomy was higher than craniotomy in survivors (89% vs. 11%, p < 0.001). Brain death was diagnosed in 12 deceased and 10 donations were utilized. Utilized donations were comparable after both procedures (5% vs. 2%, p = 0.194). Preserved brain stem reflexes as a reason against donation did not differ between decompressive craniectomy or craniotomy (32% vs. 29%, p = 0.470). Patients with severe brain injury were more likely to survive after decompressive craniectomy than craniotomy. Among the deceased, potential and utilized donations did not differ between both procedures. This suggests that brain death can occur independent of the previous neurosurgical procedure and that organ donation should always be considered in end-of-life decisions for patients with a fatal prognosis.
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Introduction
The treatment of patients with severe brain injury (BI) is based on the central concept that the prevention of secondary injuries is associated with better clinical outcomes. Increased intracranial pressure (ICP) and reduced cerebral perfusion pressure (CPP) are important causes of secondary brain injury that are associated with worsened outcomes1. These secondary processes escalate brain edema after severe BI and lead to increased ICP, which, in turn, causes a reduction in CPP and cerebral blood flow. This causes additional brain edema, forming a ‘vicious circle’ that can potentially worsen outcome and eventually lead to brain herniation and death1. Modern neurocritical care management incorporates tiered ICP- and CPP-guided strategies that include both medical and surgical interventions. The neurosurgical treatment to prevent consequential damage after severe BI can be categorized into two distinct types based on the removal of a bone flap: craniotomy (CO), as a surgical approach to remove a mass lesion (e.g. hematoma evacuation), and where the bone flap is replaced and decompressive craniectomy (DC), where craniotomy and durotomy represent the therapeutic measure and the bone flap is left out2,3. There is limited evidence with respect to the added value of performing a DC to improve patient outcomes3,4. Some studies suggest that DC has the potential to reduce mortality after severe BI5,6,7,8,9,10, although this is not consistently found for all types of BI, and DC can be associated with a higher risk of unfavorable outcomes3,11,12,13. A non-randomized cohort study demonstrated a lower mortality rate in patients undergoing primary DC compared to CO after evacuation of an acute subdural hematoma14, whereas others found no differences in outcomes3,11. Thus, it can be challenging to predict which individual patient will benefit from DC or CO15,16. Nevertheless, frequency of DC increased over the last years17. This could lead to more patients surviving after severe BI, as brain herniation and death is prevented. Consequently, it can be hypothesized that the incidence of brain death (BD) decreases with an increase in DC compared to other therapeutic options17,18. As the determination of BD is a mandatory requirement for post-mortem organ donation (donation after brain death (DBD)) in many countries, including Germany, this could lead to the assumption that the number of DBD decreases with increasing DC17.
This aspect is rarely discussed in the literature. Although death is an considered outcome criterion in studies about DC and CO after severe BI, to our knowledge, most studies did not define potential BD as a separate outcome criteria2,3,8,9,11,14. One trial reported brain herniation as the reason for death in one of 20 patients with DC after malignant middle cerebral artery infarction6. Two older studies found that DC was performed with similar frequency in donors and non-donors and that DC had no influence on the progression to BD after severe BI, suggesting no association between DC and conversion to donor status18,19. Schulte et al. postulated that despite an increasing number of DC in Germany in a period from 2010 to 2016, utilized donations should not decrease. However, they did not analyze the potential influence of DC on the incidence of BD but they detected a parallel increase in the total numbers of possible donors in the same period and suggested that this results in a constant number of possible donors17. Overall, differences in estimated DBD after severe BI cannot be satisfactorily explained yet due to an obvious lack of evidence20. Whether DC or CO have a different influence on the number of potential and utilized DBD (defined as a person whose clinical condition is suspected to fulfill brain death criteria and an actual donor from whom at least one organ was transplanted, respectively21) thus remains questionable. Patients after DC are usually not regarded to qualify for BD as ICP is not assumed to reach levels critical enough to cause cerebral perfusion failure, leading to the assumption, that DBD is less likely after DC17,22. In addition, diagnosis of BD may be more challenging, as the reliability to demonstrate cerebral circulatory arrest, as a prerequisite to determine BD, can be affected in patients after DC23,24,25,26.
The present study aimed to analyze patients who underwent CO or DC to prevent or treat consequential damage after severe BI. We sought to answer whether the number of potential and utilized DBD differed by DC or CO to aid critical care staff in estimating the potential of DBD as part of an end-of-life concept. We hypothesize that the number of potential and utilized DBD is lower in deceased after DC compared to CO.
Results
595 patients (mean age: 55.9 ± 19.7) who underwent CO or DC after severe BI were identified between 2013 and 2022 (Fig. 1). DC was performed in 399 and CO in 196 patients, respectively. Patients with DC were significantly younger than patients with CO (Table 1).
Study flowchart. CO craniotomy, DC decompressive craniectomy.
Of all identified patients, 296 (49.7%) survived. DC was performed in 263 (89%) and CO in 33 (11%) of the survivors. The remaining 299 (50.3%) patients died during their hospital stay, with DC in 136 (45%) and CO in 163 (55%) of the deceased. Diagnosis of BD was initiated in 16 deceased and confirmed in 12 by ancillary testing (4% of all deceased), whereas the remaining four cases (three after DC and one after CO) showed preserved brain stem reflexes (failed apnea testing) during BD diagnostic. In two cases with confirmed BD, consent to donation was refused, resulting in 10 utilized DBD in our cohort (3% of all deceased). Donors were significantly younger than the deceased without donation (Table 1).
Length of stay, anticoagulant medication and comorbidities in deceased patients
Mean length of stay of all deceased on the intensive care unit was 294 h. One third of the patients were taking anticoagulants at the time of hospital admission. Arterial hypertension was the most frequent comorbidity, followed by atrial fibrillation and arteriosclerosis (peripheral, coronary or cerebral, Table 2). A one-way MANOVA showed no statistically significant difference between the independent variables (DC or CO) on the combined dependent variables (length of stay, anticoagulant medication and comorbidities; F [13, 285] = 1.116, p < 0.345, partial η2 = 0.048, Wilk’s Λ = 0.952).
Type of brain damage in deceased patients
The most frequent reason for severe BI in the deceased was traumatic brain injury (TBI, 32%), followed by acute ischemic stroke (AIS, 27%) and spontaneous intracerebral hemorrhage (ICH, 20%), respectively. Proportion of DC was highest in patients with anoxic BI after cardiac arrest (60%), followed by AIS (57%), non-traumatic subarachnoid hemorrhage (SAH, 48%) and ICH (45%), respectively (Table 3).
Reasons against donation in deceased patients
Refused consent was the predominant reason for a donation not utilized (112 cases, 37%). In 86 cases, a complete loss of all brainstem reflexes was not detectable during hospitalization, so that the formal BD diagnostic was not initiated at all. In four additional cases, BD diagnostic was initiated, but the formal examination revealed preserved brainstem reflexes (preserved spontaneous breathing), so that in a total of 90 cases (30%) preserved brainstem reflexes were the reason against donation. The medical condition of the patient was the reason against donation in 51 cases (17%) (Table 3).
Influence of DC and CO on outcome parameters
Proportion of DC was significantly higher in survivors than in deceased (89% vs. 45%, p < 0.001), whereas the number of utilized DBD was not significantly different between deceased after DC or CO (5% vs. 2%, p = 0.194). The incidence of preserved brain stem reflexes/inconclusive diagnostic of BD as a reason for a donation not utilized was not different between deceased after DC or CO (33% vs. 29%, p = 0.470, Table 4).
A one-way MANOVA showed a statistically significant difference between utilized DBD on the combined dependent variables age and DC or CO (F [2, 296] = 17.625, p < 0.001, partial η2 = 0.106, Wilk’s Λ = 0.894). Post-hoc univariate ANOVA showed a statistically significant difference between the utilized DBD for age (F [1, 297] = 34.516, p < 0.001, partial η2 = 0.104), but not for DC or CO (F [1, 297] = 2.512, p = 0.114, partial η2 = 0.008).
Proportion of DC and CO during the observation period
Proportion of DC was between 49 and 81% during the observation period but did not show an increase over time (Fig. 2).
Identified patients per year. CO craniotomy, DBD donation after brain death, DC decompressive craniectomy.
Discussion
A total of 595 patients who underwent CO or DC after severe BI were identified between 2013 and 2022. The proportion of DC compared to CO was significantly higher in survivors than in deceased. 299 patients died during their hospital stay, and 10 DBD were utilized. Length of hospital stay, anticoagulatory medication and prevalence of comorbidities at the time of hospital admission did not differ between deceased after DC or CO. Preserved brain stem reflexes as a reason against utilization and the proportion of utilized DBD were not different between deceased after DC or CO. The proportion of DC compared to CO did not increase during the observation period. These results suggest that the diagnosis of BD in patients after DC or CO is generally low and the number of potential and utilized DBD are comparable in deceased after DC or CO.
Not surprisingly, patients with DC were significantly younger than patients with CO, as DC is a possible life-saving intervention, and indication to perform DC presumably increases with younger age27,28. This was also found in previous studies for DC after TBI27,29, AIS30, ICH2,28 or SAH31. It is also conceivable, that utilized DBD were significantly younger than the deceased without donation, presumably because medical contraindications are more common in older potential DBD32 and consent to donation tends to be higher in younger patients, especially after traumatic BI33.
Although this was not a primary aim of our study, results showed that the proportion of DC was significantly higher in survivors than in deceased, indicating a lowered mortality rate after DC compared to CO. Since we were not able to assess all information retrospectively, such as the severity of BI in each case, or the period between initial BI and DC, we cannot conclude with certainty from our results, that DC on its own improved patients’ outcome19. However, since more patients survived after DC, it can be assumed that DC had the potential to prevent death when considering the entire cohort studied.
Almost eighty percent of the deceased suffered from BI after TBI, AIS or ICH, whereas the proportion of DC was highest in patients with anoxic BI after cardiac arrest (albeit the total number of patients with anoxic BI (n = 5) was very low), followed by AIS and SAH. Notably, in this unselected cohort, patients with anoxic BI and SAH were younger than patients with TBI or AIS. Although broader evidence supports the use of DC in patients with TBI5 and AIS7 compared to DC after other causes of BI4, it is conceivable that in our cohort, the indication for DC was influenced to a considerable extent by the age of the patient and not only by the cause or severity of BI. Additionally, there is very limited literature on DC or CO after anoxic brain injury following cardiac arrest. A recent review describes interventions to improve outcomes for this group of patients but does not discuss neurosurgical intervention options in detail34. Patients with anoxic brain injury were the youngest in this study and the proportion of DC was the highest, suggesting that DC after anoxic brain injury may be an act of desperation in the absence of evidence.
Predominant reasons for a donation not being utilized in the deceased were refused consent and the impossibility to diagnose BD because of preserved brain stem reflexes. These results are in line with previous findings in Germany and elsewhere about reasons for a donation not utilized18,32,35,36,37.
Overall incidence of BD, and numbers of potential and utilized DBD was very low in our cohort of patients with severe BI, comparable to previous findings in patients after DC22 and to potential donor numbers in Germany38,39,40 and elsewhere41. Others reported a BD incidence of 7.3% in patients after DC22, which is comparable to our results (confirmed BD in 8 out of 136 patients with DC, which corresponds to 5.8%). Ten utilized DBD out of 299 deceased in our study correspond to 3.3% utilized DBD, what seems low at first sight, but represents an even higher rate of utilized DBD than the official numbers from the German Organ Procurement Organization about utilized DBD in Germany (1.4% utilized donors among all deceased in hospital with a diagnosed brain injury in 2022, although it should be mentioned, that these numbers include all deceased with brain injury, and not only deceased after neurosurgical procedures)42. This indicates that it is not DC or CO per se that are accountable for the low number of utilized DBD in this cohort, but that other reasons must have played a significant role. 33 patients became no DBD, because therapy was withdrawn before signs of BD established, presumably due to an inevitably poor prognosis and the possible assumption by clinical staff that patients may not develop signs of BD22. Additionally, 90 deceased became no donor because BD could not be confirmed due to preserved brain stem reflexes or inconclusive diagnostic of BD. Both groups of deceased would potentially become donors after cardiac death (DCD) after withdrawal of therapy18, but DCD is not possible in Germany due to legal regulations. It can be assumed, that a significant share of potential donors was thus lost because of these circumstances38. Refused consent precluded a donation in a further 112 cases.
We could not find a difference between DC and CO and the number of potential and utilized DBD in the cohort of the deceased. Interestingly, even more patients after DC became utilized DBD than after CO, although this finding was not statistically significant due to the overall low number of utilized DBD. As the indication for DC after severe BI is to prevent or treat an increase of ICP and thus prevent a vicious circle leading to BD, this result is unexpected at first sight. This circumstance likely reflects more severe BI in patients, where DC was performed, resulting in a more likely progression to BD. However, this assumption cannot be assured from the results, as severity of BI was not assessed in our study. Nevertheless, these findings are important for critical care and organ procurement staff. DC in patients with severe BI might indicate a more likely progression to BD and, in turn, into a utilized DBD, rather than a reason for prevention of a DBD in patients with an unfavorable prognosis. This is a relevant aspect, as being not considered by staff as a potential DBD was an important reason for DBD not utilized after DC in other studies18,43. Intensive care is probably withdrawn before patients with an inevitably poor prognosis develop signs of BD after DC. This may be because patients with DC are often not considered to qualify for BD development, as it is assumed that ICP does not reach critical levels causing loss of cerebral perfusion17,22. Critical care staff should therefore be aware to consider a potential DBD in patients with severe BI, regardless of the neurosurgical procedure. Additionally, preserved brain stem reflexes, as an indicator for the absence of BD, were not more common after DC than CO in our cohort, indicating, that the progression to BD in the deceased was independent of the neurosurgical procedure. The pathophysiological reasoning behind these findings was previously examined by Salih et al. They could show that loss of cerebral perfusion provides the key pathophysiological mechanism of BD after DC. Arterial blood pressure, dropping below a critical closing pressure was not modified by DC in their analysis. Consequently, even after DC, ICP may increase and reach levels critical enough to cause loss of cerebral perfusion22,44. In addition, cerebral ischemia can occur even if ICP and CPP are within the accepted thresholds45,46.
This study was a single-center retrospective analysis, resulting in several limitations. The practice patterns for performing DC might have varied greatly during the long period. We did not assess the surgical techniques used to perform DC (bifrontal craniectomy, unilateral or bilateral front-temporo-parietal craniectomy47), the initial severity of BI and the period between BI and DC or CO. We only included patients with DC or CO but not with other or no surgical therapy. We did not assess individual medical interventions to prevent or treat increased ICP. In addition, in cases where treatment was withdrawn due to refused consent, BD could have occurred later if treatment had been continued. All these factors might have an influence on patient outcomes. However, as the literature about accurate estimations of potential DBD is generally scarce and lack evidence20,22, our main goal was to evaluate, if DC and CO affect the progression to brain death and utilized donations differently in the cohort of patients with an unfavorable prognosis, regardless of the timing or type of the procedure or the patient’s condition. Since significantly more patients survived after DC than after CO, it can only be concluded that DC and CO had comparable effects on the progression to BD in the cohort of the deceased. Regarding the higher survival rate after DC, it must be assumed that DC was able to reduce BD when considering the entire study population.
In conclusion, these results add important information to the sparse literature on potential BD in patients after severe BI and the influence of different treatment modalities.
It was never the aim of our study to imply with our results that the choice of treatment should be influenced by considering the patient as a potential DBD. The choice of treatment is always made with the aim of doing what is best for the patient and respecting their wishes in terms of quality of life16,48. Nevertheless, in certain patients with an unfavorable prognosis, considering a potential DBD may be an important part of an end-of-life approach. Patients should not be deemed ineligible or unlikely to progress to BD based on the previous therapy. Future studies on outcomes after severe brain injury should include information on the incidence of BD to allow accurate estimation of potential DBD. This is necessary to respect a patient's possible wish for organ donation and to increase the number of utilized donations after brain death20.
Methods
This retrospective study was performed in accordance with the Declaration of Helsinki. The need for informed consent was waived by the local Ethics Committee of the University of Münster due to the retrospective analysis of routinely collected patient data and the study protocol was approved on November 22, 2019 (file number 2019-389-f-S). All patients treated at the University Hospital Münster between January 2013 and December 2022 who underwent CO or DC to prevent or treat consequential damage after severe BI were retrospectively included, regardless of the individual indication for either procedure in each case (Fig. 1). These patients were cared for in the same intensive care units, with a consistent management protocol. These protocols, which are described in our hospital's standard operating procedures, include both general instructions for neurosurgical patients (daily evaluation of the Glascow Coma Scale and the Richmond Agitation-Sedation Scale, continuous monitoring of intracranial pressure if available, definition of target values for arterial blood pressure, laboratory blood coagulation values, use of anticoagulants and interventions to decrease intracranial pressure, e.g. by the use of mannitol, venting of cerebrospinal fluid through the ventricular drain, and/or controlled hyperventilation) and specific instructions depending on the underlying disease (e.g. enteral nimodipine and daily transcranial Doppler ultrasonography in patients with non-traumatic subarachnoid hemorrhage).
Identification of patients was based on the German Operation and Procedure Code (OPS-Code, the official classification for coding operations and procedures in Germany49). All patients with the OPS-Code 5-012 (this code is to be used for an isolated CO (OPS-Code 5-012.1/x) or DC (OPS-Code 5-012.0), whereas a CO or DC as a surgical access route is coded separately) were included. The in-house medical controlling department provided the data.
In the next step, all patients who survived (reason for discharge from the hospital was not “death”) were excluded and the deceased were further analyzed. The medical record files of the deceased were screened for anticoagulatory medication and comorbidities at the time of hospital admission, hospital length of stay, the cause of BI [traumatic brain injury (TBI), non-traumatic subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (ICH), acute ischemic stroke (AIS), brain tumor (BT), infections of the central nervous system (CNS) and anoxic BI after cardiac arrest, respectively]. The number of utilized DBD or the reason for a donation not utilized (refused consent, preserved brain stem reflexes/inconclusive diagnostic of BD, medical contraindications, therapeutic limitations according to patients’ will) was recorded. Finally, to analyze the possibility of DBD, deceased with CO and DC were compared regarding the number of utilized DBD and the reasons against utilization, respectively.
Statistical methods
Statistical analysis was performed using SPSS 28 (IBM, USA). Parameters were expressed as mean ± standard deviation. The χ2-test or Fishers exact test (in case of small-sized samples) were used to check whether variables were independent and the t-test for independent samples for group comparison. A one-way multivariate analysis of variance (MANOVA) was used to compare DC or CO and predefined combined dependent variables (length of hospital stay, preexisting use of anticoagulants and comorbidities) and for the number of utilized donations and predefined combined dependent variables (age and DC or CO). Post-hoc univariate ANOVAs were conducted for every dependent variable. A statistical significance was assumed at p ≤ 0.05.
Data availability
The datasets generated and analyzed during the study are available from the corresponding author on reasonable request. Requests to access these datasets should be directed to jan.englbrecht@ukmuenster.de.
References
Smith, M. Refractory intracranial hypertension: The role of decompressive craniectomy. Anesth. Analg. 125, 1999–2008 (2017).
Shibahashi, K., Sugiyama, K., Tomio, J., Hoda, H. & Morita, A. In-hospital mortality and length of hospital stay with craniotomy versus craniectomy for acute subdural hemorrhage: A multicenter, propensity score–matched analysis. J. Neurosurg. 133, 504–513 (2019).
Hutchinson, P. J. et al. Decompressive craniectomy versus craniotomy for acute subdural hematoma. N. Engl. J. Med. 388, 2219–2229 (2023).
Hatamleh, M. M. Contemporary review on craniectomy and cranioplasty; part 1: Decompressive craniectomy. J. Craniofac. Surg. 33, 838–841 (2022).
Sahuquillo, J. & Dennis, J. A. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst. Rev. 12, 003983 (2019).
Vahedi, K. et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38, 2506–2517 (2007).
Powers, W. J. et al. 2018 guidelines for the early management of patients with acute ischemic stroke: A Guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49, e46–e110 (2018).
Cooper, D. J. et al. Decompressive craniectomy in diffuse traumatic brain injury. N. Engl. J. Med. 364, 1493–1502 (2011).
Hutchinson, P. J. et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N. Engl. J. Med. 375, 1119–1130 (2016).
Kolias, A. G. et al. The current status of decompressive craniectomy in traumatic brain injury. Curr. Trauma Rep. 4, 326–332 (2018).
Ahmed, N., Greenberg, P. & Shin, S. Mortality outcome of emergency decompressive craniectomy and craniotomy in the management of acute subdural hematoma: A national data analysis. Am. Surg. 87, 347–353 (2021).
Phan, K. et al. Craniotomy versus decompressive craniectomy for acute subdural hematoma: Systematic review and meta-analysis. World Neurosurg. 101, 677-685.e2 (2017).
Wijdicks, E. F. M. Stroke and craniectomy. Neurocrit. Care 30, 235–238 (2019).
Li, L. M. et al. Outcome following evacuation of acute subdural haematomas: A comparison of craniotomy with decompressive craniectomy. Acta Neurochir. 154, 1555–1561 (2012).
Stiver, S. I. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg. Focus 26, E7 (2009).
Lazaridis, C. & Mansour, A. To decompress or not? An expected utility inspired approach to shared decision-making for supratentorial ischemic stroke. Neurocrit. Care 34, 709–713 (2021).
Schulte, K. et al. Organ donor potential increases despite rising numbers of decompressive craniectomies. Dtsch Arztebl Int. 117, 542–543 (2020).
Fletcher, J. J., Bergman, K., Watcharotone, K., Jacobs, T. L. & Brown, D. L. Lack of association between decompressive craniectomy and conversion to donor status. Clin. Transplant. 25, 83–89 (2011).
Pereyra, C. et al. Decompressive craniectomy and brain death prevalence and mortality: 8-year retrospective review. Transplant. Proc. 44, 2181–2184 (2012).
Qu, Z. et al. Systematic review on potential brain dead donor estimations and conversion rates to actually realized organ donations. Transplant. Rev. 35, 100638 (2021).
Domínguez-Gil, B. et al. The critical pathway for deceased donation: Reportable uniformity in the approach to deceased donation. Transpl. Int. 24, 373–378 (2011).
Salih, F., Finger, T., Vajkoczy, P. & Wolf, S. Brain death after decompressive craniectomy: Incidence and pathophysiological mechanisms. J. Crit. Care 39, 205–208 (2017).
Frisardi, F. et al. Decompressive craniectomy may cause diagnostic challenges to assess brain death by computed tomography angiography. Miner. Anestesiol. 80, 113–118 (2014).
Ishiyama, M., Relyea-Chew, A., Longstreth, W. T. & Lewis, D. H. Impact of decompressive craniectomy on brain perfusion scintigraphy as an ancillary test for brain death diagnosis. Ann. Nucl. Med. 33, 842–847 (2019).
Escudero, D. et al. Diagnosing brain death by CT perfusion and multislice CT angiography. Neurocrit. Care 11, 261–271 (2009).
Zampakis, P. et al. Computed tomography angiography scoring systems and the role of skull defects in the confirmation of brain death. Sci. Rep. 11, 15081 (2021).
Gantner, D. et al. Decompressive craniectomy practice following traumatic brain injury in comparison with randomized trials: Harmonized, multi-center cohort studies in Europe, the United Kingdom, and Australia. J. Neurotrauma 39, 860–869 (2022).
Anis, S. B., Khan, S. A., Mitha, R. & Shamim, M. S. Craniotomy or craniectomy for acute subdural hematoma? Difference in patient characteristics and outcomes at a tertiary care hospital. Asian J. Neurosurg. 17, 563–567 (2022).
Reilly, A. S. et al. Disparities in decompressive cranial surgery utilization in severe traumatic brain injury patients without a primary extra-axial hematoma: A US nationwide study. World Neurosurg. 169, e16–e28 (2023).
Pilato, F. et al. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A real-world study. J. Neurol. Sci. 441, 120376 (2022).
Darkwah Oppong, M. et al. Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: Who and when? A systematic review and meta-analysis. Clin. Neurol. Neurosurg. 199, 106252 (2020).
Wesslau, C. et al. How large is the organ donor potential in Germany? Results of an analysis of data collected on deceased with primary and secondary brain damage in intensive care unit from 2002 to 2005. Transpl. Int. 20, 147–155 (2007).
Siminoff, L. A., Gordon, N., Hewlett, J. & Arnold, R. M. Factors influencing families’ consent for donation of solid organs for transplantation. JAMA 286, 71–77 (2001).
Steinberg, A. Emergent management of hypoxic-ischemic brain injury. Contin. Lifel. Learn. Neurol. 30, 588 (2024).
Hodgson, R., Young, A. L., Attia, M. A. & Lodge, J. P. A. Impact of a national controlled donation after circulatory death (DCD) program on organ donation in the United Kingdom: A 10-year study. Am. J. Transplant. 17, 3172–3182 (2017).
Vincent, A. & Logan, L. Consent for organ donation. Br. J. Anaesth. 108(Suppl 1), i80-87 (2012).
Englbrecht, J. S. et al. Advance directives and consent to organ donation in seven university hospitals in North Rhine-Westphalia: A retrospective multicenter analysis. Dtsch Arztebl Int. 120, 133–134 (2023).
Englbrecht, J. S. et al. How large is the potential of brain dead donors and what prevents utilization? A multicenter retrospective analysis at Seven University Hospitals in North Rhine-Westphalia. Transpl. Int. 36, 11186 (2023).
Esser, G. et al. Evaluation of underidentification of potential organ donors in German hospitals. PLoS ONE 15, e0242724 (2020).
Englbrecht, J. S., Schrader, D., Alders, J. B., Schäfer, M. & Soehle, M. Post-COVID-19 pandemic organ donation activities in Germany: A multicenter retrospective analysis. Front. Public Health 12, 1356285 (2024).
Opdam, H. I. & Silvester, W. Identifying the potential organ donor: An audit of hospital deaths. Intensive Care Med. 30, 1390–1397 (2004).
German Organ Procurement Organization (DSO). Report on the Activities of the Harvesting Hospitals in Germany. https://www.dso.de/EKH_Statistics/EKH-Berichte-Bundesweit/2022/Deutschland_2022.pdf (2023).
Kemp, C. D., Cotton, B. A., Johnson, J. C., Ellzey, M. & Pinson, C. W. Donor conversion and organ yield in traumatic brain injury patients: Missed opportunities and missed organs. J. Trauma 64, 1573–1580 (2008).
Salih, F. et al. Intracranial pressure and cerebral perfusion pressure in patients developing brain death. J. Crit. Care 34, 1–6 (2016).
Chang, J. J. J. et al. Physiologic and functional outcome correlates of brain tissue hypoxia in traumatic brain injury. Crit. Care Med. 37, 283–290 (2009).
Oddo, M. et al. Brain hypoxia is associated with short-term outcome after severe traumatic brain injury independently of intracranial hypertension and low cerebral perfusion pressure. Neurosurgery 69, 1037–1045 (2011).
Cunan, E. T., Dudley, R. & Shemie, S. D. Decompressive craniectomy as a potentially reversible condition in brain death: Brain stunning or skin and pericranium stretching?. Can. J. Anesth./J. Can. Anesth. 69, 811–814 (2022).
Cunan, E. T., Dudley, R. W. R. & Shemie, S. D. In reply: Withholding therapeutic interventions in brain(stem) death: Is it a self-fulfilling prophecy?. Can. J. Anesth./J. Can. Anesth. 69, 1439–1440 (2022).
Federal Ministry of Health. What are ICD and OPS Codes? https://gesund.bund.de/en/what-are-icd-and-ops-codes (2023).
Acknowledgements
We thank Dorothee Lamann for her support obtaining the data.
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JE and CB: Conception and design of the study, acquisition of data, analysis and interpretation of data, visualization, writing-original draft preparation. AZ: Supervision, interpretation of data, writing-reviewing, and editing. WS: Supervision, interpretation of data, writing-reviewing, and editing. MH: Conception and design of the study, analysis and interpretation of data, writing-reviewing, and editing, supervision. All authors are accountable for all aspects of the work.
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Englbrecht, J.S., Bajohr, C., Zarbock, A. et al. A ten-year retrospective analysis of decompressive craniectomy or craniotomy after severe brain injury and its implications for donation after brain death. Sci Rep 14, 15233 (2024). https://doi.org/10.1038/s41598-024-66129-3
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DOI: https://doi.org/10.1038/s41598-024-66129-3
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