Elsevier

Injury

Volume 41, Issue 9, September 2010, Pages 894-898
Injury

Decompressive craniectomy: Surgical control of traumatic intracranial hypertension may improve outcome

https://doi.org/10.1016/j.injury.2010.02.023Get rights and content

Abstract

Introduction

The purpose of this study was to assess the role of decompressive craniectomy (DC) in patients with post-traumatic intractable intracranial hypertension (ICH) in the absence of an evacuable intracerebral haemorrhage.

Methods

Retrospective study at LAC+USC Medical Centre including patients who underwent DC for post-traumatic malignant brain swelling or ICH without space occupying haemorrhage, during the period 01/2004 to 12/2008. The analysis included the effect of DC on intracranial pressure (ICP) and timing of DC on functional outcomes and survival.

Results

Of 106 patients who underwent DC, 43 patients met inclusion criteria. Of those, 34 were operated within the first 24 h from admission. DC decreased the ICP significantly from 37.8 ± 12.1 mmHg to 12.7 ± 8.2 mmHg in survivors and from 52.8 ± 13.0 to 32.0 ± 17.3 mmHg in non-survivors. Overall 25.6% died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). No tendency towards either increased or decreased incidence in favourable outcome was found relative to the time from admission to DC. Six of the 18 patients (33.3%) with favourable outcome were operated on within the first 6 h.

Conclusions

DC lowers ICP and raises CPP to high normal levels in survivors compared to non-survivors. The timing of DC showed no clear trend, for either good neurological outcome or death. Overall, the survival rate of 74.4% is promising and 41.9% had favourable neurological outcome.

Introduction

Following severe traumatic brain injury (TBI), brain oedema and intracranial hypertension (ICH) may lead to secondary brain damage. In addition, ICH is the most frequent cause of death and disability following severe TBI.9, 18, 21, 23, 28 The Brain Trauma Foundation (BTF) guidelines, have been established to guide the management of and indications for surgical decompression in TBI patients.6, 11 Within these guidelines, decompressive craniectomy (DC) is considered in two different situations; either it is performed prophylactically at the time of evacuation of a space occupying intracerebral haemorrhage or it is performed in patients with diffuse brain swelling and ICH after maximal medical treatment.6, 24, 25 Despite improvement in medical treatment modalities and neuromonitoring, including aggressive medical intervention such as barbiturate coma showed no improvement in outcomes for these patients.7, 13, 14, 18, 22

Decompressive craniectomy in the absence of a space occupying haemorrhage is currently regarded as a rescue therapy. The success rates of DC to restore normal ICP-levels and its impact on the outcomes, however, remain highly controversial.3, 4, 15, 16, 18, 20, 22, 23, 24, 26, 29, 30, 31, 32, 33 In addition, the optimal time point for this procedure is unclear. It appears that there may be a trend towards improved outcomes the earlier DC is performed.4, 8, 15, 19, 26, 29 Chibbaro and Tacconi found a survival rate with good neurological outcome in 18 of 48 patients when DC was performed within the first 16 h.8 These are the earliest DC patients published in the literature; however, this cohort also included patients with space occupying haemorrhages. In contrast, Aarabi et al. retrospectively investigated a homogeneous group of patients without space occupying haemorrhage. He reported a favourable outcome in 13 of 17 patients, when the decompression was performed within 48 h.3 The role of early DC to decrease ICP in TBI patients is of high interest. Currently, there are two randomised controlled trials ongoing: in Europe the RescueICP and in Australia the DECRA as well as a multicentre, retrospective trial in the United States to assess neurological outcome after DC.1, 2, 17

The purpose of this study was to investigate the outcome of patients who underwent early DC for intractable ICH in the absence of a space occupying haemorrhage and to delineate the impact of timing of DC on mortality.

Section snippets

Patients and methods

After Institutional Review Board (IRB) approval, patients who underwent DC at the Los Angeles County+University of Southern California Medical Centre from January 2004 to December 2008 were retrospectively reviewed. All patients with an AIS head >2 were pulled from the trauma registry to identify all patients who potentially underwent DC. Patients who required DC due to intracranial hypertension refractory to maximal medical treatment without space occupying haemorrhage on the CT scan were

Results

During the 5-year study period 1955 patients were admitted with severe TBI (AIS head ≥3). Overall, 106 patients (5.4%) underwent DC. Of those, 43 patients (40.6%) underwent DC for decompression of ICH without space occupying haemorrhage (Fig. 2).

In the 43 patients included in our study the mean age and ISS ± SD were 35.7 ± 15.0 years and 24.3 ± 7.6. The mean GCS ± SD was 8.6 ± 4.5 on admission. The majority (79.1%) of patients were males. A total of 83.3% sustained blunt head trauma, and 16.7% (7 of 43)

Discussion

The purpose of this study was to investigate the role of DC for intractable traumatic ICH in the absence of a space occupying haemorrhage. In this scenario DC is currently regarded as a rescue therapy in cases where herniation is expected. The success rates of DC to restore normal ICP-levels, its impact on the outcomes, and the optimal time point for this procedure remains highly controversial and the available recommendations are based on Levels II and III evidence. In particular, the role of

Conclusion

Decompressive craniectomy for isolated ICH is not a hopeless intervention. The present study is the largest published to date studying the outcome of DC performed within 24 h on patients with elevated ICP who have no space occupying haemorrhage. DC is a heroic procedure that has the potential to improve both survival and functional outcome in a selected group of patients. In particular patients, whose ICP is lowered by surgical intervention when medical management has not been successful, have a

Conflict of interest

There are no conflicts of interest to disclose.

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