Decompressive craniectomy in severe intracranial hypertension after brain injury: early or late?

Abstract

Introduction: Decompressive craniectomy is indicated for treatment of severe intracranial hypertension. However, this procedure is invasive and potentially associated with complications. We present a preliminary result of a study comparing early and late decompressive craniectomy in severe traumatic brain injury. Methods: Patients studied were all admitted to the ICU of a tertiary referral center (Careggi Teaching Hospital, Florence, Italy) during 4 years (2005 to 2009). In total, data of 62 brain-injured patients, who underwent decompressive craniectomy, were retrospectively examined and included in two groups based on decompressive craniectomy execution: {Table presented} early decompressive craniectomy group (decompressive craniectomy performed within 24 hours after brain injury, group A; n = 41) and late decompressive craniectomy (later than 24 hours, group B; n = 21). For all patients, demographic, scores, clinical data, length of stay and final outcome were collected from the institutional database. Traumatic lesions were compared at admission using the Marshall score and 24 hours after decompressive craniectomy execution with CT scan. The Glasgow Outcome Scale (GOS) at 6 months was also collected. Results: Demographic and clinical characteristics of groups are shown in Figure 1 (data expressed as mean + SD). Patients who underwent decompressive craniectomy within 24 hours after injury (group A) had a significant worst Marshall score if compared with group B (3.1 + 0.7 vs 2.4 + 0.8, respectively; P <0.05), but also showed a significant enlargement of contusions compared with group B (52.7% vs 16.6%; P <0.01). ICU/ hospital length of stay and mortality were not significantly different between groups. The GOS evaluated at 6 months showed a good recovery of surviving patients in both groups (3.7 + 1.0 in group A and 3.2 + 0.9 in group B). Conclusions: Our data, limited by the retrospective nature of the study, do not encourage an early decompressive treatment of severe intracranial hypertension. Decompressive craniectomy should be considered in case of lack of response to a medical, even intensive, approach.