Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis

Abstract

Objective: To examine the clinical and neurological outcome of patients who sustained a severe non-penetrating traumatic brain injury (TBI) and underwent unilateral decompressive craniectomy (DC) for refractory intracranial hypertension. Design: Single center, retrospective, observational. Setting: Level I Trauma Center in Portland, Maine. Patients: 31 patients aged 16–72 of either sex who sustained a severe, non-penetrating TBI and underwent a unilateral DC for evacuation of parenchymal or extra-axial hematoma or for failure of medical therapy to control intracranial pressure (ICP). Interventions: Review of the electronic medical record of patients undergoing DC for severe TBI and assessment of extended Glasgow Outcome Score (e-GOS) at 6-months following DC. Measurements and main results: The mean age was 39.3y ± 14.5. The initial GCS was 5.8 ± 3.2, and the ISS was 29.7 ± 6.3. Twenty-two patients underwent DC within the first 24 h, two within the next 24 h and seven between the 3rd and 7th day post injury. The pre-DC ICP was 30.7 ± 10.3 and the ICP was 12.1 ± 6.2 post-DC. Cranioplasty was performed in all surviving patients 1–4 months post-DC. Of the 29 survivors following DC, the e-GOS was 8 in seven patients, and 7 in ten patients. The e-GOS was 5–6 in 6 others. Of the 6 survivors with poor outcomes (e-GOS = 2–4), five were the initial patients in the series. Conclusions: In patients with intractable cerebral hypertension following TBI, unilateral DC in concert with practice guideline directed brain resuscitation is associated with good functional outcome and acceptable-mortality.