Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year.
OBJECTIVE
To assess the effect on outcome (1 yr) of decompressive craniectomy performed within or after the first 24 hrs post-trauma in severely head-injured trauma patients with intractable cerebral hypertension.


METHODS
Retrospective cohort study.


METHODS
Intensive care unit of a university hospital.


METHODS
Among 816 patients with severe head trauma (Glasgow Coma Scale < or =8), 40 underwent decompressive craniectomy. After data collection, patients were divided into two groups: early and late decompressive craniectomy. An early decompressive craniectomy was performed within the first 24 hrs in patients according to the following criteria: a Glasgow Coma Scale score <6 and the existence of clinical signs of cerebral herniation (absence of pupillary reflexes), correlated with abnormalities in computed tomography scan including hematoma, appearance of diffuse or unilateral brain swelling, and/or cerebral herniation. The intracranial pressure in these patients was not measured before the decompressive craniectomy was performed. A late decompressive craniectomy (>24 hrs) was performed according to following criteria: an intractable intracranial hypertension with intracranial pressure >35 mm Hg, a unilateral or bilateral absence of pupillary reflexes, and the same abnormalities in computed tomography scan as previously described.


METHODS
Twenty-seven patients with signs of cerebral herniation required the procedure at the time of initial evacuation of a mass lesion. In 13 patients, decompressive craniectomy was performed because of elevated intracranial pressure refractory to medical treatment consisting of cerebrospinal fluid derivation, deep sedation, osmotherapy, hyperventilation, and nesdonal or propofol.


RESULTS
Five patients (19%) in whom an early decompressive craniectomy was performed had good recoveries (social rehabilitation), eight patients (30%) remained in a persistent vegetative state or with a severe disability, and 14 died (52%). On the other hand, the performance of late decompressive craniectomy in case of medical treatment failure was followed by social rehabilitation in five patients (38%) and death in three patients (23%). A persistent vegetative state or a severe disability was observed in five patients (38%). Meningitis or cerebral abscess occurred in six patients after decompressive craniectomy and were easily cured by antibiotic treatment.


CONCLUSIONS
In 40 patients with intractable intracranial hypertension and at very high risk of brain death, decompressive craniectomy allowed 25% of patients to attain social rehabilitation at 1 yr.
Albanèse
Jacques
J
Department of Intensive Care and Trauma Center, Marseilles University Hospital System, Marseilles School of Medicine, France.
Leone
Marc
M
Alliez
Jean-Roch
JR
Kaya
Jean-Marc
JM
Antonini
François
F
Alliez
Bernard
B
Martin
Claude
C
D000328:Adult; D001930:Brain Injuries / Q000145:classification / Q000150:complications / Q000601:surgery*; D003399:Craniotomy; D019299:Decompression, Surgical; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D007362:Intensive Care Units; D019586:Intracranial Hypertension / Q000150:complications*; D007427:Intracranial Pressure; D008297:Male; D011184:Postoperative Period; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome