title: Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year.
abstract: 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.
authors.affiliation: Department of Intensive Care and Trauma Center, Marseilles University Hospital System, Marseilles School of Medicine, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Albanèse
authors.forename: Marc
authors.initials: M
authors.lastname: Leone
authors.forename: Jean-Roch
authors.initials: JR
authors.lastname: Alliez
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Kaya
authors.forename: François
authors.initials: F
authors.lastname: Antonini
authors.forename: Bernard
authors.initials: B
authors.lastname: Alliez
authors.forename: Claude
authors.initials: C
authors.lastname: Martin
mesh_terms: 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