Comparative study of decompressive craniectomy after mass lesion evacuation in severe head injury.
OBJECTIVE
This study was conducted to evaluate outcome after decompressive craniectomy (DC) in the setting of mass evacuation with or without intracranial pressure (ICP) monitoring.


METHODS
Over a 48-month period (March 2000 to March 2004), 54 of 967 consecutive head injury patients underwent DC for evacuation of a mass lesion. DC was performed without ICP monitoring in 27 patients who required urgent decompression (group A) and in 27 patients who did not require urgent surgery and who had their ICP monitored for 1 to 14 days before surgery (group B).


RESULTS
In group A, the mean Glasgow Coma Scale score was 6.0; 80% had computed tomographic evidence of a shift greater than 5 mm; and 25 patients underwent DC immediately after resuscitation. In group B, the mean Glasgow Coma Scale score was 7.3; 40% had computed tomographic evidence of shift; and 75% underwent DC 24 hours or longer after presentation. Overall, 22 patients died (12 in group A and 10 in group B), 11 remained vegetative or severely disabled (3 in group A and 8 in group B), and 19 had good recovery (11 in group A and 8 in group B). Two patients were lost to follow-up. In 18 group B patients with ICP greater than 20 mm Hg before mass evacuation, ICP dropped an average of 13 mm Hg (P < 0.001). A mass lesion greater than 50 mL (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.04-7.89) and evidence of low attenuation on computed tomography before (OR, 3.3; 95% CI, 1.1-10.3) or after (OR, 2.92; 95% CI, 1.02-8.34) DC were predictors of death. A good outcome occurred in 42% of patients with and in 63% of patients without delayed traumatic injury (OR, 0.3; 95% CI, 0.1-1.1). Outcome was favorable in 78.6% of patients who had no ICP monitoring before DC versus 47.1% of patients with ICP monitoring (OR, 0.2; 95% CI, 0.1-1.2).


CONCLUSIONS
In this study, mortality after DC for mass lesion was greater than expected, and outcome did not differ between patients with or without ICP monitoring.
Aarabi
Bizhan
B
Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. baarabi@smail.umaryland.edu
Hesdorffer
Dale C
DC
Simard
J Marc
JM
Ahn
Edward S
ES
Aresco
Carla
C
Eisenberg
Howard M
HM
McCunn
Maureen
M
Scalea
Thomas
T
D000328:Adult; D015331:Cohort Studies; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery*; D003399:Craniotomy / Q000379:methods*; D019299:Decompression, Surgical / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007427:Intracranial Pressure / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D055815:Young Adult