title: Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury.
abstract: BACKGROUND
  The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature.
  
  
  METHODS
  Patients with severe TBI (Abbreviated Injury Score 4-5) treated with DC for the management of increased ICP during 6-year period were identified from the trauma registry. Functional outcome was measured 1 year to 6 years postinjury using the Glasgow Outcome Score Extended (GOSE) via telephone interview and classified as good (GOSE 5-8) or poor (GOSE 1-4, including death). Outcomes were compared using Wilcoxon rank-sum and chi2 tests where appropriate.
  
  
  RESULTS
  One hundred and seventy-one patients were identified: 137 (80%) men and 34 (20%) women. Overall mortality (all in-hospital) was 32% (head-related = 22%). Of the 117 survivors, follow-up was obtained in all but 6 (95%). Good outcome was achieved in 96 patients (56% overall, 82% of survivors). Those with good outcome were younger (26 years vs. 43 years, p = 0.0028) and experienced a greater change in predecompression to postdecompression ICP (ICP reduced by 23 mm Hg vs. 10 mm Hg, p < 0.0001). Not surprisingly, unchanged ICP (predecompression to postdecompression) was associated with poor outcome (p = 0.0031). There was no difference in immediate predecompression ICP between survivors versus nonsurvivors. However, immediate predecompression Glasgow Coma Score was significantly higher in survivors compared with nonsurvivors (7 vs. 5, p < 0.0001).
  
  
  CONCLUSIONS
  DC resulted in good functional outcome in >50% of patients with severe TBI. The greatest benefit was observed in younger patients with a demonstrable reduction in ICP after decompression. The prospect of improved functional outcome offered by this procedure in the treatment of severe TBI warrants prospective investigation.
authors.affiliation: Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
authors.forename: Regan F
authors.initials: RF
authors.lastname: Williams
authors.forename: Louis J
authors.initials: LJ
authors.lastname: Magnotti
authors.forename: Martin A
authors.initials: MA
authors.lastname: Croce
authors.forename: Brinson B
authors.initials: BB
authors.lastname: Hargraves
authors.forename: Peter E
authors.initials: PE
authors.lastname: Fischer
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Schroeppel
authors.forename: Ben L
authors.initials: BL
authors.lastname: Zarzaur
authors.forename: Michael
authors.initials: M
authors.lastname: Muhlbauer
authors.forename: Shelly D
authors.initials: SD
authors.lastname: Timmons
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Fabian
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000601:surgery*; D003399:Craniotomy / Q000379:methods*; D019299:Decompression, Surgical; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020127:Recovery of Function; D012042:Registries; D016896:Treatment Outcome; D055815:Young Adult