title: Decompressive craniectomy for elderly patients with traumatic brain injury: it's probably not worth the while.
abstract: Decompressive craniectomy (DC) has been regarded as an ultima ratio measure in the treatment of refractory intracranial hypertension after brain injury. Most discussion about its benefits is based on studies performed in patients who are <65 years of age. The aim of this study was to identify patients aged ≥66 years who underwent DC after traumatic brain injury (TBI), in order to assess patient outcome and to correlate the values of potential predictors of survival on prognosis. From January 2002 to December 2009, 44 patients aged ≥66 underwent DC (follow-up, 12-102 months). Potential predictors of outcome were analyzed, including age, post-resuscitation Glasgow Coma Scale (GCS) score, presence of mass lesion, Simplified Acute Physiology Score (SAPS) II, Injury Severity Score (ISS), and timing of surgical decompression. Mortality was 48% at discharge from the intensive care unit (ICU), 57% at hospital discharge, and 77% at 1-year follow-up and at last follow-up. A bad outcome Glasgow Outcome Scale Dead-Vegetative State-Severely Disabled (GOS D-VS-SD) was observed in 36/44 patients both at hospital discharge and at 1-year follow-up. Mean SAPS II was 45.2 for patients who survived and 57.3 for patients who had died (p=0.0022). Patients who survived had a higher mean post-resuscitation GCS score (p=0.02). Logistical regression analysis indicated post-resuscitation GCS score as the only independent predictive factor for outcome. None of the 22 patients with a post-resuscitation GCS score of 3-5 had a good outcome, 2/10 (20%) patients with a post-resuscitation GCS score of 6-8 and 6/12 patients (50%) with a post-resuscitation GCS score ≥9 had a good outcome.
authors.affiliation: Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy. debonisvox@gmail.com
authors.forename: Pasquale
authors.initials: P
authors.lastname: De Bonis
authors.forename: Angelo
authors.initials: A
authors.lastname: Pompucci
authors.forename: Annunziato
authors.initials: A
authors.lastname: Mangiola
authors.forename: Giovanna
authors.initials: G
authors.lastname: Paternoster
authors.forename: Rossano
authors.initials: R
authors.lastname: Festa
authors.forename: Carlotta Ginevra
authors.initials: CG
authors.lastname: Nucci
authors.forename: Riccardo
authors.initials: R
authors.lastname: Maviglia
authors.forename: Massimo
authors.initials: M
authors.lastname: Antonelli
authors.forename: Carmelo
authors.initials: C
authors.lastname: Anile
mesh_terms: D000368:Aged / Q000502:physiology*; D000369:Aged, 80 and over; D001921:Brain / Q000473:pathology; D001930:Brain Injuries / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D003399:Craniotomy / Q000009:adverse effects; D003627:Data Interpretation, Statistical; D019299:Decompression, Surgical / Q000009:adverse effects; D005500:Follow-Up Studies; D015600:Glasgow Coma Scale; D023261:Glasgow Outcome Scale; D006801:Humans; D015601:Injury Severity Score; D019586:Intracranial Hypertension / Q000209:etiology; D016015:Logistic Models; D010351:Patient Discharge; D018579:Patient Selection; D011237:Predictive Value of Tests; D011379:Prognosis; D016019:Survival Analysis; D016896:Treatment Outcome