Outcome after decompressive craniectomy for the treatment of severe traumatic brain injury

Using decompressive craniectomy as part of the treatment regimen for severe traumatic brain injury (STBI) has become more common at our Level I trauma center. This study was designed to examine this practice with particular attention to long-term functional outcome.

A retrospective review of prospectively collected data was performed for patients with STBI admitted from January 1, 2003 to December 31, 2005. Our institution manages patients using the Brain Trauma Foundation Guidelines. Data collected from patients undergoing decompressive craniectomy included: age, Injury Severity Score, admission and follow-up Glasgow Coma Score, timing of, and indication for decompressive craniectomy, and procedure-related complications. The Extended Glasgow Outcome Scale (GOSE) was performed by a experienced trauma clinical research coordinator using a structured phone interview to assess long-term outcome in the survivors. Student's t test and chi2 were used to examine differences between groups.

Forty STBI patients were treated with decompressive craniectomy; 24 were performed primarily in conjunction with urgent evacuation of extra-axial hemorrhage and 16 were performed primarily in response to increased intracranial pressure with 4 of these after an initial craniotomy. Decompressive craniectomy was very effective at lowering intracranial pressure in these 16 patients (35.0 mm Hg +/- 13.5 mm Hg to 14.6 mm Hg +/- 8.7 mm Hg, p = 0.005). Twenty-two decompressive craniectomy patients did not survive to hospital discharge, whereas admission Glasgow Coma Score and admission pupil size and reactivity correlated with outcome, age, and Injury Severity Score did not. At a mean of 11 months (range, 3-26 months) after decompressive craniectomy, 6 survivors had a poor functional outcome (GOSE 1-4), whereas 12 survivors had a good outcome (GOSE 5-8). Therefore, 70% of these patients had an unfavorable outcome (death or severe disability), and 30% had a favorable long-term functional outcome. Fifteen of 18 survivors went on to cranioplasty, whereas 4 of 18 had cerebrospinal infection.

The majority of survivors after decompressive craniectomy have a good functional outcome as analyzed by GOSE. Overall, 30% of patients with STBI who underwent decompressive craniectomy had a favorable long-term outcome. Improving patient selection and optimizing timing of this procedure may further improve outcome in these very severely brain injured patients.