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Prognosis for severe traumatic brain injury patients treated with bilateral decompressive craniectomy
Hiroshi Yatsushige1, Yoshio Takasato, Hiroyuki Masaoka
1Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan. hyatsushige@hotmail.com
Insights
Bilateral decompressive craniectomy in severe head injury patients with new brain lesions shows a poor prognosis. However, younger patients with reactive pupils may benefit from this procedure if intracranial pressure and cerebral perfusion pressure stabilize post-surgery.
Area of Science:
- Neurosurgery
- Trauma Surgery
- Critical Care Medicine
Background:
- Decompressive craniectomy (DC) is used for traumatic brain injury (TBI) to reduce intracranial hypertension.
- DC can lead to increased brain edema or contralateral hematoma formation.
- The prognosis of bilateral DC in TBI patients with secondary lesions is not well-established.
Purpose of the Study:
- To evaluate the prognosis of bilateral decompressive craniectomy (BDC) in severe head injury patients.
- To assess outcomes in patients who develop bilateral or contralateral lesions after an initial ipsilateral DC.
Main Methods:
- Retrospective analysis of 12 patients who underwent BDC from 217 TBI patients treated with DC.
- Data collected included demographics, neurological status, surgical timing, and Glasgow Outcome Scale (GOS).
- Intensive care unit (ICU) physiological data (ICP, CPP, glucose, lactate) were analyzed.
Main Results:
- Overall outcomes: 3 good recovery, 1 mild disability, 2 severe disability, 1 vegetative state, 5 deaths.
- Younger patients with better admission neurological status and pupil reactivity had better outcomes.
- Significant differences in ICP, CPP, glucose, and lactate at 24h post-surgery were observed between good and poor outcome groups.
Conclusions:
- Severe head injury patients developing bilateral or contralateral lesions after initial DC generally have a poor prognosis.
- BDC may be a viable option for select younger patients with reactive pupils and stabilized ICP/CPP post-operatively.
Purpose:
Decompressive craniectomy for traumatic brain injury patients has been shown to reduce intracranial hypertension, while it often results in increased brain edema and/or contralateral space-occupied hematoma. The purpose of this study was to determine the prognosis of bilateral decompressive craniectomy in severe head injury patients with the development of either bilateral or contralateral lesions after ipsilateral decompressive craniectomy.
Methods:
Twelve patients underwent bilateral decompressive craniectomy among 217 individuals who had been treated with decompressive craniectomy with dural expansion from September 1995 to August 2006. The following patient data were retrospectively collected: age, neurological status at admission, time between injury and surgical decompression, time between first and second decompression, laboratory and physiological data collected in the intensive care unit, and outcome according to the Glasgow Outcome Scale.
Results:
Patient outcomes fell into the following categories: good recovery (three patients); mild disability (one patient); severe disability (two patients); persistent vegetative state (one patient); and death (five patients). Patients with good outcomes were younger and had better pupil reactions and neurological statuses on admission. Other factors existing prior to the operation did not directly correlate with outcome. At 24 h post-surgery, the average intercranial pressure (ICP), cerebral perfusion pressure (CPP), glucose level, and lactate level in patients with poor outcomes differed significantly from those of patients with a good prognosis.
Conclusion:
Head injury patients with either bilateral or contralateral lesions have poor prognosis. However, bilateral decompressive craniectomy may be a favorable treatment in certain younger patients with reactive pupils, whose ICP and CPP values are stabilized 24 h post-surgery.
