Late decompressive craniectomyafter traumatic brain injury: neurological outcome at 6 months after ICU discharge

The choice of optimal treatment in traumatic brain injured (TBI) patients is a challenge. The aim of this study was to verify the neurological outcome of severe TBI patients treated with decompressive craniectomy (early < 24 h, late > 24 h), compared to conservative treatment, in hospital and after 6-months.

A total of 186 TBI patients admitted to the ICU of the Emergency Department of a tertiary referral center (Careggi Teaching Hospital, Florence, Italy) from 2005 through 2009 were retrospectively studied. Patients treated with decompressive craniectomy were divided into 2 groups: "early craniectomy group" (patients who underwent to craniectomy within the first 24 hours); and "late craniectomy group" (patients who underwent to craniectomy later than the first 24 hours). As a control group, patients whose intracranial hypertension was successfully controlled by medical treatment were included in the "no craniectomy group".

Groups included 41 patients who required early decompressive craniectomy, 21 patients treated with late craniectomy (7.7 days after trauma, on average), and 124 patients for whom intracranial hypertension was successfully controlled through conservative treatment. Groups were comparable in age and trauma/critical illness scores, except for a significantly higher Marshall score in early craniectomized patients. The Glasgow Outcome Scale was comparable between groups at ICU, at the time of hospital discharge and at 6 months.

In our sample, a late craniectomy in patients with refractory intracranial hypertension produced a comparable 6-months neurological outcome if compared to patients responder to standard treatment. This data must be reproduced and confirmed before considering as goal-treatment in refractory intracranial hypertension.