Impact of frailty in elderly patients undergoing decompressive craniectomy after traumatic brain injury

Decompressive craniectomy (DC) is a surgical procedure in which a large portion of the skull is removed and the dura mater is opened to relieve intracranial pressure. The indication in elderly patients is controversial, with prevailing studies indicating an overall poor prognosis. However, some patients recover well despite their advanced age. In this study we aimed to investigate the impact of frailty and muscularity on outcome after DC for TBI. We conducted a retrospective review of clinical notes of patients aged > 60 years, who underwent DC following TBI between January 2010 and December 2021. Temporalis muscle area (TMA) was quantified from head CT-scans upon admission. Frailty was assessed retrospectively from clinical charts using the Clinical Frailty Scale (CFS). Regression analysis were employed to determine their association with postsurgical Glasgow Outcome Scale (GOS). We identified 55 patients with a median age of 72 years (IQR 67-77; range 60-93 years). The 30-day mortality rate was 14.6%. At discharge, 32.7% of patients achieved good recovery or moderate disability (GOS 4-5), while 67.3% experienced severe disability, vegetative state, or death (GOS1-3). Initial GCS and CFS were associated to GOS at discharge in univariate (p = 0.042 and p = 0.009 respectively) and multivariate regression analysis (p = 0.049 and p = 0.013 respectively). TMA showed no association with GOS at discharge (p = 0.773). Age was associated with GOS at discharge in univariate (p = 0.042), but not multivariate linear regression (p = 0.421) when adjusted for GCS and CFS as covariables. Thirty patients (54.6%) were readmitted for cranioplasty, with 17 patients (30.9% of the entire cohort) displaying a GOS of 4-5. Frailty, rather than chronological age, emerges to be a crucial predictor of GOS following decompressive craniectomy for TBI in elderly patients. Incorporation of frailty assessment by CFS into decision-making processes could help to identify elderly patients with a more favorable post-surgical outcome, thereby facilitating treatment decisions.