Long-term functional outcomes after unilateral versus bilateral decompressive craniectomy-a single center experience

Early initiation of neurological rehabilitation following stroke or traumatic brain injury requires access to ventilation and comprehensive care at neurorehabilitation centers. The recovery after decompressive craniectomy (DC) is very heterogeneous and influenced by surgical laterality and complications. This study compared long-term outcomes after unilateral (UDC) versus bilateral DC (BDC).

Patients admitted to our neurological rehabilitation center between 2000 and 2018 after BDC were matched by age, sex, and etiology to UDC. Clinical data included initial Glasgow Coma Scale, intracranial lesions, hospital admission time, complications, outcome, ventriculoperitoneal shunts and time to cranioplasty. Functional outcomes were assessed using the Extended Glasgow Outcome Scale (GOSE), Barthel Index (BI), and Early Rehabilitation Barthel Index (eBI) at discharge and follow-up. Follow-up interviews were conducted with 28 patients (15 UDC, 13 BDC) to evaluate GOSE, BI, quality of life, and home circumstances.

Fifty patients (mean age 28.2 ± 13 years; 28% female) were analyzed. Favorable outcomes occurred in 36% of UDC patients versus 16% of BDC patients, while unfavorable outcomes were more frequent in BDC (44% vs. 24%). UDC patients demonstrated significantly better eBI scores at discharge and follow-up (p = 0.043; p = 0.016) and superior GOSE outcomes (p = 0.011). Shorter hospitalization correlated with favorable outcomes in UDC (p = 0.012; r = -0.628). BDC patients experienced more neurological complications, which were associated with poorer outcomes (GOSE follow-up p = 0.019; r = -0.411; BI follow-up p = 0.022; r = 0.415).

BDC is associated with poorer functional outcomes and higher complication rates compared to UDC. Further randomized studies are needed to confirm these findings.