Decompressive craniectomy in severe traumatic brain injury

Introduction

The management of refractory post-traumatic cerebral oedema remains a frustrating endeavour for the neurosurgeon and the intensivist. Mortality and morbility rates remain high, despite refinements in medical and pharmacological means of controlling intracranial hypertension.

Materials and methods

In this retrospective study we have evaluated the efficacy of therapeutic decompressive craniectomy with uncontrollable intracranial pressure as a last resort therapy in 16 patients, from March 2000 to October 2002. The patients were treated according to a local protocol that assigned them to barbiturate coma or decompressive craniectomy. The following parameters were considered: age, GCS after stabilization, intracranial pressure, GOS at ICU discharge and at 6 months, neuropsychological evaluation for patients with GOS 4 and 5 after 6 months.

The mean age of the patients was 28 ± 11.5 years and the GCSm after stabilization varied from 1 to 5.

Results

All the 16 patients have been operated on by a FTP craniectomy when ICP was higher than 30 mmHg for more than 15 min. At 6 months three of them were dead (19%), one was in PSV (6%), one was severely disabled (6%), four were moderately disabled (25%) and seven had a good recovery (44%). All the patients with GOS of 5 had normal neuropsychological tests, and all the patients with GOS of 4 had at least one pathological neuro-psychological test.

Discussion

We evaluated our ability to be accurate to the local protocol for decompressive craniectomy. We found that when we did not respect the inclusion criteria according to the patient's age (< 50 years old) we still had good results, but when we did not respect the inclusion criteria for GCSm after stabilization (≥ 3) we obtained poor outcome. In our opinion patients with STBI, developing delayed intracranial hypertension caused by diffuse cerebral oedema, definitely benefit from craniectomy when ICP is out of control. Nevertheless, of extreme importance is our ability to identify those patients who could really benefit by this therapy in terms of GOS. In our experience, age < 50 years old could be a too restrictive criteria, but all the patients with GCSm ≤ 3 had a poor outcome irrespective of age.