Decompressive (hemi)craniectomy for refractory intracranial hypertension after traumatic brain injury

Introduction

Sedation, administration of mannitol or hypertonic saline, mild hyperventilation, moderate hypothermia and high-dose barbiturate therapy are all strategies in the treatment of intracranial hypertension in traumatic brain injury (TBI). Intracranial pressure (ICP) >20 mmHg not responding to conservative strategies caries a bad prognosis, mortality exceeding 80%. A final option in refractory intracranial hypertension might be decompressive (hemi)craniectomy.

Methods

A retrospective analysis of the outcome of 11 patients with TBI undergoing decompressive (hemi)craniectomy for increased ICP not responding to conservative treatment between July 2001 and April 2005. Outcome was measured on the Glasgow Outcome Scale (GOS). Other parameters considered were: pupil reaction, initial Glasgow Coma Scale after resuscitation (IGCS) and preoperative ICP.

Results

Eleven patients (five male, six female; mean age 20.6 years, range 2–42 years) underwent decompressive craniotomy when ICP could not be managed sufficiently by nonsurgical treatment. All patients suffered from blunt, nonpenetrating head injury, all but one had isolated TBI, and one was a multitrauma patient. Unilateral or bilateral absent pupil reaction at admission was seen in five patients. Two of these five patients had recurrent episodes with absent pupil reactions and died.

The mean IGCS was 8. In the patients that died the IGCS was 5 (range 4–6, median Motor score 2). The IGCS in survivors was 9 (range 3–15, median Motor score 4).

The mean injury–craniotomy interval was 72.4 hours (range 0–10 days). In six patients surgery was performed within 48 hours after injury. The mean ICP before surgery was 30.6 mmHg. Most times the ICP measurement device was removed at surgery. In three patients the ICP was measured after decompression and showed immediate decrease in ICP (mean 10.7 mmHg).

Favourable outcome (GOS 4 + 5) was achieved in eight patients (72.7%). Three patients (28.3%) died (GOS 1). None of the patients had severe disability (GOS 2 + 3).

Conclusion

This retrospective survey supports the use of decompressive craniotomy in the management of TBI patients with intractable high ICP. The number of patients studied is to small to discriminate predictors of good outcome. Recurrent or persistent absence of pupil reflexes indicates a poor neurological outcome.