Implementation of the protocol of decompressive craniectomy: does it really improve outcome?

Introduction

Treatment of traumatic brain injury (TBI) and other conditions that increase intracranial pressure (ICP) continues to be a challenge for intensivists and neurosurgeons. Despite adequate monitoring, the mortality and morbidity rate remain high. Decompressive craniectomy (DC) can be performed where maximum medical therapy has failed to reduce ICP.

Objective

To analyze the viability of the DC protocol, since implementation, in the former 23 months. To identify the applicability of the protocol as an instrument for DC indication.

Methods

A prospective, descriptive, series study, realized by the UPG-UCI of the Emergency and Neurosurgery Service. Criteria for ICU admission: age >18 years and <60 years, <48 hours at admission (except patients with tumor), Glasgow Coma Scale (GCS) >4, decline for 3 points with the first GCS, extensive unilateral brain trauma, intraoperative evidence of brain swelling; image evidence of intracranial hypertension (ICH), stroke or brain trauma with mass effect and midline shift. Maximum medical therapy to reduce ICP, when possible: drainage of cerebrospinal fluid; induced hyperventilation; intravenous hyperosmotic solutions; head elevation; sedation and neuromuscular paralysis; barbiturate coma; and hypothermia. The protocol includes clinical, neurological and image signs. The patients' evolution was appraised by 3-month mortality, GCS and modified Rankin Scale.

Results

Since the implementation of the DC protocol, from January 2007 to November 2008, seven clinical cases were admitted, all males, mean age of 39 years (21 to 60). Amongst them, three patients (42.8%) received specialized neurointensive care since admission. The primary mechanisms of injury include: fall of 2 m with severe concussion, fall of 6 m with subdural hematoma, carotid occlusion with hemispheric ischemia, tumor (glioblastoma multiforme), two motorcycle collisions with TBI, and gunshot with temporal contusion and subdural hematoma. The mean time between the admittance and DC was 29 hours 30 minutes (2 to 48 hours) (one tumor). None of the patients died. The mean GCS was: on admittance, 12 (8 to 15); pre-DC, 9 (6 to 15); 1 week, 12 (9 to 15); 3 months, 14 (11 to 15). The admittance GCS was higher than the pre-DC in all patients, and also the 1-week GCS was higher than the pre-DC. The mean modified Rankin scale was 1.75 (0 to 3). (See Figure 1.)

Figure 1

(abstract P52)

Conclusion

Implementation of the protocol, based on recent studies, allows one to establish, with more accuracy, the best indication for DC, improving outcome. Despite small casualties, DC was effective to treat otherwise uncontrollable ICH and improved cerebral perfusion pressure. All patients presented a satisfactory clinical evolution and outcome after the procedure. The neurointensive care unit allowed an adequate treatment indication and management of these complex patients.