Decompressive craniectomy for severe traumatic brain injury case series

The aim of the study was to predict 1-year mortality in TBI patients undergoing DC using logistic regression and random tree models.

This was a retrospective analysis of TBI patients undergoing DC from January 1, 2015, to April 25, 2019. Patient demographic characteristics, biochemical tests, and intraoperative factors were collected. One-year mortality prognostic models were developed using multivariate logistic regression and random tree algorithms. The overall accuracy, sensitivity, specificity, and area under the receiver operating characteristic curves (AUCs) were used to evaluate model performance.

Results: Of the 230 patients, 70 (30.4%) died within 1 year. Older age (OR, 1.066; 95% CI, 1.045-1.087; P < 0.001), higher Glasgow Coma Score (GCS) (OR, 0.737; 95% CI, 0.660-0.824; P < 0.001), higher D-dimer (OR, 1.005; 95% CI, 1.001-1.009; P = 0.015), coagulopathy (OR, 2.965; 95% CI, 1.808-4.864; P < 0.001), hypotension (OR, 3.862; 95% CI, 2.176-6.855; P < 0.001), and completely effaced basal cisterns (OR, 3.766; 95% CI, 2.255-6.290; P < 0.001) were independent predictors of 1-year mortality. Random forest demonstrated better performance for 1-year mortality prediction, which achieved an overall accuracy of 0.810, sensitivity of 0.833, specificity of 0.800, and AUC of 0.830 on the testing data compared to the logistic regression model.

The random forest model showed relatively good predictive performance for 1-year mortality in TBI patients undergoing DC. Further external tests are required to verify this prognostic model ¹⁾.

2018

A retrospective study included all patients undergoing DC for sTBI from 2003 to 2011. The 6-month outcome, assessed using the Glasgow Outcome Scale (GOS), was dichotomized into favorable (GOS 4-5) and unfavorable (GOS 1-3) outcome. Predictors of outcome were identified by uni and multivariate analysis.

190 patients who underwent DC for sTBI were included in this study. 60 patients (31,6%) died within 30 days after DC. Independent prognostic factors for survival after 30-days were GCS at admission > 5 (p=0,002) and bilateral pupils reactivity (p<0,0001). After 30 days from DC, 67 patients (51,5%) out of 130 had unfavorable outcome (GOS 1-3) and 63 patients (49,5%) presented favorable outcome (GOS 4-5). The independent pre-operative prognostic factors for poor outcome were age over 65 years (p < 0,0001) and bilateral absence of pupil reactivity (p = 0,0165). After DC, onset of postoperative hydrocephalus and delayed cranioplasty (3 months after DC) were associated with unfavorable outcome at multivariate analysis (p= 0,002 and p < 0,0001).

In this study, the development of hydrocephalus after DC for sTBI and delayed cranial reconstruction were associated with unfavorable outcome ²⁾.

2017

Tapper et al. conducted a single-center retrospective study on adult blunt TBI patients admitted to a neurosurgical intensive care unit during 2009-2012. Patients were divided into three groups based on their initial treatment - decompressive craniectomy, craniotomy, and conservative. Primary outcome was 6-month Glasgow Outcome Scale (GOS) dichotomized to favorable outcome (independent) and unfavorable outcome (dependent). The association between initial treatment and outcome was assessed using a logistic regression model adjusting for case-mix using known predictors of outcome.

Of the 822 included patients, 58 patients were in the craniectomy group, 401 patients in the craniotomy group, and 363 patients in the conservatively treated group. Overall, 6-month unfavorable outcome was 48%. After adjusting for case-mix, patients in the decompressive craniectomy group had a statistical significantly higher risk for poor neurological outcome compared to patients in the conservative group (OR 3.06, 95% CI 1.45-6.42) and craniotomy group (OR 3.61, 95% CI 1.74-7.51).

In conclusion, patients requiring primary decompressive craniectomy had a higher risk for poor neurological outcome compared to patients undergoing craniotomy or were conservatively treated. It is plausible that the poor prognosis is related to the TBI severity itself rather than the intervention. Further prospective randomized trials are required to establish the role of decompressive craniectomy in the treatment of patients with TBI ³⁾.

2006

During a 48-month period (March 2000-March 2004), 50 of 967 consecutive patients with closed TBI experienced diffuse brain swelling and underwent decompressive craniectomy, without removal of clots or contusion, to control intracranial pressure (ICP) or to reverse dangerous brain shifts. Diffuse injury was demonstrated in 44 patients, an evacuated mass lesion in four in whom decompressive craniectomy had been performed as a separate procedure, and a nonevacuated mass lesion in two. Decompressive craniectomy was performed urgently in 10 patients before ICP monitoring; in 40 patients the procedure was performed after ICP had become unresponsive to conventional medical management as outlined in the American Association of Neurological Surgeons guidelines. Survivors were followed up for at least 3 months posttreatment to determine their Glasgow Outcome Scale (GOS) score. Decompressive craniectomy lowered ICP to less than 20 mm Hg in 85% of patients. In the 40 patients who had undergone ICP monitoring before decompression, ICP decreased from a mean of 23.9 to 14.4 mm Hg (p < 0.001). Fourteen of 50 patients died, and 16 either remained in a vegetative state (seven patients) or were severely disabled (nine patients). Twenty patients had a good outcome (GOS Score 4-5). Among 30-day survivors, good outcome occurred in 17, 67, and 67% of patients with postresuscitation Glasgow Coma Scale scores of 3 to 5, 6 to 8, and 9 to 15, respectively (p < 0.05). Outcome was unaffected by abnormal pupillary response to light, timing of decompressive craniectomy, brain shift as demonstrated on computerized tomography scanning, and patient age, possibly because of the small number of patients in each of the subsets. Complications included hydrocephalus (five patients), hemorrhagic swelling ipsilateral to the craniectomy site (eight patients), and subdural hygroma (25 patients).

Decompressive craniectomy was associated with a better-than-expected functional outcome in patients with medically uncontrollable ICP and/or brain herniation, compared with outcomes in other control cohorts reported on in the literature ⁴⁾.

¹⁾

Cui W, Ge S, Shi Y, Wu X, Luo J, Lui H, Zhu G, Guo H, Feng D, Qu Y. Death after discharge: prognostic model of 1-year mortality in traumatic brain injury patients undergoing decompressive craniectomy. Chin Neurosurg J. 2021 Apr 21;7(1):24. doi: 10.1186/s41016-021-00242-4. PMID: 33879254.

²⁾

Nasi D, Dobran M, Rienzo AD, Somma LD, Gladi M, Moriconi E, Scerrati M, Iacoangeli M. Decompressive Craniectomy for Traumatic Brain Injury: The Role of Cranioplasty and Hydrocephalus on Outcome. World Neurosurg. 2018 May 14. pii: S1878-8750(18)30981-1. doi: 10.1016/j.wneu.2018.05.028. [Epub ahead of print] PubMed PMID: 29772371.

³⁾

Tapper J, Skrifvars MB, Kivisaari R, Siironen J, Raj R. Primary decompressive craniectomy is associated with worse neurological outcome in patients with traumatic brain injury requiring acute surgery. Surg Neurol Int. 2017 Jul 11;8:141. doi: 10.4103/sni.sni_453_16. eCollection 2017. PubMed PMID: 28781918; PubMed Central PMCID: PMC5523471.

⁴⁾

Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg. 2006 Apr;104(4):469-79. PubMed PMID: 16619648.