gms | German Medical Science

Objective: Intracranial hypertension due to cerebral edema after traumatic brain injury (TBI) can become uncontrollable even under the best medical treatment. The aim of this retrospective study was to evaluate the outcome following decompressive craniectomy (DC) based on initial clinical condition and timing of surgery.

Methods: During a 5-year period 45 of 425 (10.6%) consecutive patients with closed TBI were treated by DC in a level one trauma center. Patients with premorbid neurological deficits were excluded. The mean age was 34 (±13.5 years) with a male preponderance (80%). The technique used either unilateral, bilateral or bifrontal decompression with a bone flap diameter of at least 12 cm, all patients received an enlarged duraplasty. 29/45 patients, who presented with Glasgow Coma Scale <6, pupillary abnormalities, and/ or pathological findings such as midline shifts or a hematoma in computerized tomography (CT) underwent urgent DC within 24 hours after the TBI. 16/45 patients underwent secondary decompression because of refractory intracranial pressure, pupillary abnormalities, and/ or pathological findings in the CT on day 2 - 6 (13/16) or after day 6 (3/16) after the trauma. All survivors were reevaluated by the Glasgow Outcome Scale (GOS) after 3, 6, and 12 months and hadd follow-up CT.

Results: 6/29 (21%) of the early decompressed patients showed a favorable outcome with GOS 4 or 5, only one of these patients had brain stem deficits on admission. 11/16 (69%) of the secondary decompressed patients achieved a GOS of 4 or 5, only two of them had pupillary abnormalities before surgery.

Conclusions: Decompression after severe TBI with secondary intractable hypertension is effective with acceptable results. An opportune timing of the procedure in the absence of brain stem deficits seems preferable, whereas patients with primary broken down brain stem reflexes do not profit from DC.