gms | German Medical Science

Introduction: Decompressive hemicraniectomy has recently undergone a revival after ischemic stroke, and has thus been increasingly also considered for traumatic conditions. Severe traumatic head injury regularly causes acute and progressive impairment on cerebral function. Elevated and otherwise intractable intracranial pressure is life threatening and the last therapeutic option is decompressive craniectomy.

Material and methods: Retrospective analysis of 31 patients (2008–2013) with severe traumatic brain injury finally underwent unilateral decompressive hemicraniectomy. Clinical parameters (neurological baseline, GCS, focal deficits, technique and size of decompression, postoperative course and additional surgical procedures, and the outcome score at the time of discharge and after three months follow-up were evaluated.

Results: 12 female (38%) and 19 male (62%) consecutive patients with decompressive hemicraniectomy were analyzed. 11 patients (35%) died in the early postoperative period (GOS 1). 6 patients (19%) had a good recovery (GOS 4,5) and were reintegrated into their normal social and work lifes. 14 patients (45%) survived but in a severely disabled state (GOS 2,3). Average size of decompressed area was not different between the three outcome groups: 236 cm² with GOS1, 227cm² with GOS 2,3, and 227cm² with GOS 4,5. Surgery and postoperative management were challenging: In 5 of 31 operations dural sinuses were injured (16%). In 3 cases (10%) additional decompression was necessitated to treat recurrent intracranial hypertension. 25 patients (81%) needed temporary external CSF drainage, and 9 patients (26%) underwent shunt placement for posttraumatic hydrocephalus, 1 patient with wound revision (3%). 4 patients (13%) developed postoperative subdural hygroma. 4 patients (13%) with postoperative meningitis underwent antibiotic treatment.

Conclusion: Decompressive hemicraniectomy is the surgical method to treat otherwise intractable global intracranial hypertension. The overall outcome depends on multiple factors. The overall 19% rate of good recovery is beneficial, but necessitates a critical discussion on indication, especially in the light of 45% of patients being rescued from immanent death, but surviving in a severely disabled state.