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Original Article
11 (
4
); 601-608
doi:
10.1055/s-0040-1715998

Decompressive Craniectomy for Traumatic Brain Injury: In-hospital Mortality-Associated Factors

Department of Neurosurgery, Hospital de Emergencias José Casimiro Ulloa, Miraflores, Lima, Perú
Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen - EsSalud, La Victoria, Lima, Perú
Clínica Angloamericana, San Isidro, Lima, Perú
Address for correspondence Giancarlo Saal-Zapata, MD Grau Avenue 800, La Victoria, Lima 13 Perú gian_carlo1987@hotmail.com gsaal1987@gmail.com
Licence
This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Disclaimer:
This article was originally published by Thieme Medical and Scientific Publishers Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Objective Determine predictors of in-hospital mortality in patients with severe traumatic brain injury (TBI) who underwent decompressive craniectomy.

Materials and Methods This retrospective study reviewed consecutive patients who underwent a decompressive craniectomy between March 2017 and March 2020 at our institution, and analyzed clinical characteristics, brain tomographic images, surgical details and morbimortality associated with this procedure.

Results Thirty-three (30 unilateral and 3 bifrontal) decompressive craniectomies were performed, of which 27 patients were male (81.8%). The mean age was 52.18 years, the mean Glasgow coma scale (GCS) score at admission was 9, and 24 patients had anisocoria (72.7%). Falls were the principal cause of the trauma (51.5%), the mean anterior–posterior diameter (APD) of the bone flap in unilateral cases was 106.81 mm (standard deviation [SD] 20.42) and 16 patients (53.3%) underwent a right-sided hemicraniectomy. The temporal bone enlargement was done in 20 cases (66.7%), the mean time of surgery was 2 hours and 27 minutes, the skull flap was preserved in the subcutaneous layer in 29 cases (87.8%), the mean of blood loss was 636.36 mL,and in-hospital mortality was 12%. Univariate analysis found differences between the APD diameter (120.3 mm vs. 85.3 mm; p = 0.003) and the presence of midline shift > 5 mm (p = 0.033).

Conclusion The size of the skull flap and the presence of midline shift > 5 mm were predictors of mortality. In the absence of intercranial pressure (ICP) monitoring, clinical and radiological criteria are mandatory to perform a decompressive craniectomy.

Keywords

decompressive craniectomy
intracranial pressure
intracranial hypertension
traumatic brain injury

Introduction

Traumatic brain injury (TBI) is a serious pathology that conditions an increase in morbidity and mortality, with more than 50,000 deaths annually in developed countries.1 Secondary damage due to cerebral edema, contusions, subdural hematoma (SDH), epidural hematoma(EDH), and others lead to a progressive increase in intracranial pressure (ICP), with consequent alteration in the brain compliance.2 3

Intracranial hypertension is related to a higher prevalence of disability and death if not treated. Guidelines propose a step-wise treatment to control ICP, but when intracranial hypertension is refractory to medical or first-tier management, decompressive craniectomy (DC) is the treatment of choice.4 Randomized controlled trials and guidelines have evaluated the benefits of DC over optimal medical treatment in cases of TBI with intracranial hypertension and recommend this procedure to improve neurologic outcomes and lower mortality rates.4 5 6 7 Few studies in our country have issued this problem,8 9 so we aimed to evaluate our experience of consecutive patients with severe TBI who underwent DC in our institution and analyze in-hospital mortality-associated factors.

Materials and Methods

Patient Selection

Between March 2017 and March 2020, 33 consecutive patients with the diagnosis of severe TBI underwent 33 decompressive craniectomies at the Hospital de Emergencias José Casimiro Ulloa from Lima, Perú. Clinical charts and brain CT scans were used to analyze demographics, clinical characteristics, tomographic findings, surgical details, procedure-related complications, and mortality associated with the procedure. The study was approved by the ethics committee of the hospital.

Demographics and clinical characteristics included age, sex, the mechanism of trauma, the presence of anisocoria, and the Glasgow coma scale (GCS) score at admission. The tomographic findings analyzed were the presence of acute SDHs and EDHs, midline shift > 5 mm, traumatic subarachnoid hemorrhage (SAH), cerebral contusions, skull fracture, and the Marshall classification. Surgical details included the type of craniectomy, the side of the craniectomy in unilateral cases, the anterior–posterior diameter (APD) in unilateral craniectomies, temporal bone removal (enlargement toward the skull base or zygomatic arch with drill or rongeur), blood loss, the subcutaneous layer placement of the bone flap, and the time of surgery.

Unilateral or bifrontal craniectomies were performed according to the type and location of the lesion and CT scans. ICP monitoring was not performed in any of the cases. For unilateral DC, a question mark incision and a frontotemporoparietal bone flap with duroplasty was done. In cases of a bifrontal DC, a bicoronal incision with a flap from the frontal bone to the coronal suture with duroplasty was performed. All the procedures were catalogued as primary DC, and ICP monitoring was not performed.

Statistical Analysis

Categorical variables were expressed as percentages, and numerical variables were expressed as means ± SD. Differences between numerical variables were analyzed with t-student or Mann–Whitney tests, depending on its distribution, and the Fisher’s test was employed for categorical variables. A pvalue < 0.05 was considered statistically significant. The software Stata v14.0 (StataCorp, College Station, Texas) was used for the analysis.

Results

Population Characteristics

Thirty-three decompressive craniectomies were analyzed, of which 30 were unilateral and three were bifrontal craniectomies. Males represented 81.8% of the cases and the mean age was 52.2 ± 20.1 years (range 22 to 85 years). The principal mechanism of trauma wasfalls (51.5%), traffic accidents (36.4%), and hit by an object (12.1%). The mean GCS score at admission was 9, and 24 patients (72.7%) presented anisocoria at admission. Fifteen patients had a GCS ≤ 8 points (45.5%) (Table 1).

Table 1
Clinical and surgical-related characteristics of patients treated with decompressive craniectomy

Case

Age

Sex

Mechanism of trauma

Presence of anisocoria

GCS at admission

Surgical procedure

Side

APD

(mm)

Temporal bone

removal

Blood

loss

(mL)

Subcutaneous layer placement

Time of surgery

(minutes)

Mortality

Abbreviations: APD, anterior–posterior diameter; GCS, Glasgow coma scale.

1

38

F

Traffic accident

Present

12

Unilateral craniectomy

Left

101.4

Yes

100

Yes

90

No

2

62

M

Traffic accident

Present

11

Unilateral craniectomy

Left

88.94

No

250

Yes

150

No

3

28

M

Traffic accident

Present

7

Unilateral craniectomy

Right

120.59

No

1500

No

120

No

4

33

M

Traffic accident

Present

9

Unilateral craniectomy

Left

133.25

Yes

1000

No

150

No

5

42

F

Fall

Absent

10

Unilateral craniectomy

Right

94.05

No

500

Yes

120

No

6

84

M

Fall

Present

5

Unilateral craniectomy

Left

88.43

No

300

Yes

70

Yes

7

71

M

Traffic accident

Present

6

Unilateral craniectomy

Right

112.93

Yes

500

Yes

120

No

8

23

M

Hit by rigid object

Present

8

Bifrontal craniectomy

400

Yes

255

No

9

78

M

Traffic accident

Present

9

Unilateral craniectomy

Left

113.27

Yes

200

Yes

90

No

10

85

F

Traffic accident

Present

5

Unilateral craniectomy

Right

106.23

Yes

1000

Yes

95

No

11

24

M

Fall

Absent

6

Unilateral craniectomy

Left

97.12

Yes

300

Yes

120

Yes

12

39

M

Fall

Present

12

Unilateral craniectomy

Right

116.04

Yes

1200

Yes

180

No

13

61

F

Fall

Present

5

Unilateral craniectomy

Left

121.5

No

700

No

140

No

14

26

M

Fall

Absent

10

Unilateral craniectomy

Left

127.29

Yes

1000

Yes

195

No

15

57

M

Fall

Present

10

Bifrontal craniectomy

300

Yes

113

No

16

38

M

Fall

Present

8

Unilateral craniectomy

Right

127.67

Yes

700

Yes

170

No

17

64

F

Traffic accident

Absent

14

Unilateral craniectomy

Right

122.69

Yes

200

Yes

106

No

18

36

M

Fall

Present

8

Unilateral craniectomy

Right

139.59

Yes

400

Yes

160

No

19

65

M

Fall

Present

8

Unilateral craniectomy

Right

123.58

Yes

900

Yes

170

No

20

66

M

Traffic accident

Present

5

Unilateral craniectomy

Left

132.84

Yes

1000

No

196

No

21

66

F

Fall

Present

10

Unilateral craniectomy

Right

108.37

No

700

Yes

170

No

22

35

M

Hit by rigid object

Present

5

Unilateral craniectomy

Right

131.18

Yes

400

Yes

170

No

23

22

M

Fall

Present

11

Unilateral craniectomy

Left

100.85

No

800

Yes

160

No

24

32

M

Traffic accident

Present

4

Unilateral craniectomy

Right

112.34

Yes

1000

Yes

150

No

25

22

M

Hit by rigid object

Absent

12

Unilateral craniectomy

Right

97.17

No

500

Yes

145

No

26

26

M

Fall

Present

9

Unilateral craniectomy

Right

166.42

Yes

350

Yes

165

No

27

68

M

Traffic accident

Absent

9

Bifrontal craniectomy

1500

Yes

235

Yes

28

46

M

Fall

Present

12

Unilateral craniectomy

Right

133.88

Yes

400

Yes

150

No

29

68

M

Fall

Present

7

Unilateral craniectomy

Left

148.92

Yes

1000

Yes

135

No

30

68

M

Traffic accident

Present

7

Unilateral craniectomy

Left

138.09

Yes

500

Yes

155

No

31

27

M

Fall

Present

12

Unilateral craniectomy

Right

99.77

No

300

Yes

170

No

32

51

M

Hit by rigid object

Absent

13

Unilateral craniectomy

Left

130.77

Yes

300

Yes

120

No

33

72

M

Fall

Absent

12

Unilateral craniectomy

Left

70.26

No

800

Yes

120

Yes

Tomographic Findings

The predominant tomographic findings were the presence of midline shift > 5 mm and a SDH in 90.1% and 87.9% of the cases, respectively.

Traumatic SAH, brain contusions and skull fractures were observed in 57.6%, 51.5% and 36.4% of the cases, respectively. The presence of an epidural hematoma was found in 6.1% of the cases.

All the patients were classified according to the Marshall Classification and all of them presented a score greater than 3. Thirteen patients were catalogued as a Marshal grade 3–4 and 20 patients as a Marshal 6. Three out of fourpatients who died were catalogued as Marshall 6 (75%) (Table  2).

Table 2
Tomographic characteristics of patients who underwent decompressive craniectomy

Patient

Marshall classification

SDH

EDH

Midline shift

Cerebral contusion

Traumatic SAH

Skull fracture

Abbreviations: EDH, epidural hematoma; SAH, subarachnoid hemorrhage; SDH, subdural hematoma

1

4

+

+

+

2

6

+

+

+

3

3

+

+

+

4

3

+

+

+

+

5

3

+

+

+

6

6

+

+

7

6

+

+

+

8

6

+

+

9

6

+

+

+

+

10

6

+

+

+

11

3

+

+

+

12

6

+

+

13

6

+

+

+

+

14

4

+

+

+

+

+

15

6

+

+

+

+

16

6

+

+

+

+

17

6

+

+

+

+

+

18

6

+

+

+

+

+

19

6

+

+

+

+

20

6

+

+

+

+

21

3

+

+

+

+

22

6

+

+

+

+

23

6

+

+

+

+

24

4

+

+

+

25

3

+

+

26

6

+

+

+

+

27

6

+

+

+

28

6

+

+

+

+

29

4

+

+

30

4

+

+

31

4

+

+

32

4

+

+

33

6

+

+

+

Surgical Procedure Characteristics

Sixteen patients (53.3%) underwent a right-sided craniectomy and the mean APD of the unilateral craniectomy was 106.8 mm ± 20.4 mm (range 70.26 to 166.42 mm), the temporal bone was removed in 20 patients (66.3%) of the unilateral cases, the skull flap was preserved in the subcutaneous layer in 29 patients (87.8%), and the average time of the surgery was 2 hours and 27 minutes (Figs. 1 2). The mean blood loss was 636.4 mL± 375.1 mL.

Fig. 1 (A) Brain CT scan shows an acute subdural hematoma with midline shift. (B, C) Postoperative CT scan showing the diameter of the craniectomy with resection of temporal bone (arrow). (D) 3D reconstruction showing the defect.

Fig. 1 (A) Brain CT scan shows an acute subdural hematoma with midline shift. (B, C) Postoperative CT scan showing the diameter of the craniectomy with resection of temporal bone (arrow). (D) 3D reconstruction showing the defect.

Fig. 2 (A) Brain CT scan showing an acute subdural hematoma with frontal contusions and severe edema. (B–D) Postoperative bifrontal decompressive craniectomy.

Fig. 2 (A) Brain CT scan showing an acute subdural hematoma with frontal contusions and severe edema. (B–D) Postoperative bifrontal decompressive craniectomy.

Complications and Mortality

Four patients (12%) presented cerebrospinal fluid (CSF) fistulas and three patients (9%) developed subcutaneous abdominal infections. The in-hospital mortality rate was four patients (12%).

Univariate Analysis

When comparing both groups, there were no differences among the covariates, except for the mean APD of the skull flap, which was larger in patients who survived (120.3 mm vs. 85.3 mm; p = 0.003) and the presence of midline shift > 5 mm (p = 0.033) (Table 3).

Table 3
Univariate analysis of mortality-associated factors following decompressive craniectomy

Variable

Alive

n = 29

Dead

n = 4

p-Value

aMann–Whitney: median and ranges

Age

47.4 ± 19

62 ± 20.1

0.178

Sex

0.429

 Male

23 (85.2)

4 (14.8)

 Female

6 (100)

0 (0)

Trauma mechanism

0.781

 Fall

14 (82.4)

3 (17.6)

 Traffic accident

11 (91.7)

1 (8.3)

 Hit by object

4 (100)

0 (0)

Presence of anisocoria

23 (95.8)

1 (4.2)

0.052

Glasgow at admission

9 ± 2.8

8 ± 3.2

0.537

Surgical characteristics

Type of surgery

0.330

 Unilateral craniectomy

27 (90)

3 (10)

 Bilateral craniectomy

2 (66.7)

1 (33.3)

Side of the craniectomy

0.09

 Right

16 (100)

0 (0)

 Left

11 (78.6)

3 (21.4)

APD of craniectomy (unilateral cases)

120.3 ± 18

85.3 ± 13.7

0.003

Removal of temporal bone

19 (95)

1 (5)

0.251

Blood loss*

500 (100–1500)

550 (300–1500)

0.956

SCL placement of bone flap

25 (86.2)

4 (13.8)

0.580

Time of surgerya

150 (90–255)

120 (70–235)

0.375

Tomographic findings

Marshall at admission

0.481

 Grade 3–4

12 (92.3)

1 (7.7)

 Grade 6

17 (85)

3 (15)

Presence of subdural hematoma

26 (89.7)

3 (10.3)

0.420

Presence of epidural hematoma

2 (100)

0 (0)

0.769

Presence of midline shift > 5 mm

28 (93.3)

2 (6.7)

0.033

Presence of cerebral contusion

15 (88.2)

2 (11.8)

0.676

Presence of traumatic subarachnoid hemorrhage

16 (84.2)

3 (15.8)

0.426

Presence of cranial fracture

11 (91.7)

1 (8.3)

0.536

Discussion

Decompressive craniectomy is a live-saving procedure in cases of TBI with intracranial hypertension. In this study, we report an in-hospital mortality rate of 12%, and mortality-associated factors found were the APD of the skull flap and the presence of midline shift greater than 5 mm.

Regarding the optimal management of TBI, guidelines recommend medical treatment with first-tier management, followed by the second-tier management, which includes DC, among other options, such as barbiturate coma.10 Depending on the presence of ICP monitoring, if the DC is performed once, the diagnosis of TBI with intracranial hypertension is made; then, the procedure is termed primary DC and is usually performed within the first 24 hours. When ICP monitoring is available and intracranial hypertension is refractory to medical management, then the procedure is termed secondary DC. Current indications for DC are as follows: comatose patients with the presence of an acute SDH, severe brain swelling, midline shift > 5 mm,absence of basal cisterns due to a parenchymal hemorrhage or brain contusions with or without surrounding edema, and the presence of anisocoria.

Randomized controlled trials sought to determine the benefits of performing DC in patients with TBI. In the DECRA trial, bifrontal decompressive craniectomy was associated with unfavorable outcomes when compared with medical therapy (70% vs. 51%) and no significant differences in mortality rates between surgical and medical groups were found at 6 months (19% vs. 18%).5 11 In the RESCUEicp trial, decompressive craniectomy in patients with TBI and refractory intracranial hypertension resulted in lower mortality and higher rates of severe disability at 6 months. A favorable outcome at 6 months (better on the GOSE) with surgery was obtained (42.8% vs. 34.6%, p = 0.12) and mortality rates were significantly lower with surgery (26.9% vs.48.9%)6 The RESCUE-ASDH trial aims to address whether primary DC or craniotomy are the best strategies for patients with severe TBI who undergo evacuation of an acute SDH. Nevertheless, results from this trial are not yet available.12 In addition, a Chinese trial found lower mortality rates (26.2% vs.35.1%) and higher favorable outcomes (39.8% vs.28.6%) in patients who underwent a standard DC (12 × 15 cm flap) compared with limited DC (6 × 8 cm flap).13 Technical nuances to perform a DC have been reported.14 The AP diameters of bone flaps range from 12 to 15 cm in unilateral craniectomies; 15 16 nevertheless, the ideal bone flap diameter should be larger than 15 cm to achieve an adequate decompression.17 18

Regarding the management of TBI in Perú, a developing country in South America, scarce publications were found.8 9 19 One descriptive study in a public hospital evaluated 76 patients who underwent surgery due to TBI. Sixteen patients (21.1%) underwent DC in its two modalities (unilateral or bifrontal), ICP monitoring was used in 12 cases (15.8%), and the mortality rate was 9 patients (11.8%).8

Despite the small sample, our analysis yielded important results. The size of the bone flap is an important predictor of mortality and good outcomes, as shown in previous studies.14 15 17 18 The ideal APD to relief the high ICP is 15 cm. However, four patients had an average diameter of 85.3 mm and all of them died. Patients were classified according to the Marshall tomographic scale and all were catalogued as Marshall ≥ 3. Of the four dead patients, three had a Marshall 6 type of lesion. In-hospital mortality rates in our series is relatively lower compared with previous studies,20 21 despite the lack of ICP monitoring. This could be explained because 55% of our series presented a GCS score > 8 points on admission and the issue that 100% of the surgeries were primary DC. A combination of tomographic findings wasfound in the same patient. Midline shift was present in 90.1% of the cases, followed by the presence of a SDH in 87.9% of the cases.

The decision to perform a smaller or larger craniectomy was based on the surgeon’s decision and radiological findings. In the case of a smaller craniectomy (mean 85 mm in APD), the total evacuation of the hematoma was followed by optimal medical management. We have to take into consideration the fact that all the procedures were primary DC, two of four patients who died had a midline shift > 5 mm, and one patient underwent temporal bone enlargement. In addition, in this particular subgroup of patients when the surgery was done, the brain was not seriously edematous after hematoma evacuation.

According to the literature, factors associated withmortality are age, the low-GCS score at admission, the size of the craniectomy, effacement of basal cisterns, and severe midline shift.13 16 22 23 24 Unfavorable outcomes reported were low-GCS scores on admission, postoperative hydrocephalus, tracheostomy, sphenoid fractures, and unchanged ICP.21 25 26

DC-relatedmortality rates ranged from 12 to 55%.16 20 21 22 24 25 26 27 In-hospital mortality rates ranged between 32 to 55%,20 21 26 whereas 30-day mortality rates ranged from 12 to 28.3%.16 22 24 27 Laghari et al reported an in-hospital mortality rate of 25% at 3 months in their series. In addition, Khalili reported a mortality rate of 40.8% at 1-year follow-up.

Regarding procedure-related complications, our rate of CSF fistulas was high compared with the reported in the literature (6% vs.12%).18 Postoperative infection rates such as abdominal infections represent around 10%, similar to our 9% abdominal infection rate.18

This study has limitations. The small sample and the retrospective design did not allow to draw more robust statistical associations. None of the patients had ICP monitoring before, during, or after the surgery. Postoperative clinical outcomes were not assessed. Our institution is an emergency hospital where potentially surgical patients undergo emergent surgeries, and after their recovery, they are discharged to other institutions or to their homes. For this reason, follow-up was not feasible. Further investigations should be performed in developing countries regarding trauma and its surgical management.

Conclusions

In our analysis, the mean diameter of the bone flap in unilateral craniectomies and the midline shift were associated within-hospital mortality. In centers without ICP monitoring, primary decompressive craniectomy should be performed according to clinical and radiological criteria.

Conflict of Interest

None declared.

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