[Secondary decompression trepanation in progressive post-traumatic brain edema after primary decompressive craniotomy]

T Mussack, E Wiedemann, T Hummel, P Biberthaler, K G Kanz, W Mutschler
Der Unfallchirurg 2003, 106 (10): 815-25
Besides evacuation of epidural or subdural hematoma, early decompressive craniectomy with duraplasty has to be performed in the neurotraumatological care of patients with moderate [Glasgow Coma Scale (GCS) score 9-12 points] or severe traumatic brain injury (TBI; GCS score </=8 points) and threatening herniation. The efficacy of secondary decompressive craniectomy and duraplasty after primary trepanation is under debate due to missing evidence of improved outcome. The objectives of this study were to register the incidence of increasing brain edema after isolated TBI and primary craniectomy, to identify possible decision criteria for secondary decompressive trepanation, and to evaluate the neurological performance 6 months after discharge with the Glasgow Outcome Score (GOS). Of 131 patients who suffered from isolated TBI and had to be primarily operated between January 1997 and December 2001, 58 (male:female = 48:10; median age of 50.9 years) were included in this analysis. In 11 patients (male:female = 9:2; median age of 40.0 years) a secondary unilateral extensive or contralateral decompressive craniectomy had to be performed in the clinical course. Four of the 11 patients (36.4%) did not survive TBI; they died at a median of 1 day after revision or 6 days after TBI, respectively. In the group of secondary decompressive craniectomy we recorded admission (80.0 min after TBI) 35 min later ( p=0.009) than in the group of primary trepanation. Prehospital otorrhagia was observed more frequently ( p=0.036). In univariate analysis, arterial hypotension ( p=0.018) and otorrhagia at admission ( p=0.035), intracranial pressure (ICP) immediately after primary operation ( p=0.024), and decrease of maximal postoperative cerebral perfusion pressure (CPP; p=0.031) below the median cutoff value of 70 mmHg correlated with the event of secondary decompression craniectomy. Multivariate analysis identified decreased maximal CPP after primary trepanation as the only independent prognostic parameter (score 10.496; df=1; p=0.043) for the necessity of secondary trepanation and unfavorable GOS 6 months after discharge. In patients with isolated moderate or severe TBI, prehospital arterial hypotension as well as otorrhagia negatively influenced the mortality and morbidity. Therefore, early adjustment of arterial hypotension and the rapid transport into a neurotraumatological center are to be required for prehospital management of TBI patients. The decrease of maximal CPP below 70 mmHg despite administration of catecholamines representing the only independent prognostic parameter during monitoring in the intensive care unit seems to indicate the necessity of an operative revision as well as an unfavorable GOS 6 months after discharge.

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