Long-term outcomes following decompressive craniectomy for severe head injury.

BACKGROUND: Severe head injury is one of the commonest indications for neurosurgical intervention. For the neurosurgeon, the operative last resort in cases of generalised brain oedema of traumatic origin is the decompressive craniectomy. Is it possible to use predictive factors to ascertain what degree of success, in terms of both the acute and long-term outcome, is to be expected in patients who undergo this treatment?

METHODS: The clinical records of 131 patients treated with decompressive craniectomy for severe head injury were evaluated. All patients were operated on between September 1997 and September 2005 in the neurosurgical department of the Unfallkrankenhaus Berlin. A follow-up examination was carried out 49 +/- 25 months after the initial trauma. The clinical outcome was compared with several patient and radiographic factors to establish if any of these showed a relationship to the long-term outcome.

FINDINGS: A significant relationship was demonstrated between quality of outcome and the Glasgow Coma Scale score on admission. Quality of outcome was similarly related to the age of the patient, the condition of the basal cisterns and the degree of midline shift in the initial cranial computed tomography. Factors which correlated with poor outcome included pupil reactivity on admission, established clotting disorders and posttraumatic hydrocephalus internus. Hyperglycaemia and initial acidosis were also associated with a poor outcome.

CONCLUSIONS: The clinical outcome in patients with a severe head injury is to a great degree determined by the extent and type of the primary injury. When considering decompressive hemicraniectomy as a treatment for raised intracranial pressure following traumatic brain injury, the predictive factors detailed here should be taken into consideration.