Severe Traumatic Brain Injury: Clinical Outcome of 30 Cases Managed by Decompressive Craniectomy

Abstract
Background: Severe traumatic brain injury is correlated to increased incidence of mortality and severe disability. In the acute phase, medical and surgical management is aimed to prevent intracranial hypertension and to maintain adequate cerebral perfusion pressure. Decompressive craniectomy is a surgical intervention that revealed much interest in the management of refractory intracranial hypertension after severe traumatic brain injury.
Aim of Work: To evaluate the clinical outcome of decom-pressive craniectomy in management of severe traumatic brain injury either performed immediately in the acute phase or after failure of the initial medical therapies to control the elevated intracranial pressure.
Subjects and Methods: This retrospective study included thirty patients. All patients operated upon by Decompressive craniectomy after severe traumatic brain injury in the period between 2013 and 2017. Patients were divided into 2 groups according to the indications of Decompressive craniectomy. First group included patients whom initially treated by medical treatment and operated upon in a context of refractory intrac-ranial hypertension. The second group patients were operated upon immediately for evacuation of compressive hematoma accompanied with decompressive craniectomy due to severe edema, making it impossible to replace the bone flap. Upon admission, all patients underwent a complete physical and neurological examination. Initial imaging examinations were reviewed with description of the lesions, measurement of midline shift and classification of lesions according to Mar-shall's classification. Intracranial pressure and cerebral per-fusion pressure were monitored and analyzed during manage-ment. Clinical outcome for both groups was graded using the Glasgow Outcome Scale 3 months after operation and at long term follow-up.
Results: Twenty patients (67%) in the first group under-went delayed decompressive craniectomy within 7 days after trauma. In the second group, 10 patients (33%) operated upon immediately with decompressive craniectomy within 6 hours after injury. Favourable functional outcome was achieved in 9 patients (45%) among the first group and 3 patients (30%) in the second group at 3 month post-operatively. At 24 month follow-up, 12 patients (60%) and 3 patients (30%) showed favourable outcome in the two groups respectively. Radiologically, midline shift decreased and visibility of the mesen-cephalic cisterns was improved after the Craniectomy. Com-plications occurred in three (14%) of the survived 21 patients included in the study.
Conclusion: DC could have beneficial role in improving functional outcome, lowering ICP and mortality in management of severe traumatic brain injury. Additionally, it shows in-creased incidence of complications. Further exploring of long term effects of DC and its influence on prognosis is recom-mended.