Management of severe traumatic brain injury by decompressive craniectomy

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatm ent of head trauma patients is controversial. The aim of our study was to a ssess the value of unilateral decompressive craniectomy in patients with se vere traumatic brain injury. METHODS: We retrospectively investigated 49 patients who underwent decompre ssive craniectomy. Intracranial pressure, cerebral perfusion pressure, ther apy intensity level, and cranial computed tomographic scan features (midlin e shift, visibility of ventricles, gyral pattern, and mesencephalic cistern s) were evaluated before and after craniectomy. The gain of intracranial sp ace was calculated from cranial computed tomographic scans. Patient outcome was graded using the Glasgow Outcome Scale. RESULTS: Thirty-one patients (63.3%) underwent rapid surgical decompression within 4.5 +/- 3.8 hours after trauma; in 18 patients (36.7%), delayed sur gical decompression was performed 56.2 +/- 57.0 hours after injury. Patient s younger than 50 years or patients who underwent rapid surgical decompress ion had a significantly better outcome than older patients or patients who underwent delayed surgical decompression. Craniectomy significantly decreas ed midline shift and improved visibility of the mesencephalic cisterns. The state of the mesencephalic cisterns correlated with the distance of the lo wer border of the craniectomy to the temporal cranial base. Alterations in intracranial pressure, cerebral perfusion pressure, and therapy intensity l evel were not significant. The overall mortality of the patients correspond ed to the reports of the Traumatic Coma Data Bank (1991). CONCLUSION: Although there was a significant decrease in midline shift afte r craniectomy, this did not translate into decompressive craniectomy demons trating a beneficial effect on patient outcome.