Abstract
Objective: Decompressive craniectomy (DC) plays an important role in the treatment of patients with severe traumatic brain injury (sTBI) with mass lesions and intractably elevated intracranial hypertension (ICP). However, whether DC should be performed in patients with bilateral dilated pupils and a low Glasgow Coma Scale (GCS) score is still controversial. This retrospective study explored the clinical outcomes and risk factors for an unfavorable prognosis in sTBI patients undergoing emergency DC with bilateral dilated pupils and a GCS score <5.Methods: The authors reviewed the data from patients who underwent emergency DC from January 2012 to March 2019 in a medical center in China. All data, such as patient demographics, radiological findings, clinical parameters, and preoperative laboratory variables, were extracted. Multivariate logistic regression analysis was performed to determine the factors associated with 30-day mortality and 6-month negative neurological outcome {defined as death or vegetative state [Glasgow Outcome Scale (GOS) score 1–2]}.Results: A total of 94 sTBI patients with bilateral dilated pupils and a GCS score lower than five who underwent emergency DC were enrolled. In total, 74 patients (78.7%) died within 30 days, and 84 (89.4%) had a poor 6-month outcome (GOS 1–2). In multivariate analysis, advanced age (OR: 7.741, CI: 2.288–26.189), prolonged preoperative activated partial thromboplastin time (aPTT) (OR: 7.263, CI: 1.323–39.890), and low GCS (OR: 6.162, CI: 1.478–25.684) were associated with a higher risk of 30-day mortality, while advanced age (OR: 8.812, CI: 1.817–42.729) was the only independent predictor of a poor 6-month prognosis in patients undergoing DC with preoperative bilateral dilated pupils and a GCS score <5.Conclusions: The mortality and disability rates are extremely high in severe TBI patients undergoing emergency DC with bilateral fixed pupils and a GCS score <5. DC is more valuable for younger patients.
Highlights
Traumatic brain injury (TBI), which is a significant public health issue, has become the main cause of trauma-related death and disability worldwide [1, 2]
We investigated the prognosis of patients with bilateral dilated pupils and a Glasgow Score Scale (GCS) score
Park et al [30] performed ultraearly decompressive craniectomy in 127 severe TBI patients, and they found that the mortality rate was 82.2% in patients with GCS scores of 4 and 5
Summary
Traumatic brain injury (TBI), which is a significant public health issue, has become the main cause of trauma-related death and disability worldwide [1, 2]. The treatments, rehabilitation therapy, and permanent sequelae associated with TBI impose a substantial economic burden on patients’ families and have profound impacts on society [5, 6]. Decompressive craniectomy (DC), with or without the removal of the intracranial hematoma, plays a pivotal role in the treatment of patients with TBI with substantial mass lesions or uncontrolled elevation of the intracranial pressure (ICP) [7, 8]. The latest edition of the relevant guidelines provides the indications for and approaches to DC in patients with intractable ICP that is refractory to conservative treatment (secondary DC) and/or various types of intracranial lesions (primary DC) [9]. Some factors associated with a poor prognosis after DC have been identified, including the initial Glasgow Score Scale (GCS) and the pupillary status after trauma or on admission [13,14,15,16,17]
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