Surgical Outcome Following Early Decompressive Hemicraniectomy in Patients of Severe Traumatic Brain Injury: A Retrospective Study

Abstract

Introduction: Traumatic Brain Injury (TBI) has become an epidemic and remains the leading cause of death and disability in people of 2nd to 4th decade. Road Traffic Accidents (RTA) are responsible for the majority of cases. Primary brain injury sustained on impact and secondary brain injury that develops in following hours and days contribute together to overall injury and decides ultimate outcome. The goal of management in any TBI patient aims to prevent secondary brain injury. Understanding the importance of Intracranial Pressure (ICP) is key to minimise secondary injury. Decompressive hemicraniectomy is a novel technique of reducing ICP in patients of severe brain injury. It’s judicious and timely performance not only saves life but also prevents the dreaded consequences of raised ICP. Aim: To evaluate the role of early decompressive hemicraniectomy in improving the survival rate among patients of severe TBI and analysing the important factors (glasgow coma scale, airway status, timing of surgery) affecting the surgical outcome. Materials and Methods: It was a retrospective study conducted at the Department of Neurosurgery, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India between September 2016 to March 2020. Case records of 60 patients of TBI who had undergone unilateral Decompressive Craniectomy (DECRA) were analysed. The decision for decompressive hemicraniectomy was purely based upon Glasgow Coma Scale GCS) and Computed Topography (CT) findings. The presence of an evacuable mass lesion, diffuse oedema and obliteration of basal cistern in CT was considered to be the most important criteria for the early decompressive procedure. Patients were assessed until their discharge from ward. Statistical analysis was performed by statistical package for science version 12. Results: A total of 60 patients with severe TBI, who underwent DECRA were analysed. Road Traffic Accident (RTA) was the predominant mechanism of injury. All had presence of a surgically evacuable mass lesion along with compression/obliteration of the basal cistern. The majority of mass lesions (n=42) were frontotemporal contusions (70%). Forty patients of total achieved good surgical outcome (66.67%) and rest 20 patients (33.33%) had poor outcomes. Overall incidence of complications was around 40%. The most important factors associated with good outcomes were GCS of 7 and and above, patent airway, and early surgery. Conclusion: Decompressive hemicraniectomy is a novel technique of reducing ICP which acts by directly breaking the rigid box phenomenon of Monro-Kellie doctrine. However patient selection, prompt decision, earliest intervention, adoption of standard technique of DECRA and post operative critical care management are important aspects behind the successful outcome.