The Role of Decompressive Craniectomy on Functional Outcome, Mortality and Seizure Onset after Traumatic Brain Injury

Abstract

Decompressive craniectomy (DC) to treat increased intracranial pressure after a traumatic brain injury (TBI) is a common but controversial choice in clinical practice. This study aimed to determine the impact of DC on functional outcomes, mortality and the occurrence of seizures in a large cohort of patients with TBI. This retrospective study included patients with TBI consecutively admitted for a 6-month neurorehabilitation program between 1 January 2009 and 31 December 2018. The radiological characteristics of brain injury were determined with the Marshall computed tomographic classification. The neurological status and rehabilitation outcome were assessed using the Glasgow Coma Scale (GCS) and the Functional Independence Measure (FIM), which were both assessed at baseline and on discharge. Furthermore, the GCS was recorded on arrival at the emergency department. The DC procedure, prophylactic antiepileptic drug (AED) use, the occurrence of early or late seizures (US, unprovoked seizures) and death during hospitalization were also recorded. In our cohort of 309 adults with mild-to-severe TBI, DC was performed in 98 (31.7%) patients. As expected, a craniectomy was more frequently performed in patients with severe TBI (p < 0.0001). However, after adjusting for the confounding variables including GCS scores, age and the radiological characteristics of brain injury, there was no association between DC and poor functional outcomes or mortality during the inpatient rehabilitation period. In our cohort, the independent predictors of an unfavorable outcome at discharge were the occurrence of US (β = -0.14, p = 0.020), older age (β = -0.13, p = 0.030) and the TBI severity on admission (β = -0.25, p = 0.002). Finally, DC (OR 3.431, 95% CI 1.233-9.542, p = 0.018) and early seizures (OR = 3.204, 95% CI 1.176-8.734, p = 0.023) emerged as the major risk factors for US, independently from the severity of the brain injury and the prescription of a primary prophylactic therapy with AEDs. DC after TBI represents an independent risk factor for US, regardless of the prescription of prophylactic AEDs. Meanwhile, there is no significant association between DC and mortality, or a poor functional outcome during the inpatient rehabilitation period.