¹Assistant Professor, ^2,4Associate Professor, ³HOD and Professor, Department of General Surgery, Dr Ulhas Patil Medical College and Hospital Jalgaon Khurd, NH6, Jalgaon, Maharashtra 425309, INDIA.

Email: docswapneuro@gmail.com

Table 1: General characteristics of the patients.

At discharge from ICU - Glasgow Outcome score (GOS) outcome was poor in 22 patients (52.38 %) and good outcome noted in 20 patients (47.62 %). Mortality at discharge was noted in 16 patients (38.10%).

Table 2: Outcome at discharge from ICU - Glasgow Outcome score (GOS)

We compared various factors between survival and mortality group. Advanced age, GCS ≥ 8, timing of surgery (>12 hours), presence of pupillary asymmetry on admission, presence of lung or abdominal injury, hypotension at admission (SBP < 90 mm hg), mean midline shift ( > 7 mm), mean volume of the bleed ( > 70 ml), bone flap ≥130 cm², intraventricular extension of the bleed present and surgery-related complication (hydrocephalus , extra-axial fluid collection, post-operative acute hematoma and skin flap ischemia) were significant factors noted in mortality and can be considered as predictors for early mortality patients with severe traumatic brain injury underwent primary decompressive craniectomy. Surgery related complications such as post-operative CSF leak and wound infection were not statistically significant among survival and mortality group.

Table 3: Various factors and their comparison between survival group and mortality group.

DISCUSSION

Traumatic brain injury (TBI) is defined as an injury to the head arising from blunt or penetrating trauma or from acceleration/ deceleration forces.⁷ Decompressive craniectomy has been used for raised intracranial pressure from several etiologies, such as aneurysmal subarachnoid hemorrhage, encephalitis, acute demyelinated encephalomyelitis, cerebral venous thrombosis and parenchymal hemorrhagic stroke. However, the most important studies and evidences are greater for its use in TBI and stroke.⁸ The clinical outcome in severe TBI after DC varies from 7% to 70%.⁹ Overall mortality rates in TBI are between 25% and 30%, though mortality rises to 43.6% if initial GCS is below 15/15.¹⁰ There are many prognostic factors affecting the outcome in severe TBI after DC such as age, lowest recorded GCS, presence of cranial fracture, absence of pupillary response/brainstem reflexes, respiratory insufficiency, refractory rise in ICP and the status of the basal cisterns or third ventricle on CT scan, the volume and location of the lesion, and the timing of surgery.¹¹ Glasgow Coma Scale (GCS) is the standardized scale for measurement of neurological status in TBI and significant correlation with outcome after severe TBI had been reported as it was reported that patients with low GCS on admission have poor prognosis and usually correlates with mortality,^12,13 and the overall mortality in patients with initial GCS-3 was 76%.¹⁴  Fotakopoulos G et al.,¹⁵ studied clinical outcome in 101 patients underwent decompressive craniectomy (DC) after severe traumatic brain injury (TBI). The difference of good neurological recovery (Glasgow outcome score 4–5), between patients with ICP ≤20 mmHg, GCS ≥5, age ≤60 years, and bone flap ≥130 cm² and those with ICP >20 mmHg, GCS <5, age >60 years, and bone flap <130 cm2, was statistically significant. In study by Balasubramanian H et al.,¹⁶ 139 patients underwent decompressive craniectomy they concluded that age, severity of head injury, neurological status, and timing of surgery are the main factors influencing outcomes. After moderate head injury with acute SDH, surgery with decompressive craniectomy is the better outcome. Similar findings were noted in present study. Tang Z et al.,¹⁷ studied 94 TBI patients with bilateral dilated pupils and a GCS score lower than five who underwent emergency DC, 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, prolonged preoperative aPTT and low GCS were associated with a higher risk of 30-day mortality, while advanced age 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. Safwat Abouhashem et al.,¹⁸ studied 104 patients with severe TBI have been treated by DC and were analyzed; the early mortality occurred in 32 patients, 30.77%. After analysis, odds of early mortality increases with the lower GCS, higher Marshall scale, lung injury, and abdominal injury while male gender and the presence of isochoric pupils decrease the odds of mortality. Prediction of early mortality after DC is multifactorial, but the odds of early mortality after decompressive craniectomy in severe traumatic brain injury are progressively increased with the lower GCS, higher Marshall scale, and the presence of lung or abdominal injury. Similar findings were noted in present study. Wenxing Cui et al.,¹⁹ conducted a study to predict 1-year mortality in TBI patients undergoing DC. Of the 230 patients, 70 (30.4%) died within 1 year. Older age, higher Glasgow Coma Score (GCS), higher D-dimer, coagulopathy, hypotension and completely effaced basal were independent predictors of 1-year mortality. Specific predictors of poor outcome include low initial GCS, bilaterally non-reactive pupils, systolic blood pressure lower than 90mmHg and/or ICP higher than 25mmHg in the acute period, abnormality in the initial head CT related to the TBI (particularly cisternal effacement, midline shift and haemorrhage) and older age.²⁰ Factors known to be predictive of mortality following DC includes age, time to craniectomy, concomitant non-neurological trauma (higher ISS scores), Marshall score, mm of midline shift, dimensions of the craniectomy complication rate or e-GOS.^21,22 Many complications have been reported after DC such as herniation, bone defects, subdural effusion, hydrocephalus, and other factors that play role in unfavourable outcome.²³ A key concern is whether potentially irreversible secondary brain injury has already occurred by this point, which raises the contentious issue of whether sparing a patient’s life may leave them in such a disabled state that it may actually not constitute a good outcome.²⁴ Though decompressive craniectomy (DC) seems to be an efficient therapeutic strategy, however, a class I level of evidence to support its utilization in adult patients currently does not exist, as this procedure is not without complications, some of which result in therapeutic challenges for the treating medical team.^25,26 Experience of treating surgeon, multidisciplinary team and ICU setup plays important role in treating patients with severe TBI. Limitations of present study were observational study from a single tertiary care centre, in patients with single pathology, with a small sample size and no control group leads to difficulty in arriving at statistically significant conclusions about factors related to early mortality.

CONCLUSION

Decompressive craniectomy may have a definite role in the preemptive treatment of post-traumatic brain injuries leading to raised ICP. Advanced age, GCS ≥ 8, timing of surgery (>12 hours), presence of pupillary asymmetry on admission, presence of lung or abdominal injury, hypotension at admission (SBP < 90 mm hg), mean midline shift ( > 7 mm), mean volume of the bleed ( > 70 ml), bone flap ≥130 cm², intraventricular extension of the bleed present and surgery-related complication (hydrocephalus , extra-axial fluid collection, post-operative acute hematoma and skin flap ischemia) were predictors for early mortality patients with severe traumatic brain injury underwent primary decompressive craniectomy.

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