Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury

Regan F. Williams, Louis J. Magnotti, Martin A. Croce, Brinson B. Hargraves, Peter E. Fischer, Thomas J. Schroeppel, Ben L. Zarzaur, Michael Muhlbauer, Shelly Timmons, Timothy C. Fabian

Research output: Contribution to journalArticle

61 Citations (Scopus)

Abstract

BACKGROUND: The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature. METHODS: Patients with severe TBI (Abbreviated Injury Score 4-5) treated with DC for the management of increased ICP during 6-year period were identified from the trauma registry. Functional outcome was measured 1 year to 6 years postinjury using the Glasgow Outcome Score Extended (GOSE) via telephone interview and classified as good (GOSE 5-8) or poor (GOSE 1-4, including death). Outcomes were compared using Wilcoxon rank-sum and χ tests where appropriate. RESULTS: One hundred and seventy-one patients were identified: 137 (80%) men and 34 (20%) women. Overall mortality (all in-hospital) was 32% (head-related = 22%). Of the 117 survivors, follow-up was obtained in all but 6 (95%). Good outcome was achieved in 96 patients (56% overall, 82% of survivors). Those with good outcome were younger (26 years vs. 43 years, p = 0.0028) and experienced a greater change in predecompression to postdecompression ICP (ICP reduced by 23 mm Hg vs. 10 mm Hg, p < 0.0001). Not surprisingly, unchanged ICP (predecompression to postdecompression) was associated with poor outcome (p = 0.0031). There was no difference in immediate predecompression ICP between survivors versus nonsurvivors. However, immediate predecompression Glasgow Coma Score was significantly higher in survivors compared with nonsurvivors (7 vs. 5, p < 0.0001). CONCLUSIONS: DC resulted in good functional outcome in >50% of patients with severe TBI. The greatest benefit was observed in younger patients with a demonstrable reduction in ICP after decompression. The prospect of improved functional outcome offered by this procedure in the treatment of severe TBI warrants prospective investigation.

Original languageEnglish (US)
Pages (from-to)1570-1574
Number of pages5
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume66
Issue number6
DOIs
StatePublished - Jun 1 2009

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Decompressive Craniectomy
Intracranial Pressure
Nonparametric Statistics
Survivors
Wounds and Injuries
Hospital Mortality
Decompression
Craniocerebral Trauma
Registries
Traumatic Brain Injury
Head
Interviews
Therapeutics

All Science Journal Classification (ASJC) codes

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Williams, R. F., Magnotti, L. J., Croce, M. A., Hargraves, B. B., Fischer, P. E., Schroeppel, T. J., ... Fabian, T. C. (2009). Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury. Journal of Trauma - Injury, Infection and Critical Care, 66(6), 1570-1574. https://doi.org/10.1097/TA.0b013e3181a594c4
Williams, Regan F. ; Magnotti, Louis J. ; Croce, Martin A. ; Hargraves, Brinson B. ; Fischer, Peter E. ; Schroeppel, Thomas J. ; Zarzaur, Ben L. ; Muhlbauer, Michael ; Timmons, Shelly ; Fabian, Timothy C. / Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury. In: Journal of Trauma - Injury, Infection and Critical Care. 2009 ; Vol. 66, No. 6. pp. 1570-1574.
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abstract = "BACKGROUND: The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature. METHODS: Patients with severe TBI (Abbreviated Injury Score 4-5) treated with DC for the management of increased ICP during 6-year period were identified from the trauma registry. Functional outcome was measured 1 year to 6 years postinjury using the Glasgow Outcome Score Extended (GOSE) via telephone interview and classified as good (GOSE 5-8) or poor (GOSE 1-4, including death). Outcomes were compared using Wilcoxon rank-sum and χ tests where appropriate. RESULTS: One hundred and seventy-one patients were identified: 137 (80{\%}) men and 34 (20{\%}) women. Overall mortality (all in-hospital) was 32{\%} (head-related = 22{\%}). Of the 117 survivors, follow-up was obtained in all but 6 (95{\%}). Good outcome was achieved in 96 patients (56{\%} overall, 82{\%} of survivors). Those with good outcome were younger (26 years vs. 43 years, p = 0.0028) and experienced a greater change in predecompression to postdecompression ICP (ICP reduced by 23 mm Hg vs. 10 mm Hg, p < 0.0001). Not surprisingly, unchanged ICP (predecompression to postdecompression) was associated with poor outcome (p = 0.0031). There was no difference in immediate predecompression ICP between survivors versus nonsurvivors. However, immediate predecompression Glasgow Coma Score was significantly higher in survivors compared with nonsurvivors (7 vs. 5, p < 0.0001). CONCLUSIONS: DC resulted in good functional outcome in >50{\%} of patients with severe TBI. The greatest benefit was observed in younger patients with a demonstrable reduction in ICP after decompression. The prospect of improved functional outcome offered by this procedure in the treatment of severe TBI warrants prospective investigation.",
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Williams, RF, Magnotti, LJ, Croce, MA, Hargraves, BB, Fischer, PE, Schroeppel, TJ, Zarzaur, BL, Muhlbauer, M, Timmons, S & Fabian, TC 2009, 'Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury', Journal of Trauma - Injury, Infection and Critical Care, vol. 66, no. 6, pp. 1570-1574. https://doi.org/10.1097/TA.0b013e3181a594c4

Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury. / Williams, Regan F.; Magnotti, Louis J.; Croce, Martin A.; Hargraves, Brinson B.; Fischer, Peter E.; Schroeppel, Thomas J.; Zarzaur, Ben L.; Muhlbauer, Michael; Timmons, Shelly; Fabian, Timothy C.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 66, No. 6, 01.06.2009, p. 1570-1574.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury

AU - Williams, Regan F.

AU - Magnotti, Louis J.

AU - Croce, Martin A.

AU - Hargraves, Brinson B.

AU - Fischer, Peter E.

AU - Schroeppel, Thomas J.

AU - Zarzaur, Ben L.

AU - Muhlbauer, Michael

AU - Timmons, Shelly

AU - Fabian, Timothy C.

PY - 2009/6/1

Y1 - 2009/6/1

N2 - BACKGROUND: The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature. METHODS: Patients with severe TBI (Abbreviated Injury Score 4-5) treated with DC for the management of increased ICP during 6-year period were identified from the trauma registry. Functional outcome was measured 1 year to 6 years postinjury using the Glasgow Outcome Score Extended (GOSE) via telephone interview and classified as good (GOSE 5-8) or poor (GOSE 1-4, including death). Outcomes were compared using Wilcoxon rank-sum and χ tests where appropriate. RESULTS: One hundred and seventy-one patients were identified: 137 (80%) men and 34 (20%) women. Overall mortality (all in-hospital) was 32% (head-related = 22%). Of the 117 survivors, follow-up was obtained in all but 6 (95%). Good outcome was achieved in 96 patients (56% overall, 82% of survivors). Those with good outcome were younger (26 years vs. 43 years, p = 0.0028) and experienced a greater change in predecompression to postdecompression ICP (ICP reduced by 23 mm Hg vs. 10 mm Hg, p < 0.0001). Not surprisingly, unchanged ICP (predecompression to postdecompression) was associated with poor outcome (p = 0.0031). There was no difference in immediate predecompression ICP between survivors versus nonsurvivors. However, immediate predecompression Glasgow Coma Score was significantly higher in survivors compared with nonsurvivors (7 vs. 5, p < 0.0001). CONCLUSIONS: DC resulted in good functional outcome in >50% of patients with severe TBI. The greatest benefit was observed in younger patients with a demonstrable reduction in ICP after decompression. The prospect of improved functional outcome offered by this procedure in the treatment of severe TBI warrants prospective investigation.

AB - BACKGROUND: The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature. METHODS: Patients with severe TBI (Abbreviated Injury Score 4-5) treated with DC for the management of increased ICP during 6-year period were identified from the trauma registry. Functional outcome was measured 1 year to 6 years postinjury using the Glasgow Outcome Score Extended (GOSE) via telephone interview and classified as good (GOSE 5-8) or poor (GOSE 1-4, including death). Outcomes were compared using Wilcoxon rank-sum and χ tests where appropriate. RESULTS: One hundred and seventy-one patients were identified: 137 (80%) men and 34 (20%) women. Overall mortality (all in-hospital) was 32% (head-related = 22%). Of the 117 survivors, follow-up was obtained in all but 6 (95%). Good outcome was achieved in 96 patients (56% overall, 82% of survivors). Those with good outcome were younger (26 years vs. 43 years, p = 0.0028) and experienced a greater change in predecompression to postdecompression ICP (ICP reduced by 23 mm Hg vs. 10 mm Hg, p < 0.0001). Not surprisingly, unchanged ICP (predecompression to postdecompression) was associated with poor outcome (p = 0.0031). There was no difference in immediate predecompression ICP between survivors versus nonsurvivors. However, immediate predecompression Glasgow Coma Score was significantly higher in survivors compared with nonsurvivors (7 vs. 5, p < 0.0001). CONCLUSIONS: DC resulted in good functional outcome in >50% of patients with severe TBI. The greatest benefit was observed in younger patients with a demonstrable reduction in ICP after decompression. The prospect of improved functional outcome offered by this procedure in the treatment of severe TBI warrants prospective investigation.

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