Abstract. The first surgeon promoting DC in post traumatic brain swelling was Kocher in 1901 [9].

Transcription

1 Med. J. Cairo Univ., Vol. 80, No. 2, March: , Unilateral Decompressive Craniectomy in Traumatic Brain Injury Patients with Poor Glasgow Coma Scale as an Intraoperative Decision after Evacuation of Focal Lesion; Outcome in 30 Consecutive Cases AHMED M. KERSH, M.D.* and HANAN H. EL-GENDY, M.D.** The Departments of Neurosurgery* and Neurology**, Faculty of Medicine, Cairo University Abstract Objective: Assessment of the outcome and its predictors after decompressive craniectomy (DC) in traumatic brain injury (TBI) after evacuation of focal lesion and comparison the results to other studies in which the focal lesion evacuated without DC. Methods: A total number of 30 consecutive cases of TBI with immediate evacuation of focal lesion like subdural hematoma (SDH) or extradural hematoma with persistent brain swelling after the evacuation, managed by removal of the bone flap with or without widening of the craniectomy site with durotomy with follow-up the outcome using Glasgow outcome scale (GOS) determining the predictors for outcome and comparison the results of other studies in which the focal lesion evacuated without DC and cranioplasty for the patients when the conscious level improved. Results: The age ranged from years, the mean age in SDH was 50 year and in EDH was 28 year, male to female ratio was 1.7:1, the most common cause of injury was motor car accident, SDH was present in 16 cases (53.33%), EDH in 20 cases (66.67%), both EDH and SDH in 8 cases (26.67%) and intracerebral hematoma (ICH) in 2 cases, skull fracture was present in 20 cases (66.67%), midline shift more than 10mm in 19 cases (63.33%) and less than 10mm in 11 cases (36.67%), 12 cases had good outcome (40%), two cases had moderate disability (6.67%), five cases (16.67%) had severe disability, six cases (20%) became vegetative and five cases (16.67%) mortality, the subdural effusion was the most common complication in (23.33%). Conclusion: Reduction of morality and morbidity from TBI is the goal of DC. The most important predictors for outcome after DC were GCS and midline shift in CT brain. DC decrease the mortality more in SDH but improve the functional outcome in both SDH and EDH associated with increased intracranial pressure (ICP). The subdural effusion was the most common complication, cranioplasty was more beneficial in syndrome of trephined. Key Words: Decompressive craniectomy Intracranial pressure Traumatic brain injury. Correspondence to: Dr. Ahmed M. Kersh, Ahmedmk72@yahoo.com. Introduction TRAUMATIC brain injury is a very important cause of intracranial hypertension [1]. The management of traumatic intracranial hypertension aims the control of the intracranial pressure (ICP) and to maintain cerebral perfusion pressure (CPP) and then cerebral blood flow (CBF) preventing cerebral ischemia. The intracranial hypertension may be severe and resisting the medical management in 10-15% of traumatic brain injury (TBI) [1,2,3]. Decompressive craniectomy (DC) is an alternative line of management in these patients but long-term functional outcomes remain unknown. Gradual decrease in mortality and increase in number of patients that have good outcome after DC was reported by several authors, also others documented that DC may improve O 2 delivery to the brain tissue, cerebral compliance, CBF, CPP and decrease swelling [4-8]. The first surgeon promoting DC in post traumatic brain swelling was Kocher in 1901 [9]. Decompressive craniectomy means removal of part of the skull to allow the brain to swell without squeezing [10]. In developing countries, DC is very attractive for highly resource limited practice setting as there is no facility for ICP monitoring, no dedicated neurointensive care unit, so the main line of care for TBI is limited to empiric use of mannitol, furesamide, hyperventilation and other basic physical/nursing management practice [11,12]. Patients and Methods This is a retrospective study of thirty cases of traumatic brain injury with focal lesion with poor Glasgow coma scale less than eight after resusci- 143

2 144 Unilateral Decompressive Craniectomy in Traumatic Brain Injury Patients tation and after exclusion of the patients with lost brain stem reflexes between in Cairo University Hospitals, all patients were resuscitated in Emergency Department and assessed by Cardiothoracic, Orthopedic, General Surgery and Neurosurgery Consultants, the collected data from the Neurosurgical sheet were mode of trauma, time interval to reach the hospital, Glasgow coma scale after resuscitation, pupil size and reaction to light, neurological deficits, other systemic injuries, CT brain findings, operative data, postoperative care and outcome. All cases were admitted to Neurosurgery Emergency Department and shifted to the operating room as all cases had focal lesion i.e. subdural hematoma, extradural hematoma or intracerebral hematoma, need evacuation, the craniotomy was designed widely above the focal lesion, in all cases, the preoperative CT brain showed diffuse brain swelling and then high ICP in the form of effaced sulci, effaced sylvian fissure, effaced cisterns and midline shift, this high intracranial pressure was documented intra-operatively after evacuation of the focal lesion by very hard dural surface in case of extradural hematoma or tense and bulging brain with less pulsation in case of SDH or ICH inspite of usage of the medical methods to lower ICP by dehydration, head elevation and hyperventilation. So intra-operative decision was taken to remove the bone flap and widening the opening if necessary with wide durotomy with addition of dural slits along the perimeter of the dural opening perpendicular to the dural incision to prevent the venous congestion of the main superficial veins by dural edge compression, allowing to the brain to compensate high ICP by bulging out the edge of the craniectomy, postoperatively, the patients were monitored in the intensive care unit (ICU) with continuation of the medical methods to lower ICP as no facilities for ICP monitor in our hospital. The outcome was assessed and recorded 6 months after admission or at death by Glasgow outcome scale (GOS) including five categories: Good recovery (score 5). Moderately disabled (score 4). Severely disabled (score 3). Persistent vegetative state (score 2). Death (score 1). The outcome categories were divided into functional recovery (GOS 5,4) or non functioning recovery (GOS 3,2,1) and mortality was defined as postoperative death within 30 days after surgery [13]. Cranioplasty for the bone defect had done for all patients with good recovery or moderately disabled patients at variable times from one to three months according to the time after which the brain had no bulge out the craniectomy site. Statistical analysis: Data were expressed as number and percentage and tabulated using Microsoft Excel Results The patients ages ranged from years with a mean age (33 years), nineteen cases (63.33%) were males, eleven cases were females (36.7%), the most common mode of injury was motor car accident, maximal time to reach the hospital was three hours, the least time was 20 minutes, eight cases (36.7%) were vitally unstable on admission, many patients had multiple systemic injuries, six cases (20%) had cardiothoracic injuries, eleven (26.7%) had orthopedic injuries, eight cases (26.7%) had abdominal injuries, five cases (16.7%) had spinal injuries and five cases (16.7%) had facial fractures. Chest tube was an emergency procedure for all patients with cardiothoracic injuries. The Glasgow coma scale (GCS) was the most important prognostic factor, on admission and after resuscitation, six patients (20%) had GCS 7, five cases (16.7%) had GCS 6, six cases (20%) with GCS 5, six cases (20%) with GCS 4 and seven cases (23.3%) with GCS 3, the preservation of brain stem reflexes was a condition in this study, CT brain findings were EDH in 20 cases (66.67%), SDH in 16 cases (53.33%), both SDH and EDH in 8 cases (26.67%) and ICH in two cases (6.67%), 20 cases had skull fracture (66.67%), twelve cases of them (40% of total cases and 60% of number of cases with skull fracture) was linear fracture and eight cases (26.67%, 40%) was comminuted fracture, all patients had diffuse brain swelling in the form of effaced sulci, basal cisterns, sylvian fissure and subarachnoid space, all cases had midline shift, 11 cases (36.67%) less than 10mm and 19 cases (63.33%) more than 10mm. The outcome was assessed by Glasgow outcome scale, 12 cases (40%) had good recovery, two cases (6,7%) had moderate disability, five cases (16,7%) had severe disability, six cases (20%) were vegetative and five cases (20%) mortality, by classification of functional and non-functional recovery, 14 cases (46,7%) with functional recovery and 16 cases (53,33%) with non-functional recovery.

3 Ahmed M. Kersh & Hanan H. El-Gendy 145 Comparison of the GCS to GOS showed that the outcome was better with better GCS level, as GCS decreased, the number of severe disability, vegetative state and mortality increased, the vegetative state increased mainly in the patients with GCS 3 or 4, 4/13 (30.8%), the mortality cases were also more in these GCS levels 4/13 (30.8%), also severe disability was 3/13 (23.08%) with least percentage for good recovery 2/13 (15.38%), this means that the surgery saved life for 9/13 (69.23%) but only saving the functional recovery in 2/13 (15.38%). Comparison of midline shift to the outcome showed that, shift also was an important prognostic factor, as the functional recovery in patients with shift less than 10mm was 10/11 (90.9%) and nonfunctional recovery was in 1/11 (9.1%). While in patients with shift more than 10mm, the functional recovery was in 4/19 (21.05%), while non-functional recovery was in 15/19 (78.95%). Several complications occurred after the Decompressive craniectomy, subdural effusion in 7/30 (23.33%) was the most common complication, non of them need surgery but resolved spontaneously, postoperative infection in one case, contralateral subdural chronic hematoma in one case treated by surgical evacuation and syndrome of trephined in two cases improved after cranioplasty. Table (1): GCS & GOS in the studied cases. GCS after resuscitation Pupils Midline shift Other injuries CT findings Skull fracture GOS 1 case SDH 6 cases with Equal in 5 cases Less than 2 cases Orthopedic 3 cases EDH 3 Linear 5 cases Good recovery 5 GCS 7 Unequal in 1 case 10-mm 1 case Facial # 2 cases SDH + EDH 2 comminuted Moderate disability 1 (20%) 1 case ICH 1 case Cardiothorac. 1 case Orthopedic 2 cases SDH 3 Linear Good recovery 3 4 cases Less than 5 cases with Equal in 5 cases 1 case Abdominal 3 cases EDH 1 Comminuted Moderate disability 1 GCS 6 1 case Spine Vegetative 1 (16.7%) 1 case Facial # 1 case Cardiothorac. 1 case SDH Good recovery 2 4 cases Orthopedic 2 cases EDH 2 Linear Severe disability 2 3 cases More than 6 cases with Equal in 5 cases 2 cases Abdominal 2 cases SDH + EDH 1 Communicated Vegetative 1 GCS 5 Unequal in 1 case 1 case Spine 1 case ICH Mortality 1 (20%) 2 cases Facial # 6 cases with Equal in 4 cases GCS 4 Unequal in 2 cases More than Good 1 2 cases Cardiothorac. 1 case SDH 2 Linear 4 cases Severe 1 2 cases Orthopedic 2 cases EDH 2 Comminuted Vegetative 2 (20%) 2 cases Abdominal 2 cases SDH + EDH Mortality 2 1 case Spine 1 case ICH 2 cases Cardiothorac. Good 1 7 cases with Equal in 5 cases More than 2 cases Orthopedic 2 cases SDH 2 Linear Severe 2 4 cases GCS 3 Unequal in 2 cases 3 cases Abdominal 3 cases EDH 2 Comminuted Vegetative 2 (23.3%) 2 cases Spine 2 cases SDH + EDH Mortality 2 1 case Facial #

4 146 Unilateral Decompressive Craniectomy in Traumatic Brain Injury Patients Case No. (1): Axial CT brain showed left frontoparietal EDH + SDH with effaced sulci, cisterns with midline shift The same patient after 1 week no midline shift but still effaced sulci After ten days, wide sulci, subarachnoid space with minimal interhemispheric and left frontal subdural effusion After 20 days showed contralateral subdural chronic hematoma

5 Ahmed M. Kersh & Hanan H. El-Gendy 147 Case No. (2): Axial CT brain showed right temperoparietal EDH effacing the basal cisterns The same patient after one week with no midline shift with brain bulging out the craniectomy site, in this case the craniectomy site was not wide but no harmful strangulation occurred, with minimal subdural effusion After 20 days with less bulging out of the brain Discussion Reduction of mortality and morbidity from the TBI is the goal of Decompressive surgery. Secondary brain injury including brain swelling, high intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP) are the main causes of in hospital deaths after TBI, the aim of treatment of TBI are therefore to control brain swelling and to maintain adequate cerebral blood flow and oxygen delivery to the injured brain tissue [6]. Decompressive surgery had been used with variable success since Bergman first described this technique in 1880 then by Cushing's description of subtemporal Decompressive craniectomy for lowering ICP [6,14]. In this study, the patients with bilaterally fixed and dilated pupils or brain stem injury were excluded from this research as they are poor candidates for DC as there is known association of these findings with poor outcome [15,16].

6 148 Unilateral Decompressive Craniectomy in Traumatic Brain Injury Patients In all patients, the indication for surgery was for mass lesion with intraoperative decision to remove the bone flap with severe brain swelling not relieved by evacuation of mass lesion as mentioned by many authors [17]. The mean age for patients with SDH was 50 years, near to the mean age in Kyu-Hong Kim study (the mean age was 51.8 years) [18], while the mean age for EDH was 28, this means that EDH is an affliction in the youth [19]. Male to female ratio was 1.7:1 not far than ratio of Kyu-Hong Kim and Oertal et al. [18,20]. The most common cause of injury was motor car accident in contrast to Seung Pil Ban and Kyu- Hong Kim studies as the fall from height was the most common cause [18,22] but similar to results of Mushtaq et al. and Amos results [19,22]. The preoperative GCS was as very important predictor of outcome as mentioned by many authors [23-26]. In this study, patients with GCS 3 had mortality 2/7 (26.6%), in GCS 4 (33.3%), in GCS 5 (16.7%), in GCS 6 and 7 (0%), the overall mortality was (16.7%) which was better than mortality in SDH in GCS less than 8 in Kyu-Hong Kim study (55.4%) but near to the mortality in EDH with GCS less than 8 in Mashtaq et al., study (11.1%) but with consideration that all cases in the present study had high ICP after evacuation of EDH, also 8/30 (26.7%) had SDH with EDH. Comparison of the non-functional outcome (severe disability and vegetative), this study had eleven patients (36.7%) with non-functional outcome, while in SDH in Kyu-Hong Kim study was (21.1%) [18] and in EDH in Mushtaq et al., study was (55.6%) [19], this difference is due to high mortality in patients with SDH operated upon by evacuation without DC while in the present study and in Mushtaq et al., study (in which EDH evacuated without DC), the mortality was more less. In the present study, ICP was high in all cases documented by CT findings and the intraoperative findings, also Kyu-Hong Kim study compared the outcome to the ICP monitoring, the most significant different result was the percentage of the functional outcome in the present study was (46.7%), in SDH in Kyu-Hong Kim study (23.5%) [18] and in EDH in Mushtaq et al., study (22.2%) [19]. The DC decrease the mortality more in SDH but improve the functional outcome in both SDH and EDH associated with increased ICP. Comparison the outcome in relation to GCS showed that, all mortality cases had occurred in GCS 3-5, also all cases with severe disability and 5/6 of vegetative states also in the same GCS group like result of Bizhan Arabi [27], also the midline shift more than 10mm corresponded to GCS 3-5 in the present study with poor outcome while more favorable outcome in patients with midline shift less than 10mm [27]. No significant relation to age, sex or hematoma size but the severity of other system injuries was an important factors affecting the blood pressure and oxygen saturation which directly may influence the function of the brain tissue [27]. The subdural effusion was the most common complication (36.7%) like Seung Pil Ban result [21]. Cranioplasty was beneficial in cases complicated with syndrome of trephined with symptoms like headache, seizure, mood swing or behavioral disturbances like result of Grant FC [21] as the bone defect make the scalp to sink because of a lack of bone support with transmission of atmospheric pressure directly to the brain, reducing the subarachnoid space with pressure on the underlying cortex affecting CSF circulation and cerebral blood flow, so early cranioplasty has been recommended as soon as the conscious level improved and the patient start to ambulate [21]. Conclusion: Reduction of morality and morbidity from TBI is the goal of DC. The most important predictors for outcome after DC were GCS and midline shift in CT brain. DC decrease the mortality more in SDH but improve the functional outcome in both SDH and EDH associated with increased ICP. The subdural effusion was the most common complication, cranioplasty was more beneficial in syndrome of trephined. References 1- AARABI B., HESDORFFER D.C., AHN E.S., ARESCO C., SCALEA T.M. and EISENBERG H.M.: Outcome following Decompressive craniectomy for malignant swelling due to severe head injury. J. Neurosurg. Apr., 104 (4): , JUUL N., MORRIS G.F., MARSHALL S.B. and MAR- SHALL L.F.: Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J. Neurosurg. Jan., 92 (1): 1-6, MARSHALL L.F., SMITH R.W. and SHAPIRO H.M.: The outcome with aggressive treatment in severe head

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