Decompressive craniotomy: prognostic factors and complications in 89 patients

Abstract

-Decompressive craniotomy (DC) is applied to treat post-traumatic intracranial hypertension (ICH).The purpose of this study is to identify prognostic factors and complications of unilateral DC. Eighty-nine patients submited to unilateral DC were retrospectively analyzed over a period of 30 months. Qui square independent test and Fisher test were used to identify prognostic factors. The majority of patients were male (87%). Traffic accidents had occurred in 47% of the cases. 64% of the patients had suffered severe head injury, while pupillary abnormalities were already present in 34%. Brain swelling plus acute subdural hematoma were the most common tomographic findings (64%). Complications occurred in 34.8% of the patients: subdural effusions in 10 (11.2%), hydrocephalus in 7 (7.9%) and infection in 14 (15.7%). The admittance Glasgow coma scale was a statistically significant predictor of outcome ( p=0.0309).KEY WORDS: head injury, intracranial hypertension, decompressive craniotomy. Craniotomia descompressiva: análise de fatores prognósticos e complicações em 89 pacientesResumo -A craniotomia descompressiva (CD) é técnica utilizada para tratamento da hipertensão intracraniana (HIC) pós-traumática. O objetivo do estudo foi determinar fatores prognósticos e complicações nos pacientes submetidos a esta técnica. Realizou-se estudo retrospectivo de 89 pacientes submetidos à CD unilateral para tratamento da HIC pós-traumática durante 30 meses. Utilizou-se testes do Qui-quadrado de independência e teste exato de Fisher para análise de fatores independentes de prognóstico. A maioria dos pacientes era do sexo masculino (87%). A causa mais comum foi o acidente de trânsito (47%). A maioria apresentava traumatismo cranioencefálico grave (64%), 34% já apresentavam anisocoria. O achado tomográfico mais comum foi a associação entre tumefação cerebral e hematoma subdural agudo (64%). Em 34,8% dos pacientes houve complicações inerentes à técnica: coleção subdural (11,2%), hidrocefalia (7,9%) e infecção (15,7%). A escala de coma de Glasgow à admissão correlacionou-se estatisticamente como fator prognóstico (p=0,0309). Decompressive craniotomy (DC) is a surgical method performed to immediately reduce intracranial pressure (ICP). It is usually indicated in cases of brain swelling (BS) and acute subdural hematoma (ASDH), or even for nontraumautic lesions in order to accommodate the swollen brain 1 . It consists of a unilateral craniotomy and dural augmentation. The bone can be temporarily stored in the abdominal subcutaneous tissue or can be disposed in case of a subsequent cranioplasty (with methylmethacrylate or titanium plate, among other materials). PALAVRAS-CHAVERecent studies have been evaluating DC efficacy when performed early in patients with severe traumatic brain injury (TBI) and with intracranial hypertension (ICH), yielding a superior result as compared to late performance or to specific clinical procedures (barbiturate coma and hypothermia) [2][3][4][5][6] . The purpose of this study was to evaluate prognostic...

An Innovative Technique of Decompressive Craniectomy for Acute Ischemic Stroke

“…However, to be certain of this, further studies are required to clearly demonstrate bone resistance sufficient to sustain significant impacts, not only in the case of the procedure presented here but also after the subsequent repositioning of the bone to correct the defect left by a conventional decompressive hemicraniectomy, since bone resorption might occur (Stiver, 2009, Faleiro et al, 2008.…”

“…Among them are hemorrhagic complications, overindication, problems with flap storage and sterilization, metabolic changes associated with lack of bony covering, syndrome of the trephined, hydrocephalus and others (Chen et al, 2006;Valença et al, 2009;Faleiro et al, 2008).…”

The influence of decompressive craniectomy on the development of hydrocephalus: a review

“…Among these complications, the most frequent is subdural effusion, but the incidence differs among studies from 11.2-62%. Other complications that often occur after DC are herniation of the cortex through the bone defect (14.6-51%), seizure (3.4-22%), hydrocephalus (7.9-14%), and infection (4.5-15.7%); others, such as CSF leakage and syndrome of trephined, occur infrequently 10,17,18,19,20 . In addition to these complications, Ban et al reported that about 5.6% of patients suffer from a newly appearing subdural or epidural hematoma contralateral to the bone defect and 12.4% suffer expansion of the contusion 18 .…”

Marked reduction in wound complication rates following decompressive hemicraniectomy with an improved operative closure technique

“…[1][2][3][4][5] One common objection to the upfront, prophylactic approach to hemicraniectomy is the morbidity associated with leaving the dura open and the bone flap off. 6,7 Craniectomy procedures have been noted to have high rates of neurosurgical complications such as wound dehiscence, cerebrospinal fluid (CSF) leak, and wound infection exceeding those of routine, elective supratentorial craniotomies in which the dura is typically closed and the bone flap replaced.…”

“…In the literature, the rates of wound complication for craniectomy vary markedly, from 3% to 40%. 4,5,7,8 Potential explanations for this wide variability include differences in technique (that is, the use of duraplasty compared to durotomy techniques), the aggressive use of CSF diversion in up to 40% of patients in some series, and limitations in the ability of retrospective analyses to capture minor complications, such as a CSF leak requiring bedside repair or a wound infection treated with antibiotics.…”