Incidence and Risk Factors for Post-Traumatic Hydrocephalus following Decompressive Craniectomy for Intractable Intracranial Hypertension and Evacuation of Mass Lesions

Abstract

There continues to be a considerable interest in decompressive craniectomy in the management of severe traumatic brain injury (TBI). Though technically straightforward, the procedure is not without significant complications. In this study we assessed the incidence and risk factors for the development of subdural hygroma and hydrocephalus after decompressive craniectomy. A total of 195 patients who had had a decompressive craniectomy for severe TBI between 2004 and 2010 at the two major trauma centers in Western Australia were considered. Of the 166 patients who survived after the acute hospital stay, 93 (56%; 95% confidence interval [CI] 48,63%) developed subdural hygroma; 45 patients (48%) had unilateral and 48 patients (52%) had bilateral subdural hygromas. Of the 159 patients who survived more than 6 months after surgery, 72 (45%; 95% CI 38,53%) developed radiological evidence of ventriculomegaly, and 26 of these 72 patients (36%; 95% CI 26,48%) developed clinical evidence of hydrocephalus and required a ventriculoperitoneal (VP) shunt. Maximum intracranial pressure prior to decompression (p=0.005), subdural hygroma (p=0.012), and a lower admission Glasgow Coma Scale score (p=0.009), were significant risk factors for hydrocephalus after decompressive craniectomy. Hydrocephalus requiring a VP shunt was associated with a higher risk of unfavorable neurological outcomes at 18 months (odds ratio 7.46; 95%CI 1.17,47.4; p=0.033), after adjusting for other factors. Our results showed a clear association between injury severity, subdural hygroma, and hydrocephalus, suggesting that damage to the cerebrospinal fluid drainage pathways contributes to the primary brain injury rather than the margin of the craniectomy as the factor responsible for these complications.

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

“…Others defined hydrocephalus as progressive ventricular dilatation with trans-ependymal edema, together with (1) the presence of either clinical deterioration or failure to make neurological progress over time, and (2) some evidence of clinical improvement after insertion of a ventriculo-peritoneal shunt (V-P shunt). The incidence of hydrocephalus in these studies is low 9,11,15 . Rahme et al enrolled 17 patients in a retrospective study and found that the incidence of hydrocephalus after DC was 0% 9 .…”

“…Choi et al reported a 23.6% occurrence of hydrocephalus after DC 15 . However, in another study, this percentage increased to 45% 11 . This discrepancy may be associated with study inclusion criteria.…”

“…Injury severity is another impact factor for hydrocephalus. In a multivariate analysis, Honeybul et al found that maximum ICP prior to decompression (p=0.012) and admission Glasgow Coma Score (GCS) (p=0.009), which are indicators of injury severity, are significant independent risk factors for development of hydrocephalus after DC, but they found no relationship between the craniectomy margin and hydrocephalus 11 , which differs from a report by De Bonis et al 28 . Their results suggest that damage to the CSF drainage pathways contributes to the primary brain injury, rather than the craniectomy margin, as a factor responsible for hydrocephalus.…”

“…Kaen et al found a 27.3% incidence of hydrocephalus after DC in patients with severe TBI 16 . Jiao et al and Honeybul et al found a 45% incidence of hydrocephalus in patients with severe TBI 11,14 . Thus the incidence of hydrocephalus after DC differs among studies due to dissimilar definitions of hydrocephalus and study inclusion criteria.…”

“…The incidence of hydrocephalus varies from 0-45%, depending on the study 9,10,11,12,13 . Some authors believe that DC is a risk factor for hydrocephalus 14,15 , whereas others do not 9,11,12,16 . Thus, the relationship between DC and hydrocephalus remains controversial.…”