Observed versus Predicted Outcome for Decompressive Craniectomy: A Population-Based Study

Abstract

A number of studies have shown that decompressive craniectomy can reduce intracranial pressure and may improve outcome for patients with severe head injury. This cohort study assessed the long-term outcome of neurotrauma patients who had a decompressive craniectomy for severe head injury in Western Australia between 2004 and 2008. The web-based outcome prediction model developed by the CRASH trial collaborators was applied to the cohort. Predicted outcome and observed outcome were compared. Characteristics of outcome between those who had had a unilateral and those who had had a bilateral decompressive procedure were compared. All complications were recorded. Among a total of 1,786 adult neurotrauma patients admitted during the study period, 147 patients (8.2%) had a decompressive craniectomy. A significant proportion of patients who required unilateral (37.3%) and bilateral (46.5%) craniectomy were able to return to work or study at 18 months after the injury. The patients who required bilateral craniectomy more likely to be associated with an unfavorable outcome (Glasgow Outcome Scale score >or=3) than those who had unilateral craniectomy (odds ratio 4.42; 95% confidence interval 1.16,16.81; p = 0.029), after adjusting for the timing of surgery, mechanism of injury, and the predicted risk of unfavorable outcome. The functional outcome after either unilateral or bilateral decompressive craniectomy was significantly better than that predicted by the CRASH head injury prediction model when the predicted risk was less than 80%. This study has demonstrated that in Western Australia decompressive craniectomy is a relatively common surgical procedure for the management of neurotrauma. A significant proportion of patients had a better-than-predicted long-term functional outcome.

Prognostic significance of blood-brain barrier disruption in patients with severe nonpenetrating traumatic brain injury requiring decompressive craniectomy

“…The management strategies and outcomes of patients who had severe TBI requiring decompressive craniectomy before 2011 are described in our previous publications. 15,16 In this study, we defined BBB disruption as a total CSF protein concentration to total plasma protein concentration ratio greater than 0.007, which correlates well with the traditional biochemical marker of BBB disruption (CSF-plasma albumin quotient [correlation coefficient 0.97]). 34 Because the BBB can be disrupted across a continuum of severity, we also assessed the prognostic significance of BBB disruption by analyzing the ratio of the total CSF protein concentrations to total plasma protein concentrations as a continuous variable.…”

“…[15][16][17] In terms of developing secondary brain injury, for many years intracranial pressure (ICP) has been used as a means of assessment with little doubt of its prognostic value. 3,20,21 However, use of ICP as a measure has some limitations as it becomes increasingly apparent that it is essentially a measure of end organ injury, demonstrated by the failure of many ICP-lowering therapies to improve outcome.…”

Development of a bioactive implant for repair and potential healing of cranial defects

“…Moreover, a prospective study for cranial repair following decompressive craniec tomy will be performed, in which the ceramic implant is compared with treatment with a preserved bone flap, the gold standard treatment, with a complication rate as high as 18%-25%. 6,8,9 Disclosure A grant from the Swedish Innovation Agency Vinnova sup ported this study (no. 201100591).…”

Validation of the CRASH model in the prediction of 18-month mortality and unfavorable outcome in severe traumatic brain injury requiring decompressive craniectomy

“…The data from two previous studies were combined with data that have been collected prospectively since 2009. 11,13 This study has included all patients who had undergone a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia between 2004 and 2012 and in whom 18-month follow-up data were available. These two major trauma hospitals are the only neurosurgical centers that provide adult neurotrauma services in Western Australia, and there is a vast geographical separation from other state capital cities.…”

“…17 Previous studies have demonstrated that the predicted risk of an unfavorable outcome can be used as a surrogate index of injury severity, which can allow patients to be stratified accordingly. 11,13 Comparing the predicted outcome with the observed long-term outcome provides an objective assessment of the outcome following surgical intervention relative to the severity of injury and the expected outcome. In this study, we aimed to assess the predictive validity of the CRASH model in patients with severe TBI requiring decompressive craniectomy.…”