Acta Neurochir (2006) [Suppl] 96: 11–16
6 Springer-Verlag 2006
Printed in Austria
Decompressive craniectomy in traumatic brain injury: outcome following
protocol-driven therapy
I. Timofeev1, P. J. Kirkpatrick1, E. Corteen1, M. Hiler1, M. Czosnyka1, D. K. Menon2,3, J. D. Pickard1,3, and
P. J. Hutchinson1
1 Department of Neurosurgery, Addenbrooke’s Hospital, Cambridge, UK
2 Department of Anesthesia, Addenbrooke’s Hospital, Cambridge, UK
3 Wolfson Brain Imaging Centre, University of Cambridge, UK
Summary
Although decompressive craniectomy following traumatic brain
injury is an option in patients with raised intracranial pressure
(ICP) refractory to medical measures, its e¤ect on clinical outcome
remains unclear. The aim of this study was to evaluate the outcome
of patients undergoing this procedure as part of protocol-driven therapy between 2000–2003. This was an observational study combining
case note analysis and follow-up. Outcome was assessed at an interval of at least 6 months following injury using the Glasgow Outcome
Scale (GOS) score and the SF-36 quality of life questionnaire. Fortynine patients underwent decompressive craniectomy for raised and
refractory ICP (41 [83.7%] bilateral craniectomy and 8 [16.3%] unilateral). Using the Glasgow Coma Scale (GCS), the presenting head
injury grade was severe (GCS 3–8) in 40 (81.6%) patients, moderate
(GCS 9–12) in 8 (16.3%) patients, and initially mild (GCS 13–15) in
1 (2.0%) patient. At follow-up, 30 (61.2%) patients had a favorable
outcome (good recovery or moderate disability), 10 (20.4%) remained severely disabled, and 9 (18.4%) died. No patients were left
in a vegetative state. Overall the results demonstrated that decompressive craniectomy, when applied as part of protocol-driven therapy, yields a satisfactory rate of favorable outcome. Formal prospective randomized studies of decompressive craniectomy are now
indicated.
Keywords: Head injury; traumatic brain injury; decompressive
craniectomy; ICP; brain edema; intracranial hypertension; Glasgow
Outcome Scale.
cerebral perfusion pressure (CPP) b 60–70 mmHg,
and a number of therapeutic approaches are employed
to reduce ICP and augment CPP in order to achieve
these targets.
In patients with post-traumatic cerebral swelling
resistant to optimal medical therapy, decompressive
craniectomy may be considered. Despite observations
that craniectomy leads to reduction in ICP [3, 30, 31,
35], it is still unclear how this translates into clinical
outcome. Although prospective randomized evaluation of the e¤ects of decompressive craniectomy is required, this operation continues to be used empirically
in the management of patients with traumatic brain injury. In Cambridge, decompressive craniectomy is used
as a part of protocol-driven intensive care management of patients with severe head injury [18] (Fig. 1),
when other means of controlling elevated ICP are exhausted. It is also used in selected cases where malignant post-traumatic cerebral swelling is evident from
the outset. Encouraged by our previous observations
[31], we have evaluated the outcome following decompressive craniectomy in another consecutive cohort of
49 patients.
Introduction
Severe traumatic brain injury is associated with high
mortality and morbidity. Treatment of patients who
present in coma following severe head injury aims
to protect the brain from further insults, optimize
cerebral metabolism, and prevent secondary injury.
Intracranial pressure (ICP) monitoring is now wellestablished in neuro-intensive care. Recent guidelines
[10] recommend target levels of ICP < 25 mmHg and
Materials and methods
Study design
This study is a retrospective observational cohort study with crosssectional analysis of outcome. Hospital records, intensive care
charts, and computed tomography (CT) scans of patients who
underwent decompressive craniectomy following traumatic brain injury consecutively during the period 2000–2003 were retrospectively
analyzed. Physiological parameters recorded for 24 hours before and
12
Fig. 1. Protocol of intensive care management of head injured patients
I. Timofeev et al.
Decompressive craniectomy in traumatic brain injury: outcome following protocol-driven therapy
after operation were compared. Outcome was assessed using the
Glasgow Outcome Score (GOS) [14] recorded at follow-up assessment at least 6 months following the injury. Data were obtained
from patients’ medical records and a prospectively collected head
injury outcome database. SF-36 quality of life survey [29] questionnaires were mailed to surviving patients with favorable outcome
(good recovery or moderate disability) for more detailed evaluation
of their social and physical rehabilitation. The response rate for the
postal questionnaire was 60%.
Statistical analysis
Data were analyzed using SPSS 13.0 for Windows (SPSS Inc.,
Chicago, IL, USA). Following distribution analysis (KolmogorovSmirnov and Shapiro-Wilk tests), mean values G SD were used
for data following normal distribution, and median values G
interquartile range (IQR) for non-parametric data. Means and medians of physiological variables before and after craniectomy were
compared using paired t-test, Wilcoxon, and sign tests, respectively.
P value of <0.05 was considered significant. Pearson and Spearman
rank coe‰cients were used to test the strength of correlations.
Results
Patient characteristics
Demographic data from the study population as
well as mechanisms and severity of injury are summarized in Table 1. The majority of patients had a
Table 1. Summary of patient characteristics (n ¼ 49)
Age
28 (range 9–67)
Gender
– Male
– Female
37 (75%)
12 (25%)
Mechanism of injury
– Road Tra‰c Accident
– Fall
– Assault
– Other
29 (60%)
11 (22%)
5 (10%)
4 (8%)
Severity of injury
GCS-based head injury grade:
– Severe (3–8)
– Moderate (9–12)
– Mild (b 13)
40 (82%)
8 (16%)
1 (2%)
Preoperative CT Marshall grade (n ¼ 27):
– I
– II
– III
– IV
– V
– VI
—
4 (15%)
13 (48%)
5 (18%)
1 (4%)
4 (15%)
Injury severity score: median (IQR), n ¼ 30
APACHE score: mean (SD), n ¼ 30
Major extracranial injury
Non-cranial surgery
Median (IQR) ICU stay (days)
25 (16–27)
17 (6.7)
18 (37%)
12 (25%)
19 (range 14–26)
13
post-resuscitation Glasgow Coma Scale (GCS) score
of less than 8. The only patient who presented with
mild head injury (GCS 13) deteriorated later and required intubation and intensive care management.
Two patients had bilateral dilated unreactive pupils
on admission; both subsequently died. A significant
proportion of patients had a major intracranial injury
(37%), and 25% of patients underwent non-cranial surgical procedures. Based on preoperative CT scan appearance, most patients had a di¤use brain injury
(Marshall grade II–III) [16].
Initial ICP control measures
All patients were managed according to an ICP- and
CPP-driven protocol [18] (Fig. 1), which aims to maintain ICP < 25 mmHg and CPP b 60 mmHg. Therapeutic hypothermia was used in 44 (93.6%) patients,
mannitol in 42 (89.4%) patients, hypertonic saline in 9
(19.1%) patients, external ventricular drainage in 13
(27.7%) patients, and barbiturate-induced coma in 15
(31.9%) patients. Decompressive craniectomy was
considered when all medical measures to control ICP
failed to achieve sustained optimal levels of ICP and
CPP, and occasionally it was considered as an alternative to barbiturate therapy.
Surgical details
Decompressive craniectomy was performed on median day 2 (IQR 1;3) after injury. In 24 (49%) patients
the operation was performed within 24 hours, and in 32
(65.3%) patients within 48 hours from the time of admission. Forty-one (83.7%) patients underwent bifrontal decompressive craniectomy, and 8 (16.3%) had a
unilateral procedure. In all cases the dura was opened,
and in cases of bifrontal decompressive craniectomy
the falx cerebri was divided anteriorly if deemed necessary by the operating surgeon.
Complications associated with the operation were
observed in 4 (8%) patients. Two patients su¤ered
intracranial hemorrhage and 1 patient had an acute
subdural hematoma in the early postoperative period,
which required evacuation. One patient developed a
cerebral abscess, which was treated with needle aspiration and antibiotics.
ICP data
Decompressive craniectomy led to a reduction in
ICP pressure in all patients for whom pre- and post-
I. Timofeev et al.
14
Fig. 2. Clinical outcome of patients at 6þ months assessed by Glasgow Outcome Scale score
operative ICP monitoring data was available (n ¼ 27).
Mean G SD ICP during the 24-hour period prior to
surgical decompression was 25 G 6 mmHg as compared to 16 G 6 mmHg for the 24 hours following an
operation, and the di¤erence is statistically significant
( p < 0:01).
Outcome
The GOS showed favorable recovery in 30 (61.2%)
patients (24 [49%] patients with good recovery and 6
[12.2%] patients with moderate disability), 10 (20.4%)
patients remained severely disabled, and 9 (18.4%) patients died (Fig. 2). No patient was left in persistent
vegetative state. Four out of 9 patients presenting with
an initial GCS of 3 were severely disabled and 2 died;
however, 3 (33.3%) patients in this group had a favorable outcome. In general, outcome was related to initial GCS score (p ¼ 0:004), but there was no association with age, gender, or timing of operation with the
GOS. Interestingly, in the 5 patients over 50 years of
age, the rate of favorable outcome was not di¤erent
than in younger patients (60%), although the numbers
were too small to perform further statistical analysis.
Mortality in this group accounted for the remaining
40% of patients, with no patients left severely disabled.
Eighteen out of 30 patients with favorable outcome
responded to the SF-36 quality of life survey (60% response rate). The summary for all 8 domains is presented in Table 2 and compares general population
levels [13]. At least 10 out of 40 surviving patients returned to work (information on re-employment was
Table 2. SF-36 quality of life survey following decompressive craniectomy (n ¼ 18). Numbers represent mean G SD scores for each SF-6
domain in decompressive craniectomy patients and general population
controls. The latter values were obtained from the results of a recent
large-scale population survey [13]
SF-36 Domain
Physical Functioning (PF)
Role limitation due to
Physical problems (RP)
General Health perception (GH)
Bodily Pain (BP)
Role limitation due to
Emotional problems (RE)
Energy Vitality score (EV)
Social Functioning (SF)
Mental Health (MH)
Decompressive
Craniectomy
mean G SD
Controls
mean G SD
67.5 G 32
45.8 G 46
87.9 G 20
87.2 G 22
60.1 G 22
64.8 G 35
51.9 G 47
71.0 G 20
78.8 G 23
85.8 G 21
50.3 G 22
48.8 G 28
62.9 G 27
58.0 G 20
82.8 G 23
71.9 G 18
not available for 14 patients). Cranioplasty was performed in 30 patients (75% of survivors) at the time
of analysis. Post-traumatic hydrocephalus, which required a shunting procedure, was observed in 6 (15%)
of the 40 survivors.
Discussion
Decompressive craniectomy continues to be used as
a treatment measure for advanced cerebral edema and
intractable intracranial hypertension. It has been applied to patients with malignant cerebral swelling following middle cerebral artery thrombosis [5, 19, 22,
25] and in other conditions leading to brain edema [2,
Decompressive craniectomy in traumatic brain injury: outcome following protocol-driven therapy
7, 8, 20, 26, 28]. The indications for decompressive
craniectomy following traumatic brain injury are not
universally defined. Currently, the procedure is considered when medical treatment measures fail to control
ICP or when malignant intracranial hypertension is
present on admission.
Although decompressive craniectomy may lead to
an improvement in physiological parameters [4, 12,
32], the impact of this procedure on clinical outcome
and social rehabilitation has not been clearly established. Present evidence is based on observational
studies or case reports, with the single exception of a
small pilot prospective randomized trial [27]. Outcome
data from the published case series varies significantly.
Although mortality rates quoted by di¤erent centers
fall in the range of 20% G 5%, the rates of reported favorable outcome and severe disability are considerably
di¤erent. The proportion of patients achieving a favorable outcome (GOS: good recovery/moderate disability) after decompressive craniectomy has been reported to be as low as 30–40% [1, 6, 21, 23] and as
high as 60–70% [9, 15, 27, 31]. One of the other serious
concerns raised with regard to decompressive craniectomy is that the operation may reduce mortality, but
increase the subset of patients with severe disability
and persistent vegetative state. Indeed, some authors
report high levels of severe disability [21, 23] and persistent vegetative state [6]. The discrepancy in published outcome data may, to some extent, be explained
by di¤erence in patient selection, indications, timing
and technique of surgery, as well as an assessment of
outcome.
In our unit, decompressive craniectomy is used as
part of a protocol-based management of severe head
injury (Fig. 1). The multidisciplinary decision to perform surgical decompression involves liaison between
a senior neurosurgeon and neuro-intensivist. We have
previously reported high rates of favorable outcome
in a smaller series of patients [31], and the results of
this study are consistent with our earlier findings. The
current study shows that favorable outcome can be
achieved in a large proportion of patients presenting
with severe and potentially fatal head injury, with at
least one-quarter returning to work. A high rate of severe disability or vegetative state after surgical decompression is not supported by our findings, as no patient
was left in a vegetative state and the severe disability
rate was not higher than generally accepted. In terms
of quality of life, the response to the SF-36 questionnaire indicates that patients with favorable clinical
15
outcome continue to experience physical and emotional consequences of their injury. The mean scores
for patients’ quality of life di¤er from a general population in all SF-36 domains; however, the large SDs reflect di¤erences in response between individuals and
suggest that some patients rate their quality of life as
high.
Although the complication rate associated with surgery [17, 24, 33, 34] is low, the impact on outcome and
the exact relationship with craniectomy requires further evaluation.
In conclusion, despite the results from this and other
observational studies, consensus on the indications and
timing of decompressive craniectomy following traumatic brain injury has not been achieved. There is now
a need to obtain Class I evidence by proceeding with
randomized, multi-center, prospective studies [11].
Acknowledgments
P. J. Hutchinson is supported by an Academy of Medical Science/
Health Foundation Senior Surgical Scientist Fellowship. I. Timofeev
is supported by a grant from Codman Division, Johnson and Johnson Corporation.
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Correspondence: Peter Hutchinson, Department of Neurosurgery,
Addenbrooke’s Hospital, Box 167, Hills Road, Cambridge, UK,
CB2 2QQ. e-mail: [email protected]