A Study on Decompressive Craniectomy in Moderate to Severe Head Injury patients

INTRODUCTION: An injury to the brain may cause edema and produce swelling of brain. Pressure within the skull then increases as the brain has no room to expand; this excess pressure, known as high intracranial pressure, can cause further secondary brain injury. High intracranial pressure is the most frequent cause of death and disability in brain-injured patients. The management of increased intracranial pressure is common clinical scenario in neurosurgery. If high intracranial pressure (ICP) cannot be controlled using general or First-line therapeutic measures, second-line treatments are initiated, one of these procedure is decompressive craniectomy (DC) and also performed while intracranial hematoma evacuation. DC involves the removal of a section of skull so that the brain has room to expand and the ICP decreased. There is however still clinical uncertainty regarding the use of DC and a lack of consensus on the optimal management of traumatic brain injury. The present study was undertaken to analyze the factors that affects the patient’s outcome in our setup, and to analyze the role of decompressive craniectomy and also the factors predicting the outcome. OBJECTIVES: Decompressive craniectomy (DC) is widely used to treat intracranial hypertension following traumatic brain injury (TBI). Decompressive craniectomy performed alone or in conjunction with evacuation of the mass lesion, can reduce the raised intra cranial pressure (ICP). The present study was undertaken to analyze the factors that affects the patient’s outcome, and to analyze the role of primary decompressive craniectomy and also the factors predicting the outcome. METHODS: It is a prospective analytical study; study period is from August 2009 to February 2012 in the Institute of Neurology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai. All Patients admitted in our hospital trauma ward with moderate to severe head injury who are undergoing primary decompressive craniectomy according to brain trauma foundation guidelines are included in this study. Entry was determined using the inclusion and exclusion criteria after resuscitation, and data were entered in proforma. The postoperative GCS and GOCS (Glasgow outcome score) at discharge from the hospital were noted, primary and secondary outcomes were analyzed. RESULTS: In our present study there were 136 cases underwent decompressive craniectomy, of these 90% were males and the remaining 10% were females. The most common mode of injury was road traffic accident (76%). Out of 136 patients 56 patients were survived (41%), of whom 30 patients had good recovery (22.1%), 19 patients had mild disability (14%), 4 patients had moderate disability (2.9%) and 3 patients were in vegetative state (2.2%) at the time of discharge. 80 patients died accounting for a mortality rate of 58.8%. Favourable outcome rate was 36.1% (GOS 4&5), unfavourable outcome rate was 63.9%(GOS1, 2 & 3). CONCLUSION: The age, mode of injury, timing of surgery, clinical parameters like Glasgow coma score, associated injury, pupillary status, adequacy of bone removal and duraplasty, are important in predicting the outcome of decompressive craniectomy. A generous craniotomy and augmented duraplasty facilitating ICP reduction and better outcome of decompressive craniectomy