Modified “in-window” technique for decompressive craniotomy for severe brain injury

Increased intracranial pressure and decreased cerebral perfusion in patients with severe traumatic brain injury are associated with cerebral ischemia and poor outcome. Lowering intracranial pressure is one of the goals of treatment. We analyzed the effects of decompressive craniotomy on intracranial pressure levels and outcome. In addition, we compared the results of decompressive craniotomy performed with our original technique (modified “in-window” technique, with no need for cranioplasty) with results of classic techniques. We formed two groups: 52 patients with TBI (GCS≤8), with monitored intracranial pressure, and the control: 45 patients without intracranial pressure monitoring. In the first group, malignant intracranial hypertension was treated by decompressive craniotomy, using a modified "in-window" technique. Results were analyzed using standard statistical methods. In the first group, with intracranial pressure monitoring, 17/52 had decompressive craniotomy, and significant reduction of intracranial pressure appeared in the early postoperative period (38.82 to 22.76 mmHg, mean), with significant decrease of intracranial pressure at the end of treatment, compared to the control group (mean=25.00, and 45.30 mmHg, respectively). Late complications were similar to results of other studies. Our results were 20% of epileptic seizures, 8% of hydrocephalus, 12% contusion/hematoma progression and 12% subdural hygroma. Outcome (measured with Glasgow Outcome Score-GOS) in the first group, at the time of discharge, was better with decompressive craniotomy than without decompressive craniotomy (GOS=2.47, and GOS=1.00, respectively). Modified "in-window" technique for decompressive craniotomy in severe traumatic brain injury is safe, promising and according to our experience offers a lower rate of complications with no need for additional cranioplastic surgery