Page 38 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 2
Apart from the timing of decompressive surgery, another factor was the surgical technique, which varied, caused by the extent of diffuse swelling and presence of intracranial hematoma. The difference between DC with and without mass evacuation was investigated comparing 93 patients with mass lesions and 71 patients with diffuse injury and swelling.40 The first group showed lower mortality (14 vs. 32.4%) and appeared to be a significant predictor to 60-day mortality (OR=0.31). Only good outcome was significantly worse for vs-TBI patients.40 Performing large DC (10 cm x (13-15)cm) on patients resulted in overall satisfactory outcome (GOS 3-5) in 71.1% compared to 58.6% in the routine DC group (6-8 cm diameter) (P<0.05).35 Superiority was especially seen in vs-TBI patients (63.0% vs. 36.7%, P<0.01).35
A higher initial GCS Score, typically compared to GCS 3-5 (vs-TBI) subgroups, was correlated with more favorable outcome in almost all studies.15-17, 30-32, 34, 36-41 Patients with GCS 6-8 were more likely to have a good outcome than the GCS 3-5 group (OR 10.0, 95% CI 1.6-60.9).37 A GCS motor-score of 5-6 resulted more in good outcome than a motor-score of 1-4 (OR 4.2, 95% CI 1.1-16.3).37 Pupillary abnormalities were associated with mortality,36, 40 even up to 100% when bilaterally fixed and dilated 32 (except in one study).37 A younger age was associated with a favorable outcome,15-17, 30, 31, 34, 38-42 only two studies mentioned no statistical significance between age and prognosis.32, 37 Other factors like small size of bone flap,31, 35 association of intracranial lesions, midline shift> 15 mm, ICP>20 at time of DC,31 Revised Trauma Score <5, Charlson Comorbidity Index Scores >5, glucose >180 (mg.dL-1), PaO2 <160 (mmHg), SO2 <96 (%) were all linked to poor prognosis and unfavorable outcome.34
Outcome, hypothetically can be improved by two suggested changes in technique.29, 33, 42 A prospective study showed that DC combined with a new multi-dural stabs technique (SKIMS) in patients with ASDH and severe brain edema seems very effective in patients with low GCS.29 Patients with vs-TBI receiving DC with SKIMS showed a mortality of 36.7% and favorable outcome (GOS 4+5) in 30%, while 59% of the conventional group died and 19% achieved favorable outcome.29 Two small retrospective patient series described that creating vascular tunnels during decompressive surgery dropped mortality for GCS<5 patients with severe brain edema (ICP>30 mmHg for >3 hours) from 80% to ±40% and good outcome (GOS 4+5) improved from 10% to ±40%.33, 42 Series were compared with a historic control group receiving a large bilateral frontotemporoparietal craniectomy.
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