Moron General Hospital

Ciego de Avila

Cuba

Department of Neurological Surgery

Early decompressive craniectomy in severe

head injury with intracranial hypertension

Angel J. Lacerda MD PhD, Daisy Abreu MD, Julio A. Diaz MD.

Introduction:

Severe traumatic brain injury (TBI) is one of the

major causes of death in younger age groups in the

world.

The incidence of head trauma in United State

of America is 1.4 million / year, 235 000 are admitted

and 50 000 die from head injury.

In Cuba traffic accidents are the fourth cause

of death in adults and, the commonest cause in

those under the 45 years old . Fifty percent of those

suffering from traffic accident sustain a head injury.

The control of elevated intracranial pressure (ICP),

is fundamental to the management of patients with

severe head injury. Approximately 40% of patients

suffering traumatic loss of consciousness will

develop intracranial hypertension during the course

of their treatment. Brain edema, increased ICP and

reduced cerebral blood flow, are the main

prognostic factors despite progress in the diagnosis

and treatment of severe post-traumatic brain injury.

There is today enough evidence that the

implementation of protocols to standardize therapy

in patients with post-traumatic intracranial

hypertension have, resulted in an improvement in

neurological outcome. The steps of protocol driven

include, medical measures such as maintaining

blood pressure and oxygenation, prophylactic

hypothermia, using anaesthetics, analgesics and

sedatives, drainage of cerebrospinal fluid (CSF) by

ventriculostomy, mild hyperventilation,

administering mannitol, hypertonic saline and

barbiturates.

Decompressive craniectomy (DC), is considered to

be one of the “second tier therapies” in post-

traumatic medically refractory intracranial

hypertension. It is a kind of the urgent neurosurgical

“cerebral rescue” procedures, to increase the

volume of the cranial cavity and decrease the

secondary damage in patients with severe traumatic

brain injury.

The literature published to date does not reveal a

definitive evidence regarding the effectiveness and

indications of DC. In this article we present our

analysis of the clinical data from a non-randomized

control trial using early decompressive craniectomy

in patients with severe head injuries with intracranial

hypertension.

Moron General Hospital

The aims of this investigation were to know the

effectiveness of early decompressive craniectomy in

patients with severe head injury associated with

refractory intracranial hypertension using this

procedure as the initial second tier surgical therapy;

also to describe CT findings and the effects over

ICP, CPP, compliance, hemodynamic and other

intracranial parameters in this kind of patients.

This study was carried out to examine with

particular attention the relation between early

decompressive craniectomy to long-term functional

outcome.

Objectives:

Methods:

We have conducted a non-randomized

controlled trial, in 68 patients admitted at intensive

care unit of Moron General Hospital in Ciego de

Avila, Cuba, with severe head injury (Glasgow coma

scale (GCS) < 8) , in the period between January

2003 and December 2007.

Initial computarized tomography (CT) scans

were obtained from all patients on admission; they

were classified according to Marshall´s system.

Sequentials CT scan were indicated to assess

neurological deterioration in the ICU patients or

every 72 hours.

According to initial CT scan results, the time span

between admission and starting intracranial

hypertension and the treatment modality, the

patients were distributed in two groups.

Group I (Early DC): Included patients with diffuse

injury IV (midline shift > 5 mm, not high or mixed

density lesion > 25 cc) or non-evacuated mass

lesion (high or mixed density lesion > 25 cc not

surgically evacuated). DC was performed in the first

12 hours post-trauma in patients with clinical,

radiological and by continuous ICP monitoring

evidence of refractory intracranial hypertension

(ICP> 25 mmHg) as the first second tier therapy. DC

was performed without ICP monitoring only in

patients who require urgent surgery.

Group II (Conventional treatment): Included patients

with diffuse injury I - III, whom were admitted in

intensive care unit to continuous ICP monitoring and

medical treatment, showing clinical deterioration,

worsening of GCS score and/or dilation of pupils

unresponsive to light, with intracranial hypertension

to more than 25 mmHg and or reduction of cerebral

perfusion pressure to less than 55 mmHg longer

than 12 hours after head trauma. If sequential CT

scan showed worsening of images with appearance

of diffuse injury IV or high/mixed density lesions >

25 cc and refractory intracranial hypertension

appeared, surgical treatment was needed at this

moment and it was considered as delayed DC.

Patients with CT scan imaging demonstration of

severe brainstem injury, with initial GCS of 3,

without improvement and bilateral dilated and fixed

pupils were excluded.

Moron´s train station

Surgical Technique:

The surgical procedure included a large unilateral or

bilateral curvilinear incision in the fronto-temporal-

parietal (F-T-P) area or a large bifrontal skin incision.

After preparation of a myocutaneous flap, a

craniectomy with a free F-T-P bone flap is performed

(>12 cms), with expansive duroplasty starting at the

temporal base. In bilateral frontal-temporal-parietal

DC, only a rim of bone remains on the sagittal suture

to avoid ligating the sagittal sinus.

The extension of bifrontal DC with expansive

duroplasty was from the floor of the anterior cranial

base to the coronal suture posteriorly, and to the

pterion laterally. A bridge of bone in the midline can

be left over the superior sagittal sinus. We advocate

to avoid the frontal air sinus an sagittal sinus. In

both procedures the dura is enlarged with temporal

fascia followed by watertight closure and the bone

flap was preserved in anterior abdominal wall.

Bifrontal decompressive craniectomy with

bone flap prepared to keep out in anterior

abdominal wall.

Hydrocephalus after decompressive craniectomy. VP CSF

shunt

Petient with 58 years old, He was received in the emergency

room 1 hour after head trauma, 7 points in GCS, initial CT

scan is showed below. He was taken to operating room and

ICP was monitored by external ventriculostomy showing

values over 25 mmHg after manitol bolus administration. A

bifrontal decompressive craniectomy was performed.

Initial CT Scan

Intraoperative images

A 30 year old patient operated on with intracranial hypertension after

initial unenough decompressive FTP hemicraniectomy

ICP monitoring:

The ICP monitoring was performed by external strain

gauge pressure transduction technology. External

strain gauge transducer was coupled to the patient´s

lateral ventriculostomy, where the catheter tip

transducer was placed, via fluid-filled lines. The

external transducer was maintained fixed at the

ventricular level to avoid measurement error. The

duration of ICP monitoring was 5 days on average

and all patients received prophylactic antibiotics.

Standardized protocol for medical therapy:

Medical management of intracranial hypertension

included the following measures: elevation of the

head 20º, hemodynamic stabilization, sedation with

analgesics and sedative, CSF drainage, intravenous

administration of manitol in intermittent boluses

(0,25g / kg / dosis / 4 hours), controlled mild

hyperventilation (PaCO2: 30-35 mmHg) and muscle

relaxation if indicated. Barbiturate medication was

not used.

Data collection:

The following patient data were prospectively

collected: date of the accident, mechanism of injury,

age of the patient, neurological status at admission

(GCS score), pupillary response, initial and

sequential CT scan results, data of medical ICP

therapy, surgical procedures and complications.

Outcome was scored using the Glasgow Outcome

Scale (GOS). A GOS score of good recovery (grade

5) and with moderate disability (grade 4) was

considered to be a satisfactory outcome. A GOS

score with severe disability (grade III), vegetative

state (grade II) or dead (grade I), was considered to

be unsatisfactory outcome.

Statistical analysis:

A data base was created using SPSS system,

version 11.5. The Chi-Square test was used to

tabulates the variables into categories and

compares the observed and expected frequencies in

each category. p-value of less than 0.05 was deemed

significant.

The bivariate Pearson’s correlation coefficient, was

used to measure how variables were related in

linear association with GOS.

10

15

14

6

8

6

4

5

0 2 4 6 8 10 12 14 16

15-30

31-46

47-60

>60

15-30

31-46

47-60

>60

Gro

up

IG

ro

up

II

Age distribution

22,22%

33,33%

31,11%

13,33%

34,78%

26,07%

17,39%

21,74%

20

23

2

12

8

3

0 5 10 15 20 25

0-3h

4-6h

7-12hs

0-3h

4-6h

7-12hs

Gro

up

IG

ro

up

II

Mean time of patients arrival to Emergency Room

after head trauma

44,44%

51,11%

4,44%

52,17%

34,78%

13,04%

Initial Glasgow Coma Scale.

12

21

12

10

10

3

0 5 10 15 20 25

8 points

7-6 points

5-4 points

8 points

7-6 points

5-4 points

Gro

up

IG

ro

up

II

26,67%

46,67%

26,67%

43,48%

43,48%

13,04%

11

13

3

3

2

1

8

9

7

8

3

0 2 4 6 8 10 12 14

8 points

7-6 points

5-4 points

8 points

7-6 points

5-4 points

Gro

up

IG

ro

up

II

Unsatisfactory

Satisfactory

Relation between initial GCS and Outcome.

91,67%

8,33%

61,90%

38,10%

25%

75%

30%

70%

20%

80%

100%

5

11

29

4

3

16

0 5 10 15 20 25 30 35

Diffuse injury III

Diffuse injury IV

Non evacuated mass lesion

Diffuse injury III

Diffuse injury IV

Non evacuated mass lesion

Gro

up

IG

ro

up

II

11,11%

24,44%

64,44%

17,39%

13,04%

69,57%

Initial CT classification of severe head injury.

5

32

8

7

16

0 5 10 15 20 25 30 35

1-5 mm

6-10 mm

> 10 mm

1-5 mm

6-10 mm

Gro

up

IG

ro

up

II

11,11%

71,11%

17,78%

30,43%

69,57%

Presence of midline shift deviation on initial CT

scan.

4

8

7

10

1

3

6

0 2 4 6 8 10 12

1-5 mm

6-10 mm

1-5 mm

6-10 mm

Gro

up

IG

ro

up

II

> 25 mmHg

20-25 mmHg

Relation between midline shift deviation and ICP

(in patients monitoring before operation).

80%

20%

72,73%

27,27%

100%

62,5%

37,5%

27

9

9

5

13

5

0 5 10 15 20 25 30

Better

Non modified

Worst

Better

Non modified

Worst

Gro

up

IG

ro

up

II

Sequential CT scan.

60%

20%

20%

21,74%

56,52%

21,74%

Initial CT

scan

Sequential CT scan

Group I Group II

Better Non modified Worst Better Non modified Worst

Diffuse

injury III

4

(8,89%)

1

(2,22%)

- 1

(4,35%)

3

(13,04%)

-

Diffuse

iinjury IV

9 *

(20%)

1

(2,22%)

1

(2,22%)

1

(4,35%)

2

(8,70%)

-

Non

evacuated

mass

lession

14

(31,11%)

7

(15,56%)

8

(17,78%)

3

(13,04%)

8

(34,78%)

5

(21,74%)

Total 27 *

(60%)

9

(20%)

9

(20%)

5

(21,74%)

13

(56,52%)

5

(21,74%)

Relation between initial CT scan and sequential CT scan.

20

3

4

4

3

7

6

5

1

10

5

0 5 10 15 20 25

Better

Non modified

Worst

Better

Non modified

Worst

Gro

up

IG

ro

up

II

Unsatisfactory

Satisfactory

74,07%25,93%

33,33%

66,67%

44,44%

55,56%

80%

20%

23,06%

76,92%

100%

Relation between sequential CT scan and Outcome.

23

15

7

7

10

6

0 5 10 15 20 25

<20mmHg

20-25mmHg

>25mmHg

<20mmHg

20-25mmHg

>25mmHg

Gro

up

IG

ro

up

II

51,11%

33,33%

15,56%

30,43%

43,48%

26,09%

ICP at first 24 hours of treatment.

33

6

6

12

6

5

0 5 10 15 20 25 30 35

<20mmHg

20-25mmHg

>25mmHg

<20mmHg

20-25mmHg

>25mmHg

Gro

up

IG

ro

up

II

ICP between 2nd-5th days of treatment.

73,34%

13,33%

13,33%

52,17%

26,09%

21,74%

25

2

5

2

8

4

6

4

6

6

0 5 10 15 20 25 30

<20mmHg

20-25mmHg

>25mmHg

<20mmHg

20-25mmHg

>25mmHg

Gro

up

IG

ro

up

II

Unsatisfactory

Satisfactory

75,76%

24,24%

33,33%

66,67%

100%

100%

55,56%

45,44%

25%

75%

Relation between mean ICP and Outcome.

20

5

3

6

2

5

0 5 10 15 20 25

>20 ml

20-15 ml

<15 ml

>20 ml

20-15 ml

<15 ml

Gro

up

IG

ro

up

II

Compliance behavior.

71,43%

17,86%

10,71%

43,15%

38,46%

15,38%

N=28

N=13

18

3

2

2

5

3

3

2

3

0 5 10 15 20

>20 ml

20-15 ml

<15 ml

>20 ml

20-15 ml

<15 ml

Gro

up

IG

ro

up

II

Unsatisfactory

Satisfactory

90%

10%

100%

100%

50%

50%

100%

40%

60%

Relation between compliance behavior and

outcome.

4

1

2

6

32

2

5

2

4

10

0 5 10 15 20 25 30 35

CSF drainage

CSF drainage and manitol

CSF drainage,manitol and muscle relaxant

Mild hyperventilation

Non treatment

CSF drainage

CSF drainage and manitol

CSF drainage,manitol and muscle relaxant

Mild hyperventilation

Delayed decompressive craniectomy

Gro

up

IG

ro

up

II

Treatment for intracranial hypertension.

8.89%

2.22%

4.44%

13.33%

71.11%

8.70%

21.74%

8.70%

17.39%

43.48%

8

34

3

15

8

0 5 10 15 20 25 30 35 40

< 60 mmHg

60-70 mmHg

> 70 mmHg

< 60 mmHg

60-70 mmHg

Gro

up

IG

ro

up

II

17.78%

75.56%

6.67%

65.21%

34.79%

Cerebral Perfusion Pressure (CPP).

1

24

2

2

5

7

10

1

13

3

0 5 10 15 20 25 30

< 60 mmHg

60-70 mmHg

> 70 mmHg

< 60 mmHg

60-70 mmHg

Gro

up

IG

ro

up

II

Unsatisfactory

Satisfactory

Relation between CPP and Outcome.

12.5%

87.5%

70.59%

29.41%

66.67%

33.33%

13.33%

86.67%

62.5%

37.5%

Cerebral Hemodynamic.

8

3

34

12

1

10

0 5 10 15 20 25 30 35 40

Ischemic

Hyperhemic

Normohemic

Ischemic

Hyperhemic

Normohemic

Gro

up

IG

ro

up

II

17.78%

6.67%

75.56%

52.17%

4.34%

43.48%

4

2

21

7

4

1

13

12

1

3

0 5 10 15 20 25

Ischemic

Hyperhemic

Normohemic

Ischemic

Hyperhemic

Normohemic

Gro

up

IG

ro

up

II

Unsatisfactory

Satisfactory

50%

50%

66,67%

33,33%

61,76%

38,24%

100%

100%

70%

30%

Relation between Cerebral Hemodynamic and

Outcome.

12

5

6

5

2

38

30

14

15

16

20

5

0 5 10 15 20 25 30 35 40

Intracranial hypertension

Hydrocephalus

Skin flap infection

Non enough craniectomy

CSF fistulae

Pneumonia

Fluid, electrolyte and acid-basic disbalances

Systemic Hypotension

Neu

ro

su

rg

icals

Gen

erals

Group II

Group I

Complications.

88,44%

26,67%65,22%

86,96%

9

2

7

21

6

8

8

5

2

0 5 10 15 20 25

Dead

Persistent vegetative state

Severe disability

Moderate disability

Mild disability

Dead

Persistent vegetative state

Severe disability

Moderate disability

Mild disability

Gro

up

IG

ro

up

II

Glasgow Outcome Scale.

20%

4,44%

15,56%

46,67%

13,33%

34,78%

34,78%

21,74%

8,70%

27

7

18

16

0 5 10 15 20 25 30

Group I

Group II

Unsatisfactory

Satisfactory

General Outcome.

60%

40%

30,43%

69,57%

9

2

7

21

6

5

1

3

1

0 5 10 15 20 25

Dead

Persistent Vegetative State

Severe disability

Moderate disability

Mild disability

Delayed decompressive

craniectomy (Group II)

Early decompressive

craniectomy (Group I)

20%

50%

4,44%

15,56%

30%

46,67%

10%

10%

13,33%

Comparison between early and delayed

decompressive craniectomy.

Severe head injury mortality in Moron General

Hospital.

Conclusion:

1.Our results seem to support that decompressive

craniectomy may be an effective way to reduce

intractable raised intracranial pressure, and

probably to improve patients outcome.

2.A linear relationship exists between

characteristics of initial CT scan and ICP level

monitoring in the first 24 hours.

3.There was correlation between CPP values over 60

mmHg and good results.

4.A high number of patients with early DC (Group I)

didn´t need other medical therapy to control

intracranial pressure.

5. The majority of survivors after decompressive

craniectomy have a good functional outcome.

6. Complications related to surgical decompression

not affect the benefits of decompressive craniec

tomy.