Elsevier

World Neurosurgery

Volume 105, September 2017, Pages 765-774
World Neurosurgery

Original Article
Neurologic Outcome After Decompressive Craniectomy: Predictors of Outcome in Different Pathologic Conditions

https://doi.org/10.1016/j.wneu.2017.06.069Get rights and content

Objective

Decompressive craniectomy (DC) has been proposed as a lifesaving treatment in patients with elevated intracranial pressure, but its effectiveness on reaching a favorable neurologic outcome remains unclear. We identified predictors of outcome in a large, single-center cohort of patients undergoing DC for different pathologic conditions.

Methods

This retrospective study included all patients undergoing DC from 2006 to 2014. The 1-year outcome, assessed using the Glasgow Outcome Scale (GOS), was dichotomized into favorable (GOS 4–5) and unfavorable (GOS 1–3) outcome. Predictors of outcome were identified by analyzing patient characteristics.

Results

DC was performed in 204 patients for ischemic stroke (n = 57), traumatic brain injury (n = 50), aneurysmal subarachnoid hemorrhage (aSAH) (n = 44), intracerebral hemorrhage (ICH) (n = 29), cerebral venous thrombosis (CVT) (n = 14), or other indications (n = 10). Overall, 69 (34%) patients survived favorably, 39 (19%) survived unfavorably, and 96 (47%) died. Higher age, poor Glasgow Coma Scale score, intubated status before DC, bilateral absence of pupillary light reflexes, DC for aSAH, and additional surgeries after DC (excluding cranioplasty) were significant predictors of unfavorable outcome. When patients were sorted for pathologic conditions and predictors of outcome, favorable outcome rates differed remarkably, ranging from 91% for CVT patients undergoing uncomplicated DC to 0% for aSAH patients undergoing DC for secondary infarction or ICH patients with unilateral or bilateral abnormal pupillary light reflexes upon admission.

Conclusions

Long-term neurologic outcome after DC differed remarkably among subpopulations of patients, with favorable outcome rates ranging from 0% to >90%.

Introduction

Decompressive craniectomy (DC) can be lifesaving in patients with space-occupying middle cerebral artery (MCA) infarction, traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage (aSAH), and cerebral venous thrombosis (CVT).1, 2, 3, 4 However, many survivors do not regain independence in activities of daily living. The value of DC in daily clinical practice therefore remains unclear.

To address this issue, we analyzed the long-term neurologic outcome in a cohort of consecutive patients undergoing DC, and we analyzed patient characteristics for predictors of outcome to identify subpopulations that benefit most from surgical intervention.

Section snippets

Patient Population

This retrospective case series was designed to include all patients with ischemic stroke, TBI, CVT, aSAH, intracerebral hemorrhage (ICH), brain infection, or brain tumor who underwent DC in our academic medical center between January 1, 2006, and January 1, 2014. Patients were selected from a retrospectively created operative database that included all patients undergoing DC in the same time frame. Because this was an observational study, formal approval was waived by the institutional ethical

Results

A total of 212 consecutive patients underwent DC. Six foreign patients (2 with aSAH, 2 with ICH, 1 with TBI, and 1 with ischemic stroke) were repatriated to their home countries in the weeks after DC and were lost to follow-up. In addition, 2 ischemic stroke patients were excluded from analysis because of the unavailability of long-term neurologic outcome information. Therefore, 204 patients were included in the analysis. Patient characteristics sorted by clinical outcome are presented in

Discussion

We retrospectively reviewed the long-term clinical outcome in patients undergoing DC by analyzing an 8-year, single-center, consecutive patient cohort. Overall, higher age, a poor GCS score in nonintubated patients, intubated status before DC, bilateral absence of pupillary light reflexes, DC for aSAH, and additional surgeries after DC (excluding cranioplasty) were significant predictors of unfavorable outcome. When groups were compared by pathologic condition, the percentage of favorable

Conclusion

The long-term neurologic outcome in patients undergoing DC differed remarkably when the patients were sorted for cause of injury and additional predictors of outcome, with favorable outcome rates ranging from 91% for CVT patients undergoing uncomplicated DC to 0% for aSAH patients undergoing DC for secondary infarction, or ICH patients with unilateral or bilateral abnormal pupillary light reflexes upon admission. Overall results from DC RCTs, showing one third of patients surviving favorably

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    • Cited by (0)

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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