Outcome of Decompressive Craniectomy for Severe Traumatic Brain Injury Patients with persistently elevated Intracranial Pressure on Medical Treatment. (A Prospective Study Controlled by Intra-parenchymal Pressure Monitoring)

Back ground: Traumatic brain injury (TBI) can result in cerebral edema and vascular changes resulting in an increase in intracranial pressure (ICP), which can lead to further secondary damage.Monitoring of ICP is the standard of care for patients with TBI . Objectives: To evaluate outcome of decompressive craniotomy (DC) for management of severe traumatic brain injury (STBI) with persistently elevated intracranial pressure (ICP) on medical treatment and to determine feasibility, safety and accuracy of intraparenchymal ICP monitoring (IPM). Patients and Methods: Forty-one patients admitted to ICU with STBI underwent clinical evaluation. CT scanning was performed for lesions' description and grading with measurement of midline shift (MLS). IPM was inserted and initial ICP was recorded. Patients failed to respond to medical treatment underwent DC. Study outcome included frequency of postoperative (PO) complications and functional outcome judged by Extended Glasgow Outcome Scale (GOSE) 3, 6 and 12-m after hospital discharge. Results: Twenty-seven patients underwent early DC, while 14 patients had late DC. Unilateral craniectomy was performed in 38 patients and bifrontal craniectomy in 3 patients with diffuse cerebral edema and no MLS. During 48-hr PO, arterial pressure measures gradually increased, while ICP gradually decreased and CPP was progressively increased. Mean duration of ICP monitoring was 4±2.4 days, mean duration of ICU stay was 6.8±3.4 days and mean total hospital stay was 11.4±5 days. Five patients developed surgery-related PO complications and 12 patients died, but there was no surgery related mortality. At end of 12-m follow-up; 9 patients had good recovery, 9 patients had moderate disability and 3 had severe disability, while 3 patients were in vegetative state. Conclusion: Short-term trial of medical treatment judged by ICP monitoring of STBI patients allows early surgical decision making. Decompressive craniectomy for patients with persistently elevated ICP provided rapid control of ICP with subsequent improvement of CPP and little PO surgery-related morbidity and no mortality. DC provided acceptable functional outcome with good recovery rate of 37.5%. ICP monitoring using intraparenchymal  sensor provided satisfactory perioperative ICP monitoring.