Publication: Intracranial pressure changes in moderate to severe traumatic brain injury patients undergoing unilateral decompressive craniectomy with dural expansion
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Date
2021
Authors
Shahrom, Idris
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Abstract
Background: Decompressive craniectomy (DC) has been widely used to treat refractory increased intracranial pressure (ICP) in traumatic brain injury (TBI). The aim of this study is to assess the ICP changes induced by a unilateral frontotemporoparietal DC with dural expansion after moderate to severe TBI. The effect of different bone flap sizes on ICP and the neurological outcomes were also evaluated after the decompressive surgery. Methods: 52 TBI patients with clinical and radiological evidences of increased ICP were included in this prospective study. The patients were categorised into 3 groups according to the primary lesions causing the mass effects – subdural hematoma (SDH), cerebral contusion and cerebral swelling. All patients received unilateral frontotemporoparietal DC with dural expansion and ventriculostomy at contralateral Kocher’s point. Postoperatively, the patients were admitted to Intensive Care Unit (ICU) for ICP monitoring and medical therapy. ICP values were measured via ventricular catheter before DC, at each of decompressive steps during DC and in postoperative period. The largest antero-posterior (AP) diameter of bone flap removed was measured at the end of surgery and the clinical outcomes were assessed using Extended Glasgow Outcome Scale (GOS-E) at discharge and 6 months after DC. Results: The median ICP significantly decreased from 30.0 (26.0-33.8) mmHg to 19.0 (16.0-22.0) mmHg after craniectomy. After dural opening, the median ICP further decreased to 12.0 (9.3-14.0) mm Hg. Finally, the median ICP upon completion of skin closure was 13.0 (11.0-15.0) mmHg. This demonstrates that unilateral DC with dural expansion led to an average of 56.7% reduction from the initial opening ICP. Similar ICP changes were observed in all groups. This study also found that the large bone flap group (AP diameter >15cm) demonstrated better postoperative ICP control as compared to the small bone flap group (AP diameter 12 – 15cm), although not statistically significant. The SDH and cerebral swelling groups did better in the GOS-E at 6 months after TBI compared with cerebral contusion group. Conclusion: The ICP reduction in moderate to severe TBI patients undergoing unilateral frontotemporoparietal DC with dural expansion occurred in accordance with decompressive steps, regardless of intracranial lesions and the surgical procedure should be performed with the bone flap size of at least 12cm in AP diameter for adequate and sustained ICP control.
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Keywords
traumatic brain injury , intracranial pressure