Evaluation of prognostic factors of decompressive craniectomy in the treatment of severe traumatic brain injury

OBJECTIVE: to determine predictive factors for prognosis of decompressive craniectomy in patients with severe traumatic brain injury (TBI), describing epidemiological findings and the major complications of this procedure.METHODS: we conducted a retrospective study based on analysis of clinical and neurological outcome, using the extended Glasgow outcome in 56 consecutive patients diagnosed with severe TBI scale treated in the emergency department from February 2004 to July 2012. The variables assessed were age, mechanism of injury, presence of pupillary changes, Glasgow coma scale (GCS) score on admission, CT scan findings (volume, type and association of intracranial lesions, deviation from the midline structures and classification in the scale of Marshall and Rotterdam).RESULTS: we observed that 96.4% of patients underwent unilateral decompressive craniectomy (DC) with expansion duraplasty, and the remainder to bilateral DC, 53.6% of cases being on the right 42.9% on the left, and 3.6% bilaterally, with predominance of the fourth decade of life and males (83.9%). Complications were described as transcalvarial herniation (17.9%), increased volume of brain contusions (16.1%) higroma (16.1%), hydrocephalus (10.7%), swelling of the contralateral lesions (5.3%) and CSF leak (3.6%).CONCLUSION: among the factors studied, only the presence of mydriasis with absence of pupillary reflex, scoring 4 and 5 in the Glasgow Coma Scale, association of intracranial lesions and diversion of midline structures (DML) exceeding 15mm correlated statistically as predictors of poor prognosis.研究目的：明确重型创伤性脑损伤（severe traumatic brain injury, TBI）患者接受去骨瓣减压术（decompressive craniectomy, DC）后的预后预测因素，并阐明该手术的流行病学特征与主要并发症。 研究方法：本研究为回顾性研究，纳入2004年2月至2012年7月于急诊就诊的56例连续收治的重型TBI患者，所有患者均接受去骨瓣减压术治疗；以扩展版格拉斯哥预后量表（extended Glasgow outcome scale）评估患者的临床与神经功能转归，并对相关变量进行分析。本次评估的变量包括：年龄、损伤机制、瞳孔改变情况、入院时格拉斯哥昏迷量表（Glasgow coma scale, GCS）评分、CT影像学表现（颅内病变的体积、类型与合并情况、中线结构移位程度，以及马歇尔（Marshall）评分与鹿特丹（Rotterdam）评分分级）。 研究结果：本研究中96.4%的患者接受单侧去骨瓣减压联合硬脑膜扩大修补术，剩余患者接受双侧去骨瓣减压术；其中53.6%的手术为右侧去骨瓣，42.9%为左侧，3.6%为双侧。患者以40岁年龄段男性居多，占比达83.9%。本次记录的并发症包括：骨窗疝（17.9%）、脑挫伤体积增大（16.1%）、硬膜下积液（16.1%）、脑积水（10.7%）、对侧病变肿胀（5.3%）以及脑脊液（cerebrospinal fluid, CSF）漏（3.6%）。 研究结论：在本次研究评估的各项因素中，仅存在瞳孔散大且对光反射消失、格拉斯哥昏迷量表评分4~5分、合并颅内病变以及中线结构移位（DML）超过15mm这几项指标，与不良预后具有统计学意义上的相关性，可作为该手术预后不良的预测因素。