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Table 16.59 Miscellaneous Outcomes – Decompressive Craniectomy for Acute Management Post ABI

by | Dec 13, 2018

Table 16.59 Miscellaneous Outcomes – Decompressive Craniectomy for Acute Management Post ABI

 
Author/Year/ Country/ Study Design/N Methods Outcomes
Khan et al. (2016) Pakistan RCT PEDro=4 N=59 Population: ABI; Gender: Male=53, Female=6; GCS:3-5=23, 6-8=28, 9-11=8. Intervention: Expansile Duraplasty and dural-slits were compared for patients who underwent decompressive craniectomy for acute subdural haematoma. Outcome Measure: Glasgow Outcome Scale (GOS), mortality.
  1. Neither mortality nor postoperative GOS scores differed significantly between groups
  2. Surgery duration was significantly shorter for the Expansile Duraplasty group (p=0.000).
Moein et al. (2012) RCT PEDro=6 N=20 Population: ABI; Treatment Group (TG, n=10): Mean Age=34.6 yr; Mean GCS=5.6. Control Group (CG, n=10): Mean Age=31.8 yr; Mean GCS=5.6. Intervention: Participants were randomized to receive decompressive craniectomy with standard treatment (TG) or standard treatment alone (CG). Outcomes were assessed at 6mo. Outcome Measure: Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS).
  1. GCS improved after treatment in the TG when compared to the CG, but the difference was not significant (p=0.087).
  2. Favourable outcome (GOS=4-5) was found in 60% of the TG and 20% of the CG, but the difference was not significant (p=0.85).
  3. Mortality (GOS=1) was found in 10% of the TG and 30% of the CG, but the difference was not significant (p=0.28).
  1. Age group was not significantly correlated with GOS (p=0.57).
Jehan et al. (2017) USA Case Control N=99 Population: TBI; DC (n=33): Mean Age=47.9 yr; Gender: Male=23, Female=10; Mean Time Post Injury=3.8 hr; Median GCS=9. CO (n=66): Mean Age=49.2 yr; Gender: Male=46, Female=20; Mean Time Post Injury=3.5 hr; Median GCS=11. Intervention: Patients with TBI underwent decompressive craniectomy (DC) in conjunction with evacuation of intracranial hemorrhage (ICH) to control intracranial pressure (ICP). Controls were treated by craniotomy (CO) in conjunction with ICH evacuation. Outcome Measure: Mortality, Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), Complications, Length of Stay (LOS).
  1. There were no significant differences between groups for mortality, LOS, GOS or GCS.
  1. The DC group had significantly more returns to the OR (p=0.04), events of hydrocephalus requiring shunt (p=0.03) and median days on ventilator (p=0.02) than the CO group.
Shibahashi et al. (2017) Japan Case Series N=1391 Population: TBI; with Emergency Trepanation (n=305): Median Age=62 yr; Gender: Male=207, Female=98; Median GCS=4. without Emergency Trepanation (n=1086): Median Age=65 yr; Gender: Male=717, Female=369; Median GCS=6. Intervention: Patients with thick subdural hemorrhages who had undergone craniotomy were retrospectively identified. Those who underwent trepanation in an emergency room were compared with those who did not. Outcome Measure: Survival at Discharge
  1. Survival at discharge was significantly lower for those who underwent emergency trepanation (37.7%) compared with those who did not (59.3%), even after adjusting for possible cofounders (adjusted odds ratio=0.55; p<0.001).
Tapper et al. (2017) Australia Case Series N=822 Population: TBI; No operation (n=363): Median Age=57 yr; GCS:3-8=133, 9-12=83, 13-15=147. Craniotomy (n=401): Median Age=61 yr; GCS:3-8=183, 9-12=100, 13-15=118. Craniectomy (n=58): Median Age=45 yr; GCS:3-8=42, 9-12=13, 13-15=3. Intervention: Patients admitted to a neurosurgical ICU during 2009-2012 were divided into 3 groups (decompressive craniectomy, craniotomy, and conservative). Outcome Measure: Glasgow Outcome Scale (GOS), Mortality.
  1. Patients in the decompressive craniectomy group (60%) were more likely to have an unfavourable outcome when compared to the craniotomy (53%) and conservative group (41%) (p<0.001).
  2. Decompressive craniectomy was not associated with increased mortality at 6mo compared to conservatively treated patients. However, it was associated with increased 6mo mortality compared to patients in the craniotomy group (p=0.029).
Rush et al. (2016) USA & Canada Case Series N=1940 Population: TBI; Craniotomy (n=1763): Mean Age=68.9 yr; Gender: Male=1150, Female=613. Craniectomy (n=177): Mean Age=49.5 yr; Gender: Male=127, Female=50. Intervention: Patients data was gathered retrospectively to compare craniectomy and craniotomy for the management of acute subdural hemorrhage (ASDH). Outcome Measure: Mortality, Length of Hospital Stay (LOS).
  1. Compared to craniotomy (22%), craniectomy (32%) was associated with increased hospital mortality (p=0.044).
  2. LOS is significantly higher in craniectomy patients (14.3 days) compared to craniotomy (10.9 days) (p<0.0001).
Quintard et al. (2015) France Case Control N=25 Population: TBI; Treatment Group (TG, n=13): Mean Age=32 yr; Gender: Male=11, Female=2; Mean GCS=8. Control Group (CG, n=12): Mean Age=30 yr; Gender: Male=10, Female=2; Mean GCS=8. Intervention: Participants who received decompressive craniectomy (TG) were compared to those who received standard care (CG). Outcome Measure: Glasgow Outcome Scale (GOS).
  1. At baseline, the CG had significantly lower ICP than the TG.
  2. No significant differences were found between groups on GOS (p>0.05).
Gong et al. (2014) China Case Series N=72 Population: TBI; Mean Age=46 yr; Gender: Male=47, Female=25; Mean GCS=5. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Glasgow Outcome Scale (GOS), Mortality.
  1. Mortality at was 23% at 1 mo and 29% at 6mo.
  2. Favourable outcome (GOS=4-5) at 6 mo was seen in 39%.
  1. GOS was significantly associated with GCS on admission.
Nirula et al. (2014) USA Case Control N=420 Population: TBI; Mean Age=40yr; Gender: Male=330, Female=90; Mean GCS=7. Intervention: Participants received standard care (SC) and early decompressive craniectomy (DC, n=210) or SC alone (n=210). Outcome Measure: Mortality.
  1. There was no survival benefit SC+DC when compared to SC (RR=1.07, p=0.77).
Galal et al. (2013) Egypt Case Series N=37 Population: ABI; Age Range=14-65 yr; Gender: Male=30, Female=7; GCS<8. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Glasgow Outcome Scale (GOS).
  1. At discharge, 70% of participants had favourable outcomes (GOS=4-5).
  2. At discharge, 14% of participants had died (GOS=1).
Huang et al. (2013) China Case Series N=201 Population: TBI; Mean Age=45.78 yr; Gender: Male=144, Female=57; Mean GCS=6.95. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Mortality.
  1. Overall, mortality was 26.4% at 30 days.
  2. In univariate analysis, significant predictors of 30 days mortality included age (OR=1.020, p=0.014) and GCS (OR=0.5444, p<0.001).
  1. In multivariate analysis, significant predictors of 30 days mortality included age (OR=1.035, p=0.018) and GCS (OR=0.0769, p=0.041).
Limpastan et al. (2013) Thailand Case Series N=159 Population: TBI; Mean Age=37 yr; Gender: Male=130, Female=29; Mean GCS=6. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Glasgow Outcome Scale (GOS), Mortality.
  1. Mortality at discharge was 45%.
  2. Favourable outcome (GOS=4-5) was seen in 13% at discharge and 24% at 6mo.
  1. GOS was significantly associated with age and GCS.
Yuan et al. (2013) China Case Series N=164 Population: TBI; Mean Age=47.60 yr; Gender: Male=123, Female=41; GCS: 3-5=51, 6-8=52, 9-12=61. Intervention: Participants were included in retrospective analysis following decompressive craniectomy with (n=93) or without (n=71) mass evacuation. Outcome Measure: Glasgow Outcome Scale (GOS), Mortality.
  1. At 60 days, good outcome (GOS>4) was found in 42%, poor outcome in 36% (GOS=2-3), and death (GOS=1) in 22% of patients.
  2. Predictors of death at 60 days included age>50 yr (OR=2.36, p=0.047) and mass evacuation (OR=0.31, p=0.014).
  1. Predictor of good outcome at 60 days was GCS=9-12 (OR=2.43, p=0.002).
Agrawal et al. (2012) India Case Series N=273 Population: TBI; Mean Age=34 yr; Gender: Male=229, Female=44; Mean GCS=6. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Glasgow Outcome Scale (GOS), Mortality.
  1. In-hospital mortality rate (GOS=1) was 54%.
  2. At discharge, 22% of participants showed favourable outcome (GOS=4-5).
Li et al. (2012) UK Case-Control N=91 Population: ABI;Treatment Group 1 (TG1, n=36): Median Age=59 yr; Gender: Male=18, Female=18; Median GCS=9.5. Treatment Group 2 (TG2, n=49): Median Age=49 yr; Gender: Male=33, Female=16; Median GCS=5. Intervention: Participants were compared on treatment received for elevated intracranial pressure (ICP): craniotomy (TG1) versus decompressive craniectomy (TG2). Outcomes were assessed at 6 mo. Outcome Measure: Glasgow Outcome Scale (GOS), Mortality.
  1. Initially, TG2 were significantly older (p=0.015), more severely injured (p=0.001), and had a higher rate of extracranial injury (33% versus 3%, p=0.001) than TG1.
  2. At 6mo, there was no significant difference between TG1 and TG2 for mortality (32% versus 38%, p=0.65).
  3. At 6mo, there was no significant difference between TG1 and TG2 for poor outcome (GOS<4; 55% versus 58%, p=0.83).
Chen et al. (2011) Taiwan Case-Control N=102 Population: ABI; Treatment Group 1 (TG1, n=42): Mean Age=47.4 yr; Gender: Male=21, Female=21; Mean Time Post Injury=6.7 hr; Mean GCS=6.3. Treatment Group 2 (TG2, n=60): Mean Age=41.2 yr; Gender: Male=41, Female=19; Mean Time Post Injury=5.8 hr; Mean GCS=5.9. Intervention: Participants were compared based on treatment for ICP: craniotomy (TG1) or decompressive craniectomy (TG2). Outcomes were assessed at 1 yr. Outcome Measure: Glasgow Outcome Scale (GOS),Complications.
  1. Mortality (GOS=1) was significantly higher in TG2 than TG1 (23.3% versus 7.1%, p=0.04).
  2. There was no significant difference between groups in GOS scores (p=0.21), functional survival (GOS>4; p=0.78), non-functional survival (GOS=2-3; p=0.57), or poor outcome (GOS<4; p=0.78).
  3. There were no significant differences between groups in clinical features of injury (e.g. severity, timing, CT scan).
  4. There were no significant differences between groups in postoperative complications.
Chibbaro et al. (2011) France Post-Test N=147 Population: TBI; Median Age=39 yr; Gender: Male=111, Female=36; Median GCS=6. Intervention: Participants received decompressive craniectomy (DC) within 28 hr and cranioplasty within 12 wk. Outcomes were assessed at a mean follow-up of 26 mo. Outcome Measure: Glasgow Outcome Scale (GOS).
  1. Outcome was good (GOS>4) in 67% of participants and poor (GOS=2-3) in 19%; 14% died (GOS=1).
  2. Significant predictors of positive outcome were age <50 yr (p<0.0001) and DC <9 hr post injury (p<0.03).
Ho et al. (2011) Australia Post-Test N=104 Population: TBI; Mean Age=33yr; Gender: Male=86, Female=18; Mean GCS=7. Intervention: Participants who received decompressive craniectomy and had moderate to severe neurological disability at 6mo were recruited and analyzed. Outcomes were assessed at 6, 12, and 18 mo. Outcome Measure: Glasgow Outcome Scale (GOS).
  1. At 6mo, 43% had good outcomes (GOS>4) and 57% had poor outcomes (GOS<4).
  2. At 12mo, 54% had good outcomes, 43% had poor outcomes, and 1% died; 2% were lost to follow-up.
  3. At 18mo, 55% had good outcomes, 37% had poor outcomes, and 2% died; 8% were lost to follow-up.
  4. GCS score was a predictor of improvement from poor to good outcome over 6-18 mo (OR=1.44, p=0.18) and of good outcome at 18 mo (OR=1.47, p=0.001).
Wen et al. (2011) China Cohort N=44 Population: TBI; Treatment Group (TG1, n=25):  Mean Age=46.7 yr; Gender: Male=17, Female=8; Mean GCS=6.0. Treatment Group 2 (TG2, n=19): Mean Age=50.2 yr; Gender: Male=15, Female=4; Mean GCS=6.6. Intervention: Participants who received decompressive craniectomy (DC) were recruited and compared based on timing of DC: early (<24 hr, TG1) or late (>24 hr, TG2). Outcomes were assessed at 1mo and 6mo. Outcome Measures: Glasgow Outcome Scale (GOS), Mortality.
  1. There was no significant difference between TG1 and TG2 in good outcome (GOS>4) at 1mo (28% versus 37%, p=0.533) or 6mo (52% versus 63%, p=0.459).
  2. There was no significant difference between TG1 and TG2 in mortality at 1mo (16% versus 15.8%, p=0.985) or 6mo (20% versus 21%, p=0.932).
Otani et al. (2010) Japan Case Control N=80 Population: TBI; Mean Age=37.3 yr; Gender: Male=60, Female=20; Severity: Severe=40, Moderate=16, Mild=24. Intervention: Participants underwent either hematoma evacuation (HE) or HE with decompressive craniectomy (HE+DC). Outcome Measure: Glasgow Outcome Scale (GOS).
  1. Significant differences in patient characteristics were noted between groups.
  2. Favorable outcome on GOS was noted in 78.2% of patients in the HE group, while only in 55.8% of the HE+DC group.
Rubiano et al. (2009) Colombia Case Control N=36 Population: TBI; Mean Age=20yr; Gender: Male=21, Female=15; Mean GCS=4.5. Intervention: Participants received early frontotempoparietal decompressive craniectomy (DC, n=16) or standard care (SC, n=10). Outcome Measure: Glasgow Outcome Scale (GOS), Mortality.
  1. Mortality was significantly higher in the DC group than in the SC group (25% versus 65%, p<0.05).
  2. Mean GOS was significantly higher in the DC group than in the SC group (3.1 versus 1.6, p=0.0002).
Williams et al. (2009) USA Case Series N=171 Population: TBI; Median Age=35yr; Gender: Male=137, Female=34; Median GCS=8. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Glasgow Outcome Score Extended (GOSE), Mortality.
  1. Thirty-two percent of patients died in hospital.
  2. Of the survivors, 82% achieved good outcomes (GOSE=5-8 )
  3. Patients who experienced good outcomes were younger (26yr versus 43yr, p=0.0028), had higher pre-surgery GCS (7 versus 5, p<0.001), and experienced a greater reduction in ICP post surgery (23mmHg versus 10 mmHg, p<0.0001).
Flint et al. (2008) USA Pre-Post N=40 Population: TBI; Mean Age=43 yr; Gender: Male=30, Female=10; Median GCS=7.5. Intervention: Participants received decompressive craniectomy. Outcome Measure: Glasgow Outcome Score (GOS), Mortality, Contusions.
  1. New or expanded hemorrhagic contusions of ≥ 5cc were observed in 58% of participants.
  2. Mean volume of increase hemorrhage in these participants was 37.1 cc.
  3. Contusions expanded >20 cc post treatment were strongly associated with mortality and poor outcome on the GOS at 6 mo, even after controlling for age and GCS.
Huang et al. (2008) Taiwan Case Control N=54 Population: TBI; Mean Age=43.37 yr; Median Time Post Injury=48.65 min; Mean GCS=7.98. Intervention: Participants who received standard craniotomy (n=16) or decompressive craniectomy (DC, n=38) for hemorrhagic contusions were retrospectively analyzed. Outcome Measure: Glasgow Outcome Score-Extended (GOSE), Length of Stay (LOS), Reoperation Rate, Mortality.
  1. Reoperation rates (7.9% versus 37.5%, p<0.05) were significantly lower after DC than craniotomy.
  2. GOSE scores at 6 mo were significantly higher in DC than craniotomy (5.55 versus. 3.56, p<0.01)
  3. LOS and mortality were not significantly different between groups.
Li et al. (2008) China Case Control N=135 Population: TBI; Mean Age=46.3 yr; Gender: Male=91, Female=44; GCS≤8 Intervention: Participants received routine (10x15cm, n=128) or large (n=135) decompressive craniectomy (DC). Outcome Measure: Glasgow Outcome Score (GOS), Complications, Recurrent Surgery
  1. Satisfactory outcomes (GOS=3-5) were obtained from 71.1% of the large DC group, compared to 58.6% of routine DC group (p<0.05).
  2. Large DC was more effective in treating very severe TBI than routine DC (p<0.01).
  3. Large DC was associated with a lesser need for recurrent surgery and fewer complications than routine DC.
Meier et al. (2008) Germany Case Series N=131 Population: TBI; Mean Age=36 yr; Gender: Male=99, Female=32; Mean Time Post Injury=49 mo; GCS≤8. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Glasgow Outcome Scale (GOS).
  1. GOS was correlated with age and GCS.
Morgalla et al. (2008) Germany Case Series N=33 Population: TBI; Mean Age=36.3 yr; Gender: Male=20, Female=13; Mean Time Post Injury=3 yr. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Barthel Index (BI), Mortality.
  1. Twenty percent died and 20% remained in a vegetative state.
  2. Thirteen of the surviving patients made a full recovery (BI=90-100).
Chibbaro et al. (2008) USA Case Series N=80 Population: TBI; Mean Age=35 yr; Gender: Male=58, Female=22; Mean GCS=5. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Glasgow Outcome Score (GOS).
  1. Seventy-five percent of patients had a favourable outcome.
  2. Younger age and earlier operations were associated with better outcomes.
  3. Preoperative GCS had no effect on outcome.
Yang et al. (2008) China Case Series N=108 Population: TBI; Mean Age=44.3 yr; Gender: Male=74, Female=34; Severity: Severe=94, Moderate/Mild=14. Intervention: Participants who received decompressive craniectomy were retrospectively analyzed. Outcome Measure: Glasgow Outcome Score (GOS), Mortality, Complications.
  1. Twenty-five patients died within 1mo.
  2. Lower GCS was associated with poorer outcomes on GOS.
  3. Complications secondary to surgery occurred in 50%, 28% of whom developed >1 complication.
  4. Older patients and more severe injuries were associated with more complications.
PEDro=Physiotherapy Evidence Database rating scale score (Moseley et al., 2002).