Unilateral Decompressive Craniotomy for Management of Refractory Intracranial Hypertension following Traumatic Brain Injury: Surgical Technique and Clinical Outcome

Background: Post-traumatic intracranial hypertension due to brain swelling following Traumatic Brain Injury (TBI) remains presenting a challenge for neurosurgeons. The aim of treatment is usually directed towards maintaining the cerebral perfusion pressure as well as prevention of progressive intracranial hypertension which aggravates brain hypoxia. Objective: To estimate the efficacy of unilateral decompressive craniotomy as well as predicting factors of favorable clinical outcome. Patients and Methods: A prospective study included twenty five patients with unilateral brain edema and midline shift following TBI. All patients were clinically assessed using Glasgow coma scale (GCS) on admission and at time of surgery. Unilateral decompressive craniotomy was performed immediately for eight patients presenting with GCS ≤ 8, fifteen patients with GCS 8 were operated upon within 2-4 days of admission after having decline of their GCS despite aggressive cerebral dehydration. Postoperative clinical outcome during six months follow up interval was assessed using Glasgow outcome scale (GOS) in addition to serial brain imaging. Results: Good clinical outcome was achieved in fifteen patients (75%) at 6 months follow up interval, while stationary course was noted in four patients (20%) and poor outcome for one patient (5%). The overall survival rate was 80% (twenty patients) with five cases of mortality (20%). Complications were encountered in seven patients (28%). Conclusion: Decompressive craniotomy is quite beneficial and may be the only choice for management of refractory intracranial hypertension due to unilateral brain swelling after severe TBI. It should be performed immediately for cases with GCS ≤ 8, while cerebral dehydration must be tried for cases with GCS 8 saving surgical intervention for those showing no improvement or deterioration. Initial GCS more than 8 and younger age groups seem to be the most important predictors of favorable clinical outcome.