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Abstract
Traumatic brain injury (TBI) is the leading cause of death in people under age 45. Major causes of TBI include falls, vehicle accidents, and violence. In addition to the damage caused at the moment of injury, brain trauma causes secondary injury, which is a variety of events that take place in the brain in the minutes and days following the injury. Secondary injury processes include alterations in cerebral blood flow and the pressure within the skull. Substantially this will contribute to the damage from the initial injury.
In patients with head injury, raised intracranial pressure (ICP) secondary to cerebral edema is associated with poor outcome. Yet vigorous debate has continued regarding the optimal management of the problem.
Decompressive craniectomy is a prime example of this debate. The use of decompressive craniectomy in the treatment of severe head trauma was initially described by Cushing (4) and again in the modern era by Kjellberg and Prieto (5).
Decompressive craniectomy is a neurosurgical procedure in which part of the skull is removed to allow a room for the swelling brain to expand without being squeezed.
We carried this prospective cross sectional study on 21 patients presented after traumatic brain injury with disturbed conscious level. Patients admitted to neurosurgery department of Suez Canal university hospital from January 2009 till March 2010. Study group had preoperative GCS 5-10 with radiological evidence of increased ICP, midline shift 3mm or more and refractory ICP uncontrolled by medical treatment.
Medical history, physical examination and emergency investigations were carried in emergency department. In study population urgent ICP monitoring and ICP reducing measures were carried.
Patients with refractory ICP uncontrolled by medical treatment were subjected for urgent decompressive craniectomy, where wide fronto-tempro-parietal bone flap accounting 50-70% of lateral surface of the skull was removed and preserved in anterior abdominal wall. The dura was opened widely and augmented with dural graft. Follow up CT brain was done 1st day postoperatively and in cases of suspected complications. ICP was monitored pre and post operatively. Cranioplasty was done 2 months postoperatively or after stabilization of general condition. GOS was assessed 1, 3 and 6 months postoperatively.
GCS of study population ranged from 5-10, with ages ranged from 15- 57 years. Most of them presented after motor car accidents (81%).
The most common CT finding was brain contusion (100%) then subdural hematomas which were reported among 80.9% of the patients.
In our study ICP was significantly decreased postoperatively (16.38 mmHg) in comparison to preoperative values (39.05 mmHg).
The most common postoperative complication was expanded contusion that was reported in 8 patients (38.1%). Syndrome of Tephined was found in one patient. Other reported complications were superficial wound infection (19.1%), herniation from craniectomy defect (14.3%) and evolution of contralateral mass lesion (9.5%), other complications like CSF leak, epilepsy, meningitis, hydrocephalus and subdural effusion or hygroma were not reported in our study.