Lotfy et al.: Decompressive craniotomy in traumatic brain injury Egypt J Neurol Psychiat Neurosurg. │April 2010 │ Vol 47 │ Issue 2 255 Decompressive Craniotomy after Traumatic Brain Injury: Post Operative Clinical Outcome Mohamed Lotfy, Ahmed El Said, Sameh Sakr Department of Neurosurgery, Cairo University; Egypt ABSTRACT Background: A decompressive craniotomy can relieve critically increased intracranial pressure. Objective: to assess the postoperative clinical outcome and compare it with other series. Methods: (a) patient selection: patients presented to the Neuroemergency unit in Kasr El-Eini Hospitals from January 2006 to December 2007 with traumatic brain injury and fulfilling the following criteria 1) clinical deterioration to Glasgow coma scale (GCS) 11 or presented to us with GCS (5-11) and refractory to conservative treatment of increased intracranial tension, 2) age ranging from 20 to 60 years, 3) radiological criteria: unilateral brain swelling with midline shift. (b) procedure: decompressive hinge craniotomy. (c) Evaluation of postoperative clinical outcome by the Glasgow outcome scale (GOS) at the time of hospital discharge and at 6-months thereafter, then comparing the clinical outcomes with those of in other researches. Results: The overall outcomes at 6- months follow up were good in 9 patients (45%), fair in 2 patients (10%), poor in 9 patients (45%).mortality in 6 cases (30%), vegetative state was seen in 3 cases (15%), overall survival was 70% with favorable outcome in 65% of the survivors. Conclusion: Age and initial posttraumatic GCS remain to be the most important factors in determining the postoperative clinical outcome. Decompressive hinge craniotomy provided favorable clinical results in nearly 45% of patients who were otherwise most likely to die. (Egypt J Neurol Psychiat Neurosurg. 2010; 47(2): 255-259) Key words: Decompressive hinge craniotomy, traumatic brain injury. INTRODUCTION Decompressive craniectomy is performed in the treatment of uncontrollable unilateral cerebral edema resulting from trauma and other conditions. 1-5 This procedure and its indications remain controversial 6-11 , yet much study data suggest the procedure is beneficial for some conditions, particularly head trauma 12-14 . Conservative treatment options for brain edema, which include hyperventilation, mannitol or hypertonic saline solution, and barbiturate coma, often cannot control rapidly increasing intracranial pressure (ICP) resulting from brain swelling after severe traumatic brain injury (TBI). Techniques of neuromonitoring certainly have improved the management of comatose patients. The clinical status of the patient can be monitored continuously, and the resulting therapy will be adjusted accordingly. However, faced with the constant increase in ICP despite aggressive medical treatment, a critical situation arises. The last option is left with the decompressive craniectomy. 15 One important drawback of this operation seems to be the unsatisfactory long- term outcome. new surgical modality for craniotomy appears to reduce the need for subsequent cranioplasty among patients undergoing surgical cerebral decompression. The efficacy of the hinge craniotomy Correspondence to Sameh A. Sakr. Department of Neurosurgery, Cairo University, Egypt. Tel.: +20101417185 Email: sameh_a_sakr@yahoo.com. technique in reducing the mortality rate remains undetermined due to the absence of comparable groups undergoing craniotomy/craniectomy techniques. 16 Therefore, we have examined the postoperative clinical outcome of decompressive hinge craniotomies after TBI associated with unilateral brain edema and midline shift. PATIENTS AND METHODS Patient Population In a two-year period from January 2006 to December 2007, twenty patients (14 males and 6 females) with TBI underwent decompressive hinge craniotomy to control raised ICP. The age ranged from 20 to 60 years (Table 1). On admission, the initial GCS score was assigned by the evaluating neurosurgeon present in the emergency department, Cairo University hospitals after resuscitation, to establish a diagnosis; a cranial CT scan was obtained. Unilateral brain edema, compression of the cortical gyri or basal cisterns, signs of incipient herniation, midline shift, were indicators of raised ICP. After completing the diagnostic procedures, the patients either underwent emergency surgery or were admitted to the ICU and the following protocol for treating raised ICP was used, The patient’s head was elevated up to 30º. Patients were ventilated artificially, and the PaCO2 was kept between 30 and 35 mm Hg. Extensive hyperventilation was avoided. Hyperosmotic Original Article