Decompressive craniectomy for severe traumatic brain injury: is life worth living?

Clinical article

Stephen Honeybul F.R.A.C.S.1, Courtney Janzen B.Kin.(Hons), M.O.T.2, Kate Kruger Dip.O.T.2, and Kwok M. Ho F.C.I.C.M., Ph.D.3
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  • 1 Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital;
  • | 2 Department of Occupational Therapy, Sir Charles Gairdner Hospital;
  • | 3 Department of Intensive Care Medicine, Royal Perth Hospital and School of Population Health, University of Western Australia, Perth, Western Australia, Australia
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Object

The object of this study was to assess the long-term outcome and quality of life of patients who have survived with severe disability following decompressive craniectomy for severe traumatic brain injury (TBI).

Methods

The authors assessed outcome beyond 3 years among a cohort of 39 patients who had been adjudged either severely disabled or in vegetative state 18 months after decompressive craniectomy for TBI. Assessments performed included the Extended Glasgow Outcome Scale, modified Barthel Index (mBI), Zarit Burden Interview, and 36-Item Short-Form Health Survey (SF-36). The issue of retrospective consent for surgery was also assessed.

Results

Of the 39 eligible patients, 7 died, 12 were lost to follow-up, and 20 patients or their next of kin consented to participate in the study. Among those 20 patients, 5 in a vegetative state at 18 months remained so beyond 3 years, and the other 15 patients remained severely disabled after a median follow-up of 5 years. The patients' average daily activity per the mBI (Pearson correlation coefficient [r] = −0.661, p = 0.01) and SF-36 physical score (r = −0.543, p = 0.037) were inversely correlated with the severity of TBI. However, the SF-36 mental scores of the patients were reasonably high (median 46, interquartile range 37–52). The majority of patients and their next of kin believed that they would have provided consent for surgical decompression even if they had known the eventual outcome.

Conclusions

Substantial physical recovery beyond 18 months after decompressive craniectomy for severe TBI was not observed; however, many patients appeared to have recalibrated their expectations regarding what they believed to be an acceptable quality of life.

Abbreviations used in this paper:

CRASH = Corticosteroid Randomisation After Significant Head Injury; GOS-E = Extended Glasgow Outcome Scale; ICP = intracranial pressure; IQR = interquartile range; mBI = modified Barthel Index; SF-36 = 36-Item Short-Form Health Survey; TBI = traumatic brain injury; ZBI = Zarit Burden Interview.

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  • 1

    Aarabi B, , Hesdorffer DC, , Ahn ES, , Aresco C, , Scalea TM, & Eisenberg HM: Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 104:469479, 2006

    • Search Google Scholar
    • Export Citation
  • 2

    Agrawal D, & Hussain N: Decompressive craniectomy in cerebral toxoplasmosis. Eur J Clin Microbiol Infect Dis 24:772773, 2005

  • 3

    Ahmed AI, , Eynon CA, , Kinton L, , Nicoll JA, & Belli A: Decompressive craniectomy for acute disseminated encephalomyelitis. Neurocrit Care 13:393395, 2010

    • Search Google Scholar
    • Export Citation
  • 4

    Baussart B, , Cheisson G, , Compain M, , Leblanc PE, , Tadie M, & Benhamou D, et al.: Multimodal cerebral monitoring and decompressive surgery for the treatment of severe bacterial meningitis with increased intracranial pressure. Acta Anaesthesiol Scand 50:762765, 2006

    • Search Google Scholar
    • Export Citation
  • 5

    Cooper DJ, , Rosenfeld JV, , Murray L, , Arabi YM, , Davies AR, & D'Urso P, et al.: Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:14931502, 2011. (Erratum in N Engl J Med 365: 2040, 2011)

    • Search Google Scholar
    • Export Citation
  • 6

    Cooper PR, , Rovit RL, & Ransohoff J: Hemicraniectomy in the treatment of acute subdural hematoma: a re-appraisal. Surg Neurol 5:2528, 1976

    • Search Google Scholar
    • Export Citation
  • 7

    Cremer OL, , Moons KG, , van Dijk GW, , van Balen P, & Kalkman CJ: Prognosis following severe head injury: Development and validation of a model for prediction of death, disability, and functional recovery. J Trauma 61:14841491, 2006

    • Search Google Scholar
    • Export Citation
  • 8

    Delashaw JB, , Broaddus WC, , Kassell NF, , Haley EC, , Pendleton GA, & Vollmer DG, et al.: Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke 21:874881, 1990

    • Search Google Scholar
    • Export Citation
  • 9

    De Luca GP, , Volpin L, , Fornezza U, , Cervellini P, , Zanusso M, & Casentini L, et al.: The role of decompressive craniectomy in the treatment of uncontrollable post-traumatic intracranial hypertension. Acta Neurochir Suppl 76:401404, 2000

    • Search Google Scholar
    • Export Citation
  • 10

    Di Rienzo A, , Iacoangeli M, , Rychlicki F, , Veccia S, & Scerrati M: Decompressive craniectomy for medically refractory intracranial hypertension due to meningoencephalitis: report of three patients. Acta Neurochir (Wien) 150:10571065, 2008

    • Search Google Scholar
    • Export Citation
  • 11

    Ferro JM, , Crassard I, , Coutinho JM, , Canhão P, , Barinagarrementeria F, & Cucchiara B, et al.: Decompressive surgery in cerebrovenous thrombosis: a multicenter registry and a systematic review of individual patient data. Stroke 42:28252831, 2011

    • Search Google Scholar
    • Export Citation
  • 12

    Fins JJ: Being conscious of their burden: severe brain injury and the two cultures challenge. Ann N Y Acad Sci 1157:131147, 2009

  • 13

    Foerch C, , Lang JM, , Krause J, , Raabe A, , Sitzer M, & Seifert V, et al.: Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Neurosurg 101:248254, 2004

    • Search Google Scholar
    • Export Citation
  • 14

    Giacino JT, , Ashwal S, , Childs N, , Cranford R, , Jennett B, & Katz DI, et al.: The minimally conscious state: definition and diagnostic criteria. Neurology 58:349353, 2002

    • Search Google Scholar
    • Export Citation
  • 15

    Gillett GR, , Honeybul S, , Ho KM, & Lind CR: Neurotrauma and the RUB: where tragedy meets ethics and science. J Med Ethics 36:727730, 2010

    • Search Google Scholar
    • Export Citation
  • 16

    Guerra WK, , Gaab MR, , Dietz H, , Mueller JU, , Piek J, & Fritsch MJ: Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 90:187196, 1999

    • Search Google Scholar
    • Export Citation
  • 17

    Güresir E, , Schuss P, , Vatter H, , Raabe A, , Seifert V, & Beck J: Decompressive craniectomy in subarachnoid hemorrhage. Neurosurg Focus 26:6 E4, 2009

    • Search Google Scholar
    • Export Citation
  • 18

    Ho KM, , Honeybul S, & Litton E: Delayed neurological recovery after decompressive craniectomy for severe nonpenetrating traumatic brain injury. Crit Care Med 39:24952500, 2011

    • Search Google Scholar
    • Export Citation
  • 19

    Holtkamp M, , Buchheim K, , Unterberg A, , Hoffmann O, , Schielke E, & Weber JR, et al.: Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry 70:226228, 2001

    • Search Google Scholar
    • Export Citation
  • 20

    Honeybul S, , Gillett G, , Ho K, & Lind C: Ethical considerations for performing decompressive craniectomy as a life-saving intervention for severe traumatic brain injury. J Med Ethics 38:657661, 2012

    • Search Google Scholar
    • Export Citation
  • 21

    Honeybul S, & Ho KM: Long-term complications of decompressive craniectomy for head injury. J Neurotrauma 28:929935, 2011

  • 22

    Honeybul S, , Ho KM, , Gillett GR, , Lind CRP, & O'Hanlon S: Futility and neurotrauma: can we make an objective assessment?. Med J Aust 196:531533, 2012

    • Search Google Scholar
    • Export Citation
  • 23

    Honeybul S, , Ho KM, , Lind CRP, , Corcoran T, & Gillett GR: The retrospective application of a prediction model to patients who have had a decompressive craniectomy for trauma. J Neurotrauma 26:21792183, 2009

    • Search Google Scholar
    • Export Citation
  • 24

    Honeybul S, , Ho KM, , Lind CRP, & Gillett GR: The future of decompressive craniectomy for diffuse traumatic brain injury. J Neurotrauma 28:21992200, 2011

    • Search Google Scholar
    • Export Citation
  • 25

    Honeybul S, , Ho KM, , Lind CRP, & Gillett GR: Observed versus predicted outcome for decompressive craniectomy: a population-based study. J Neurotrauma 27:12251232, 2010

    • Search Google Scholar
    • Export Citation
  • 26

    Honeybul S, , O'Hanlon S, & Ho KM: Decompressive craniectomy for severe head injury: does an outcome prediction model influence clinical decision-making?. J Neurotrauma 28:1319, 2011

    • Search Google Scholar
    • Export Citation
  • 27

    Hoofien D, , Gilboa A, , Vakil E, & Donovick PJ: Traumatic brain injury (TBI) 10–20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning. Brain Inj 15:189209, 2001

    • Search Google Scholar
    • Export Citation
  • 28

    Hutchinson PJ, , Corteen E, , Czosnyka M, , Mendelow AD, , Menon DK, & Mitchell P, et al.: Decompressive craniectomy in traumatic brain injury: the randomized multicenter RESCUEicp study (www.RESCUEicp.com). Acta Neurochir Suppl 96:1720, 2006

    • Search Google Scholar
    • Export Citation
  • 29

    Kiphuth IC, , Köhrmann M, , Lichy C, , Schwab S, & Huttner HB: Hemicraniectomy for malignant middle cerebral artery infarction: retrospective consent to decompressive surgery depends on functional long-term outcome. Neurocrit Care 13:380384, 2010

    • Search Google Scholar
    • Export Citation
  • 30

    Kobylarz EJ, & Schiff ND: Functional imaging of severely brain-injured patients: progress, challenges, and limitations. Arch Neurol 61:13571360, 2004

    • Search Google Scholar
    • Export Citation
  • 31

    Lanterna LA, , Gritti P, , Manara O, , Grimod G, , Bortolotti G, & Biroli F: Decompressive surgery in malignant dural sinus thrombosis: report of 3 cases and review of the literature. Neurosurg Focus 26:6 E5, 2009

    • Search Google Scholar
    • Export Citation
  • 32

    Leonhardt G, , Wilhelm H, , Doerfler A, , Ehrenfeld CE, , Schoch B, & Rauhut F, et al.: Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in MCA infarction. J Neurol 249:14331440, 2002

    • Search Google Scholar
    • Export Citation
  • 33

    Perel P, , Arango M, , Clayton T, , Edwards P, , Komolafe E, & Poccock S, et al.: Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336:425429, 2008

    • Search Google Scholar
    • Export Citation
  • 34

    Polin RS, , Shaffrey ME, , Bogaev CA, , Tisdale N, , Germanson T, & Bocchicchio B, et al.: Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 41:8494, 1997

    • Search Google Scholar
    • Export Citation
  • 35

    Puetz V, , Campos CR, , Eliasziw M, , Hill MD, & Demchuk AM: Assessing the benefits of hemicraniectomy: what is a favourable outcome?. Lancet Neurol 6:580581, 2007. (Letter)

    • Search Google Scholar
    • Export Citation
  • 36

    Rahme R, , Zuccarello M, , Kleindorfer D, , Adeoye OM, & Ringer AJ: Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? Clinical article. J Neurosurg 117:749754, 2012

    • Search Google Scholar
    • Export Citation
  • 37

    Sbordone RJ, , Liter JC, & Pettler-Jennings P: Recovery of function following severe traumatic brain injury: a retrospective 10-year follow-up. Brain Inj 9:285299, 1995

    • Search Google Scholar
    • Export Citation
  • 38

    Schiff ND, , Ribary U, , Moreno DR, , Beattie B, , Kronberg E, & Blasberg R, et al.: Residual cerebral activity and behavioural fragments can remain in the persistently vegetative brain. Brain 125:12101234, 2002

    • Search Google Scholar
    • Export Citation
  • 39

    Schiff ND, , Rodriguez-Moreno D, , Kamal A, , Kim KH, , Giacino JT, & Plum F, et al.: fMRI reveals large-scale network activation in minimally conscious patients. Neurology 64:514523, 2005

    • Search Google Scholar
    • Export Citation
  • 40

    Schneider GH, , Bardt T, , Lanksch WR, & Unterberg A: Decompressive craniectomy following traumatic brain injury: ICP, CPP and neurological outcome. Acta Neurochir Suppl 81:7779, 2002

    • Search Google Scholar
    • Export Citation
  • 41

    Schwab S, , Steiner T, , Aschoff A, , Schwarz S, , Steiner HH, & Jansen O, et al.: Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29:18881893, 1998

    • Search Google Scholar
    • Export Citation
  • 42

    Shah S, , Vanclay F, & Cooper B: Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol 42:703709, 1989

    • Search Google Scholar
    • Export Citation
  • 43

    Smith ER, , Carter BS, & Ogilvy CS: Proposed use of prophylactic decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas. Neurosurgery 51:117124, 2002

    • Search Google Scholar
    • Export Citation
  • 44

    Steyerberg EW, , Mushkudiani N, , Perel P, , Butcher I, , Lu J, & McHugh GS, et al.: Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 5:e165, 2008

    • Search Google Scholar
    • Export Citation
  • 45

    Thomsen IV: Late outcome of very severe blunt head trauma: a 10-15 year second follow-up. J Neurol Neurosurg Psychiatry 47:260268, 1984

    • Search Google Scholar
    • Export Citation
  • 46

    Timmons SD, , Ullman JS, & Eisenberg HM: Craniectomy in diffuse traumatic brain injury. N Engl J Med 365:373, 376, 2011. (Letter)

  • 47

    Vahedi K, , Hofmeijer J, , Juettler E, , Vicaut E, , George B, & Algra A, et al.: Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6:215222, 2007

    • Search Google Scholar
    • Export Citation
  • 48

    Voss HU, , Uluç AM, , Dyke JP, , Watts R, , Kobylarz EJ, & McCandliss BD, et al.: Possible axonal regrowth in late recovery from the minimally conscious state. J Clin Invest 116:20052011, 2006

    • Search Google Scholar
    • Export Citation
  • 49

    Ware JE, & Sherbourne CD: The MOS 36-Item Short-Form Health Survey (SF-36): I. Conceptual framework and item selection. Med Care 30:473483, 1992

    • Search Google Scholar
    • Export Citation
  • 50

    Wilson JTL, , Pettigrew LEL, & Teasdale GM: Structured interviews for the Glascow Outcome Scale and the Extended Glascow Outcome Scale: guidelines for their use. J Neurotrauma 15:573585, 1998

    • Search Google Scholar
    • Export Citation
  • 51

    Wood RL, & Rutterford NA: Psychosocial adjustment 17 years after severe brain injury. J Neurol Neurosurg Psychiatry 77:7173, 2006

  • 52

    Yang XF, , Wen L, , Shen F, , Li G, , Lou R, & Liu WG, et al.: Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 150:12411248, 2008

    • Search Google Scholar
    • Export Citation
  • 53

    Zarit SH, , Todd PA, & Zarit JM: Subjective burden of husbands and wives as caregivers: a longitudinal study. Gerontologist 26:260266, 1986

    • Search Google Scholar
    • Export Citation

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