Decompressive craniectomy for severe traumatic brain injury: the relationship between surgical complications and the prediction of an unfavourable outcome.

OBJECT: To assess the impact that injury severity has on complications in patients who have had a decompressive craniectomy for severe traumatic brain injury (TBI). METHODS: This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia from 2004 to 2012. All complications were recorded during this period. The clinical and radiological data of the patients on initial presentation were entered into a web-based model prognostic model, the CRASH (Corticosteroid Randomization After Significant Head injury) collaborators prediction model, to obtain the predicted risk of an unfavourable outcome which was used as a measure of injury severity. RESULTS: Complications after decompressive craniectomy for severe TBI were common. The predicted risk of unfavourable outcome was strongly associated with the development of neurological complications such as herniation of the brain outside the skull bone defects (median predicted risk of unfavourable outcome for herniation 72% vs. 57% without herniation, p=0.001), subdural effusion (median predicted risk of unfavourable outcome 67% with an effusion vs. 57% for those without an effusion, p=0.03), hydrocephalus requiring ventriculo-peritoneal shunt (median predicted risk of unfavourable outcome 86% for those with hydrocephalus vs. 59% for those without hydrocephalus, p=0.001), but not infection (p=0.251) or resorption of bone flap (p=0.697) and seizures (0.987). We did not observe any associations between timing of cranioplasty and risk of infection or resorption of bone flap after cranioplasty. CONCLUSIONS: Mechanical complications after decompressive craniectomy including herniation of the brain outside the skull bone defects, subdural effusion, and hydrocephalus requiring ventriculo-peritoneal shunt were more common in patients with a more severe form of TBI when quantified by the CRASH predicted risk of unfavourable outcome. The CRASH predicted risk of unfavourable outcome represents a useful baseline characteristic of patients in observational and interventional trials involving patients with severe TBI requiring decompressive craniectomy.

Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases.

BACKGROUND: Decompressive craniectomy is an important method for managing refractory intracranial hypertension in patients with head injury. We reviewed a large series of patients who underwent this surgical procedure to establish the incidence and type of postoperative complications. METHODS: From 1998 to 2005, decompressive craniectomy was performed in 108 patients who suffered from a closed head injury. The incidence rates of complications secondary to decompressive craniectomy and risk factors for developing these complications were analysed. In addition, the relationship between outcome and clinical factors was analysed. FINDINGS: Twenty-five of the 108 patients died within the first month after surgical decompression. A lower GCS at admission seemed to be associated with a poorer outcome. Complications related to surgical decompression occurred in 54 of the 108 (50%) patients; of these, 28 (25.9%) patients developed more than one type of complication. Herniation through the cranial defect was the most frequent complication within 1 week and 1 month, and subdural effusion was another frequent complication during this period. After 1 month, the "syndrome of the trephined" and hydrocephalus were the most frequent complications. Older patients and/or those with more severe head trauma had a higher occurrence rate of complications. CONCLUSIONS: The potential benefits of decompressive craniectomy can be adversely affected by the occurrence of complications. Each complication secondary to surgical decompression had its own typical time window for occurrence. In addition, the severity of head injury was related to the development of a complication.

Bacterial meningitis in childhood in an African city. Factors influencing aetiology and outcome.

In a retrospective study of 120 children aged 1 month and above with bacterial meningitis confirmed by positive CSF culture, 88.4% were found to be due to three common organisms: H. influenzae, Str. pneumoniae and N. meinigitidis. Gram-negative enteric organisms accounted for 10% of the infections. Despite intensive antibiotic and ancillary therapy, there has been no significant change in case fatality and sequelae over the past decade in this institution. The present study confirms that factors related to the organism and the host are important in determining the outcome of therapy. H. influenzae and Str. pneumoniae infections are associated with statistically significant rise in case fatality rate and neurologic sequelae at the end of therapy. The presence of neurological abnormality at the time of diagnosis significantly increases case fatality rate while delay in diagnosis appears to primarily influence the frequency of neurological sequelae. Protein-energy malnutrition increases the frequency of neurological sequelae and death from bacterial meningitis without significantly influencing the pattern of bacterial aetiology. The finding of enteric Gram-negative meningitis in association with diarrhoeal disease in the present study adds a new dimension to one of the most prevalent health problems in developing countries and needs to be confirmed.