Quality of Life After Hemicraniectomy for Traumatic Brain Injury in Adults

Shabbar F. Danish, M.D.; Dean Barone, P.a.-C.; Bradley C. Lega, M.D.; Sherman C. Stein, M.D.

Disclosures

Neurosurg Focus. 2009;36(6):E2 

In This Article

Abstract and Introduction

Abstract

Decompressive hemicraniectomy is well accepted for the surgical treatment of intractable intracranial hypertension in cases in which medical management fails. Although it is performed as a life-saving procedure when death is imminent from intracranial hypertension, little is known about the functional outcomes for these patients on long-term follow-up. In this study, the authors performed a systematic review of the literature to examine neurological outcome after hemicraniectomy. A literature search revealed 29 studies that reported outcomes using GOS scores. The GOS scores were transformed to utility values for quality of life using a conversion method based on decision analysis modeling. Based on the literature, 1422 cases were analyzed. The average 6-month-postoperative mortality rate was 28.2%. The mean QOL value among survivors was 0.592, which corresponds roughly to a GOS score of 4. Although more studies are needed for validation of long-term neurological outcome after hemicraniectomy, the assumption that most patients remain in a vegetative state after this intervention is clearly incorrect.

Introduction

HEAD injury is a major cause of morbidity and mortality worldwide. Trauma itself is the leading cause of death in the first 4 decades of life, with traumatic brain injury being implicated in at least half the cases.[13] One of the fundamental pathophysiological processes after traumatic brain injury is the development and propagation of an escalating cycle of brain swelling and an increase in ICP. The goals of the clinical management of severe head injury consist of interrupting this cycle by controlling ICP and maintaining cerebral perfusion pressure and cerebral blood flow to avoid brain ischemia. This management strategy has been developed as a result of reported strong correlations between uncontrollable high ICP and high rates of morbidity and mortality. The relationship between high ICP and poor outcome has been demonstrated consistently in both single-center and multicenter studies, and the ability to bring elevated ICP under control has long been considered a requirement for improving outcome of patients with severe head injuries.[8,17,20,23] In an effort to reduce ICP, hemicraniectomy has evolved as a surgical option that has recently seen a "re-birth." Logically, it seems that opening a tight skull would reduce ICP, improve blood flow, and reduce swelling, leading to reduced morbidity and mortality. This concept has yet to be proved, however, with respect to improvement in clinical outcome.[30]

Those who are skeptical of the procedure raise several questions. Does the craniectomy quantitatively control raised ICP? Does brain herniating through the defect escalate the problems? What prognostic information can we give the families of those for whom the procedure is being proposed? Do the results justify the treatment? The last question is the focus of this review. Because of the lack of prospective, randomized trials, debate exists over the clinical outcome expected for patients undergoing the procedure. Especially in centers where craniectomy has not gained acceptance, there is a notion that patients whose head injuries are severe enough to mandate hemicraniectomy persist with severe disability or in a vegetative state, rendering the procedure futile and wasteful. Furthermore, because most studies use GOS scores to report outcomes, results from different studies cannot be combined and simply averaged. Finally, we must ask if the growing experience with hemicraniectomy over the years has led to better outcomes.

The present work is a review of the literature with respect to outcomes following hemicraniectomy. By converting GOS scores to utility values for QOL, we provide an average outcome for patients undergoing hemicraniectomy that is derived from the literature and is statistically sound.

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