Decompressive Craniectomy for Intracranial Pathologies in the Intensive Care Unit : Effects on Mortality and Clinical Course.

objectiveDecompressive craniectomy (DC) is a surgical procedure in which a portion of the skull overlying edematous and vulnerable brain tissue is removed to reduce intracranial pressure. In cases where all other treatment modalities fail, DC can be life-saving. However, this procedure is not a "panacea;" it can prolong the death process and condemn the patient to a life in need of care, with severe neurological sequelae.

methodsThis multicenter, retrospective study recorded patients' comorbidities, Glasgow coma scale (GCS), Acute physiology and chronic health evaluation II (APACHE II) and Sequential organ failure assessment (SOFA) scores, as well as relevant laboratory parameters. Patients were categorized into three groups according to the Glasgow outcome scale.

resultsAmong 201 patients, 41.3% expired, 33.8% survived with severe vegetative sequelae, and 24.9% had mild to moderate sequelae. Non-survivors had significantly lower preoperative and postoperative GCS scores (median 7 vs. 9, p=0.010; 3 vs. 10, p<0.001) and higher 24-hour peak glucose levels (186 vs. 164 mg/dL, p=0.009). Steroid therapy was ineffective. Preoperative GCS scores were significantly lower in patients who later developed severe sequelae compared to those with better outcomes (median 8 vs. 11, p<0.001). Postoperative GCS scores were also lower in this group (8 vs. 13, p<0.001).Additionally, APACHE II (22 vs. 18, p=0.002) and SOFA scores (4 vs. 3, p<0.001) were higher, indicating greater disease severity.

conclusionDC can be a lifesaving procedure in selected patients with appropriate indications and appropriate timing. However, the possibility of this procedure resulting in high mortality and severe sequelae cannot be ignored. Therefore, the clinical outcomes that the patient and their families would find acceptable should be carefully considered.