What are the indications for craniotomy in patients with severe head injury from road traffic accidents (RTA)?

Indications for Craniotomy in Road Traffic Accidents (RTA)

In severe head injury from RTA, craniotomy is indicated for evacuation of mass lesions (extradural hematoma, acute subdural hematoma >5mm with >5mm midline shift, intracerebral hematoma with mass effect), drainage of acute hydrocephalus, and closure of open/displaced skull fractures with brain compression, while decompressive craniectomy should be considered for refractory intracranial hypertension after failure of medical management. 1

Primary Surgical Indications

The following are established neurosurgical indications at the early phase of severe traumatic brain injury:

• Removal of symptomatic extradural hematoma regardless of location 1, 2
• Removal of significant acute subdural hematoma with thickness >5mm and midline displacement >5mm 1, 2
• Drainage of acute hydrocephalus 1
• Closure of open displaced skull fracture 1
• Closed displaced skull fracture with brain compression (thickness >5mm, mass effect with midline displacement >5mm) 1
• Removal of brain contusions with mass effect after failure of first-line treatment of intracranial hypertension 1

Decompressive Craniectomy vs. Standard Craniotomy

When to Consider Decompressive Craniectomy

Decompressive craniectomy should be performed for refractory intracranial hypertension in the early phase of TBI (within first 72 hours) through multidisciplinary discussion. 1

Key considerations for decompressive craniectomy:

• Mortality benefit: Reduces mortality from 48.9% to 26.9% compared to medical management alone 1, 2
• Functional outcome trade-off: While mortality decreases, more patients have poor neurological outcomes (8.5% vs 2.1% with severe disability) 1
• Favorable outcomes: No significant difference in favorable outcomes at 6 months (26.6% medical vs 27.4% surgical) 1

Technical Specifications

• Large temporal craniectomy (>100 cm²) with enlarged dura mater plasty is the most commonly used technique 1, 2
• Bifrontal craniectomy is indicated for diffuse lesions but associated with worse outcomes (70% poor outcome vs 51% in controls) 1

Age Considerations

Age is a critical factor in surgical decision-making, with most studies excluding patients above 60-70 years 1, 2. The decision must be individualized based on:

• Age thresholds used in trials: 60 years (1 study), 65 years (2 studies), 70 years (1 study) 1
• Younger patients show better outcomes with earlier surgery 3

Timing of Intervention

Early surgical intervention is crucial for optimal outcomes:

• Early decompressive craniectomy (within 72 hours) before initiation of therapeutic hypothermia and barbiturates 1
• Early intervention before brainstem compression develops yields better outcomes 2
• Earlier surgery correlates with better outcomes (P < 0.05) 3

Intracranial Pressure Management Algorithm

First-Line Treatment

• Sedation and correction of secondary brain insults 1

Second-Line Treatment

• External ventricular drainage for persistent intracranial hypertension despite sedation 1
• CSF drainage can markedly reduce ICP even with small volume removal 1

Third-Line Treatment (Refractory ICP)

• Decompressive craniectomy when ICP remains elevated despite maximal medical therapy 1, 2
• ICP 20-40 mmHg: 3.95 times higher risk of mortality and poor outcome 1
• ICP >40 mmHg: 6.9 times higher mortality risk 1

Critical Pitfalls to Avoid

Contraindications to Decompressive Craniectomy

• Bilateral nonreactive, non-drug-induced pupillary dilation with coma 2
• Severe irreversible brainstem ischemia (clinical or radiological signs) 2
• Severe comorbidities: severe heart failure, incurable neoplasia 2

Important Caveats

• Bifrontal craniectomy should be avoided when possible due to association with poor outcomes 1
• Decompressive craniectomy has higher complication rates compared to craniotomy alone, including increased ventilator days 4
• No difference in mortality between decompressive craniectomy and craniotomy alone for acute ICH evacuation in propensity-matched analysis 4

Monitoring Requirements

ICP monitoring is suggested after severe TBI in the following cases: 1

• Signs of high ICP on brain CT scan (compression of basal cisterns, disappearance of cerebral ventricles, midline shift >5mm, intracerebral hematoma >25mL) 1
• Neurological evaluation not feasible 1
• Abnormal initial CT scan (>50% will present intracranial hypertension) 1

Outcome Expectations

For unilateral craniectomy:

• Good outcome (GOS 4-5 at 6 months): 40-57% vs 28-32% in controls (P = 0.03) 1
• Higher preoperative GCS score correlates with better outcome (P < 0.034) 3