Delayed neurological recovery after decompressive craniectomy for severe nonpenetrating traumatic brain injury

Objective: This study aimed to assess the incidence and factors associated with delayed neurologic recovery after decompressive craniectomy for severe nonpenetrating traumatic brain injury. Design: Retrospective cohort study. Setting: Two major neurotrauma centers in Western Australia. Patients: One hundred and four adult neurotrauma patients who had had a decompressive craniectomy and remained moderately disabled or worse at 6-month follow-up. Measurements and Main Results: Glasgow Outcome Scale scores at 6, 12, and 18 months were used to assess the neurologic recovery of the patients, and logistic regression was used to identify the factors associated with delayed neurologic recovery between 6 and 18 months after surgery. Among a total of 176 patients who required decompressive craniectomy between 2004 and 2010, 104 (59%) had moderate to severe disability 6 months after surgery. Fifty of these patients (48%, 95% confidence interval: 39-58) had >= 1 grade of improvement in Glasgow Outcome Scale score between 6 and 18 months after surgery. Of the 59 patients who had an unfavorable outcome (severe disability or vegetative state) 6 months after surgery, 15 patients (25%, 95% confidence interval: 16-38) improved and had attained a favorable outcome (moderate disability or near normal neurologic function) by the 18-month follow-up. An absence of nonevacuated intracerebral hematoma (> 1 cm in diameter) (odds ratio 6.67, 95% confidence interval: 1.12-33.3; p = .038) and a higher admission Glasgow Coma Scale (odds ratio per point increment 1.44, 95% confidence interval: 1.07-1.96; p = .018) were the only two factors significantly associated with a higher chance of delayed neurologic improvement from unfavorable to favorable neurologic outcome between 6 and 18 months after surgery. Conclusions: Delayed neurologic recovery after decompressive craniectomy for severe nonpenetrating traumatic brain injury was very common; absence of nonevacuated intracerebral hematoma and a high admission Glasgow Coma Scale were associated with a higher chance of delayed neurologic recovery after decompressive craniectomy. (Crit Care Med 2011; 39: 2495-2500)