The use of decompressive craniectomy in patients with progressive and intractable traumatic brain swelling has been a subject of renewed interest, after having been practically abandoned several decades ago. Guerra and colleagues reported on 57 such patients, mostly young adults, who underwent wide frontotemporal craniectomy, unilateral in 31 and bilateral in 26. Of these, 58 percent attained surprisingly good states of rehabilitation. These authors were of the opinion that these results represented a significant improvement over the expected outcome in this particular group of patients. A similar open trial conducted by Aarabi and colleagues described 40 percent with good outcome. Similar results in children were reported by Polin and associates. The few cases with which we have been involved, mostly children operated late, have not been as encouraging.
However, these generally favorable results could not be validated in the randomized DECRA trial carried out by Cooper and colleagues, or in the trial reported by Cooper and coworkers. Decompression did indeed reduce ICP, as expected, when the intracranial contents are exposed to atmospheric pressure, but surgery did not improve outcome and in the latter trial, outcome was worse with decompression. Rounding out these trials is the one reported by Hutchinson and colleagues (2016) of patients with refractory intracranial hypertension that showed higher rates of survival but also higher rates of vegetative state with decompression. The details of the operations and choice of ICP level that were chosen to trigger operation have been criticized in each of these trials, but they remain the best information to date and broadly but paradoxically do not favor indiscriminate decompression to reduce ICP. A review of intracranial hypertension that appeared soon after the DECRA trial is provided by
Stochetti and Maas.
The treatment of the general medical diseases relating to protracted coma was outlined in Chap. 16. Each patient presents unique problems.
As has been intimated, the outcome in severe injury is particularly discouraging, more so with increasing age. Some aspects of prognosis were mentioned earlier but the following general comments serve to frame the problem. In the survey of the large European Brain Injury Consortium, comprising 10,005 adult patients, the injury proved fatal in 31 percent; 3 percent were left in a persistent vegetative state, and 16 percent remained severely disabled neurologically (Murray et al). Data from the extensively analyzed Traumatic Coma Data Bank are comparable, as reported by Marshall and coworkers (1983). The signs of focal brain disease, whether because of closed head injuries or open and penetrating ones, tend always to ameliorate as the months pass. A hemiplegia is often reduced to a minimal hemiparesis or to ineptitude of voluntary motor function with exaggerated reflexes and an equivocal Babinski sign on that side, and aphasia is gradually transformed into a stuttering or hesitant paraphasia or dysnomia that is not disabling. Many of the signs of brainstem disease (cranial nerve dysfunction and ataxia) improve also, usually within the first 6 months after injury (Jennett and Bond) and often to a surprising extent. Most patients who had been in coma for many hours or days—that is, those with severe brain injuries—are left with memory impairment and other cognitive defects and with personality changes. These may be the only lasting sequelae as detailed earlier. According to Jennett and Bond, these mental and personality changes are a greater handicap than focal neurologic ones as far as social adjustment is concerned. In open head wounds and penetrating brain injuries, Grafman and coworkers found that the magnitude of tissue loss and location of the lesion were the main factors affecting the outcome.
The prognosis of head injury is influenced by several other factors as mentioned. The age of the patient is the most important factor (Vollmer et al). Increasing age reduces the chances of survival and of good recovery. Older patients often remain disabled, especially when compensation is involved. Young and middle-aged patients do better, particularly if they are not entitled to compensation.