gms | German Medical Science

Objective: The benefit of decompressive craniectomy (DC) in cerebral infarction (CI) and traumatic brain injury (TBI) is an ongoing debate in which the aspect of a reduced mortality seems to ignore the procedural complication rate accompanied by clinical disability. Here, we report the first interim analysis of the German Cranial Reconstruction Registry (GCRR) with special regard to the timing and technique of DC and perioperative complications.

Methods: A subgroup analysis of the GCRR, aprospective multicenter database for DC and subsequent cranioplasty, was performed. All patients enrolled at the time of DC were included in the analysis.

Results: A total of 93 patients out of 351 registered in the GCRR were included. Depending on the diagnosis we divided them into three groups: 1. TBI (38.5%), 2. Malignant CI (27.5%) and 3. Other, like intracerebral or aneurysmatic subarachnoid hemorrhage (34%). Patients in group 2 showed a significant worse neurological outcome (mRs 4.7±0.4) at discharge compared to patients in group 1 (mRs 3.8±1.5) or 3 (3.1±2.2). In addition, patients in group 1 received a significant earlier DC (Mdn 15h) than patients in group 3 (Mdn 34h). Nevertheless, independent of the diagnosis, the direct comparison of different DC time points showed no significant difference in neurological outcome between ultra-early (<12h) vs. early (12–24h) vs. delayed DC (>24h). Surprisingly, patients with a smaller craniectomy size (72.7±65.1cm²vs. 110.4±31cm²) showed a better outcome (mRs 0–1 vs. 2–5), confirmed by correlation analysis (p=0.0382).The surgery-related mortality rate was 1.4%, whereas the overall complication rate after DC was 24.8% (23/93 patients). Most common complications were wound healing disorders (7.5%), CSF-fistulas (6.5%) and postoperative hemorrhage (6.5%). A revision surgery was necessary in 16.1% of patients. A detailed statistical analysis of possible influencing factors like patient’s age, sex, comorbidities, duration of surgery, experience of the surgeon or different techniques of dural opening had no influence on the complication rate. Only the placement of subgaleal drains revealed significant (p<0.043) higher complication rates.

Conclusion: We provide evidence-based multi-center results for a large DC patient collective. High complication rates of more than 20% in TBI and CI require a critical reevaluation of previous DC studies and call our daily management into question. Upcoming analyses of the GCRR will further sharpen our understanding of this treatment.