Choice of a Trephination Method in Casualties with Severe Craniocerebral Trauma

A.E. Talypov, V.V. Krylov, S.V. Tsarenko, Yu.V. Puras

Sklifosovsky Research Institute of Emergency Care,
Moscow State Medical-Stomatologic University, Moscow, Russia

 

Introduction. A choice of a trephination method (decompressive or osteoplastic) in severe craniocerebral trauma (SCCT) is one of the most disputable problems of neurotraumatology, sometimes characterized by absolutely contrary appraisals. The choice difficulty is conditioned by considerable scantiness of time for diagnosis and decision making and frequent impossibility to use modern diagnostic methods and means of control.

The goal of the present study was estimation of outcomes of SCCT in various versions of trephinatiom.

Materials and Methods. A problem of choosing a trephination type in patients with SCCT was studied at the Sklifosovsky Research Institute of Emergency Care in 2002-2003. Terms for including patients into the group under study were as follows:

  1. Presence of an intracranial traumatic focus, demanding dura dissection.
  2. A volume of a pathologic focus of 50 -120 cm3.
  3. An acute course of a process.
  4. A level of consciousness before operation, characterized by Glasgow Coma Scale score of 4-9.

The present study was based on results of clinical and instrumental examinations of 96 patients with SCCT. Investigation of 41 cases was prospective; their selection was randomized. Retrospective analysis of 55 medical histories of patients, who met the above requirements, was carried out. Osteoplastic trephination with dura suturing and fixation of a bone graft was performed in 41 cases (group I). Decompressive craniotomy with subtemporal resection, dura plasty with a liophilized transplant or Core membrane was made in 55 cases (group II). A bone graft was sutured into femoral soft tissues.

Results. Accidental distribution of patients into groups was analyzed. The groups were compared by sex, age, a period between trauma and operation, a level of consciousness before operation and CT findings (a volume of a traumatic focus, a value of lateral dislocation, a degree of axial dislocation). We did not reveal any reliable difference between these parameters in these groups (p>0.05); it confirmed possibility of their comparison.

The analysis of factors, effecting an outcome in patients with different types of trephination, was carried out. These factors were as follows: sex and age, a level of consciousness before operation, a period of time between trauma and operation, a volume of a traumatic focus, a value of lateral dislocation, a degree of axial dislocation, a state of brain during operation, operation duration. There was moderate correlation between an outcome and operation duration in both groups (R=0.43; p<0.05; n=96). This value was an indirect sign of technical difficulties, experienced during operation.

Mortality in the group of patients with osteoplastic trephination and in the group of cases with decompressive craniotomy was 70% and 74% respectively. Good results were watched in 7% of cases of the first group and 8% of patients of the second group. Satisfactory results were observed in 23% and 18% of cases respectively. We explain this high rate of mortality by considerable severity of a state and an extreme level of consciousness disorders. Postoperative mortality in casualties with SCCT, treated in the Neuroresuscitation Department of the above Institute, was 25-27%.Decompressive craniotomy was followed by development of external liquorrhea and meningitis in 2 casualties.

Conclusions. There was no reliable dependence of an outcome on a type of trephination. Despite a state severity, osteoplastic trephination is preferable, as it allows to reduce a risk of purulent complications and does not demand subsequent plasty of a skull defect.