Pulmonary Complications Following Emergency Craniotomy Versus Craniectomy For Acute Subdural Hematoma In Severe TBI

Author(s):
Nasim Ahmed; Patricia Greenberg

Background:

Patients who sustain a severe traumatic brain injury (TBI) with Subdural Hematoma (SDH) have shown better outcomes when operative interventions are performed within 4 hours of admission. The procedures typically used for the evacuation of hematoma are craniotomies or craniectomies. Therefore, the purpose of the study was to evaluate the impact of both procedures on post-operative pulmonary complications and sepsis.

Hypothesis:

Evacuation of acute subural hematoma in severe TBI either by craniotomy or craniectomy does not effect  pulmonary complications

Methods:

Study data was obtained from the National Trauma Data Bank (2007-2010). Only patients who sustained blunt or penetrating injuries, presented with severe TBI with SDH and an initial GCS ≤ 8, and who underwent a craniotomy or craniectomy within 4 hours of hospital arrival were included in the analysis. Patient characteristics and outcomes were compared between the two procedural groups: craniotomy (Group 1) and craniectomy (Group 2). These measures were first compared between the two unmatched groups then later In an attempt to better balance the groups, propensity score matching analysis was also performed using baseline characteristics; paired analyses was performed.

Results:

A total of 2,414 patients qualified for the study and of those, 1,880 (77.9%) patients underwent craniotomy (Group 1) and 534 (22.1%) underwent craniectomy (Group 2). There were significant differences between the two groups regarding age (Mean [SD]: 47.7 [22.7] vs 39.3 [20.0], P<0.001), sex (male, 70.5% vs 75.3%, P=0.03), race (white, 77.0% vs 72.7%, P=0.04), the injury type (blunt, 98.5% vs 97.0%, P=0.03), the injury mechanism (fall, 50.0% vs 32.2%, P<0.001), Injury Severity Score[ISS] (28.0 [9.3] vs 30.3 [10.0], P<0.001) and GCS (4.0 [1.6] vs 3.7 [1.4], P=0.01). In order to balance the groups, 534 patients from each group were pair-matched on patient’s characteristics. Afterward, there were no significant differences between the groups. There were also no significant differences seen in the occurrence of acute respiratory distress syndrome (ARDS) (11.2% vs 9.1%, P=0.5), pneumonia (38.8% vs 38.8%, P=1.0), pulmonary embolism (1.4% vs 1.4%, P=1.0), or systemic sepsis (8% vs 10.5%, P=0.38).

Conclusions:

Approximately 80% of patients who sustained severe TBI with SDH at hospital presentation underwent craniotomy within 4 hours of hospital arrival, while the remaining patients underwent craniectomy. However, no significant differences were observed in the incidence of ARDS, pneumonia, pulmonary embolism, or systemic sepsis.