PRIMARY DECOMPRESSIVE CRANIECTOMY IN TRAUMATIC BRAIN INJURY: CLINICAL OUTCOMES AND A PRELIMINARY RISK-SCORING SYSTEM FOR PATIENT SELECTION

Abstract

Background: Traumatic brain injury (TBI) is a leading global cause of mortality and neurological disability. Decompressive craniectomy (DC) addresses refractory intracranial hypertension, but the optimal selection of patients for this procedure remains a critical and unresolved clinical challenge, particularly in resource-limited settings. Methods: A prospective observational study was conducted at a tertiary hospital in Meerut, India (July 2024 November 2025). Patient enrollment was stopped in November 2025 to allow 3-month follow-up completion for all cases by February 2026. Fifteen patients aged 18–65 years who underwent primary unilateral DC for TBI were enrolled. Clinical (GCS, pupillary response, fall in GCS, anticipated prolonged ventilation), radiological (Modified Rotterdam CT score with sulcal effacement in higher fronto-parietal cuts), and intraoperative (brain bulge) variables were recorded. Serial CT evaluation was performed to guide surgical intervention. Three-month functional outcome was assessed using the Glasgow Outcome Scale (GOS), dichotomised as favorable (GOS 4–5) or unfavorable (GOS 1–3). Results: The cohort comprised predominantly young adult males (mean age 34.7 ± 14.6 years; 73.3% male) injured in road traffic accidents (73.3%). Favorable outcomes were achieved in 33.3% of patients; mortality was 33.3%. Age was the only variable significantly associated with mortality: survivors were substantially younger than non-survivors (mean 26.1 vs. 51.8 years; p = 0.003). GCS improved significantly from admission (mean 8.07) to 3-month follow up (mean 12.18; p = 0.047). A six-variable preliminary risk score — incorporating age, GCS, anticipated prolonged ventilation, radiological severity, intraoperative brain bulge, and in-hospital fall in GCS — demonstrated a progressive increase in unfavorable outcomes with higher scores. Conclusion: Primary DC reduces mortality in severe TBI, though functional recovery is strongly age-dependent. The proposed risk-scoring model offers a simple, resource-independent tool for patient selection pending prospective multicentric validation.