Repeat Surgery After Decompressive Craniectomy for Traumatic Intracranial Hemorrhage: Outcomes and Predictors

Introduction: Repeat surgery (RS) after decompressive craniectomy/craniotomy (DC) for traumatic intracranial hemorrhage (TICH) is a devastating complication. In patients undergoing DC for TICH, we sought to 1) describe the population requiring RS, 2) compare outcomes of those requiring RS with those who did not, and 3) discern RS predictors.

Methods: A single-institution retrospective case-control study was conducted from 2000 to 2015. Inclusion criteria were DC for acute supratentorial TICH (subdural hemorrhage, epidural hemorrhage, and intraparenchymal hemorrhage) and ≥7 day survival. Patients underwent RS within 7 days of DC; controls did not require RS. Outcomes and predictors of RS were evaluated with univariate and multivariate logistic regression (MLR).

Results: Of 201 patients requiring DC, 28 (14%) underwent RS. Common mechanisms were ground-level fall (45%) and motor vehicle collision (29%). Anticoagulation/antiplatelet medication was used by 44 patients (21%). Subdural hemorrhage was the most common hemorrhage (64%). Using MLR, those requiring RS were more likely to experience major complications (odds ratio [OR], 22.6; 95% confidence interval [CI], 5.06-101.35; P < 0.001) and in-hospital mortality (OR, 2.76; 95% CI, 1.02-7.43; P = 0.045) and be dead/dependent at 6 months (OR, 2.50; 95% CI, 1.08-5.82; P = 0.033) and 2 years (OR, 2.44; 95% CI, 0.99-6.00; P = 0.051). Predictors of undergoing RS identified by MLR were smaller hemorrhage (OR, 0.32; 95% CI, 0.13-0.78; P = 0.012), larger midline shift (OR, 4.40; 95% CI, 1.43-13.51; P = 0.010), and better preoperative Glasgow Coma Scale score (OR, 1.28; 95% CI, 1.13-1.46; P < 0.001).

Conclusions: Patients requiring RS after DC represent a heterogenous population with worse outcomes. Although the identified risk factors for RS are not modifiable, surgeons should be aware of these factors during the initial surgery.