Outcome Analysis of Early Decompressive Craniectomy vs Craniotomy in Traumatic Brain Injury

Abstract

Background: Traumatic brain injury (TBI) is a major cause of death and long-term disability, and severe cases may require surgical intervention to control intracranial hypertension, evacuate traumatic hematomas, and prevent secondary brain injury. Although decompressive craniectomy (DC) may be life-saving in patients with severe cerebral edema and refractory intracranial hypertension, its long-term neuropsychological and functional outcomes compared with craniotomy (CO) remain uncertain. Objective: To compare the long-term neuropsychological, functional, and global neurological outcomes of patients with TBI undergoing early decompressive craniectomy versus craniotomy. Methods: This prospective comparative observational study was conducted in a tertiary-care hospital in Chittagong, Bangladesh, from January 2024 to December 2024. A total of 100 adult patients with TBI requiring surgical treatment were enrolled, including 50 patients who underwent early DC and 50 who underwent CO. Demographic, clinical, radiological, and operative data were collected prospectively. Long-term outcomes were assessed using the Wechsler Adult Intelligence Scale–Chinese Revision (WAIS-RC), Wechsler Memory Scale–Chinese Revision (WMS-RC), Activities of Daily Living (ADL) scale, and Glasgow Outcome Scale–Extended (GOSE). Propensity score matching was used to reduce baseline differences between the groups. Statistical significance was set at p<0.05. Results: Before matching, patients in the DC group had more severe injuries, including lower GCS scores, more frequent unconsciousness, unreactive pupils, traumatic subarachnoid hemorrhage, greater midline shift, and compressed or absent basal cisterns. After matching, the baseline characteristics were comparable between the groups. Long-term outcomes remained significantly better in the CO group. Patients undergoing CO had higher mean WAIS-RC verbal intelligence quotient (76.16±14.44 vs. 69.30±12.30; p=0.006), operation intelligence quotient (77.88±12.51 vs. 70.47±11.51; p=0.001), full intelligence quotient (74.82±12.94 vs. 67.20±11.55; p=0.001), and WMS-RC memory quotient (63.98±12.80 vs. 58.43±12.45; p=0.019) than those undergoing DC. The CO group also demonstrated better daily functioning, with lower PSMS, IADL, and total ADL scores (p=0.002, p=0.001, and p<0.001, respectively), and a higher median GOSE score (7.0 vs. 6.0; p<0.001). These differences persisted after propensity score matching. Conclusion: Patients undergoing craniotomy demonstrated significantly better long-term cognitive, functional, and global neurological outcomes than patients undergoing decompressive craniectomy. However, DC remains an essential and potentially life-saving procedure for patients with severe cerebral edema and refractory intracranial hypertension. When clinically appropriate, individualized surgical selection and adequate management of the underlying intracranial pathology may help optimize long-term recovery after TBI.