Ortuño-Andériz Francisco, Castaño-Montoya Juan Pablo, de Miguel-Martín Sarah, Zlatkov-Aleksandrov Viktor Yordanov, Alonso-Martínez Patricia, Pérez-Alfayate Rebeca
Neurocritical Care Unit, University Hospital Clínico, Calle Martín Lagos s.n, Madrid, 28040, Spain.
Department of Neurosurgery, University Hospital Clínico San Carlos, Calle Martín Lagos s.n. 28040, Madrid, Spain.
Eur J Trauma Emerg Surg. 2025 Aug 8;51(1):264. doi: 10.1007/s00068-025-02942-3.
Decompressive craniectomy (DC) reduces mortality in traumatic brain injury (TBI), but its impact on functional outcomes remains debated. DC is classified as primary or secondary; however, most studies analyze both together. This study aims to compare clinical and epidemiological differences between primary and secondary DC.
A retrospective cohort study analyzed severe TBI patients requiring primary vs. secondary DC admitted to our Intensive Care Unit (ICU) (2014-2024). Epidemiological, clinical, and radiological variables were evaluated.
Among 312 ICU-admitted TBI patients, 72 underwent DC (45 primary, 33 secondary). Primary DC was performed intraoperatively during mass evacuation without prior intracranial pressure (ICP) assessment, while secondary DC was performed for refractory intracranial hypertension (ICH). Patients who underwent primary DC showed signs of more severe injury at admission, which was associated with higher mortality.
Secondary DC patients had a better initial prognosis and ICU course, likely due to the selection of less severe cases. Higher mortality in the primary DC group may reflect the greater severity of the initial injury rather than the negative impact of early intervention. A predictive model incorporating clinical (hemodynamic instability) and radiological (perimesencephalic cistern collapse, midline shift) criteria effectively differentiates primary DC candidates (AUC = 0.821, p < 0.0001).
去骨瓣减压术（DC）可降低创伤性脑损伤（TBI）的死亡率，但其对功能结局的影响仍存在争议。DC分为原发性或继发性；然而，大多数研究将两者合并分析。本研究旨在比较原发性和继发性DC之间的临床和流行病学差异。
一项回顾性队列研究分析了2014年至2024年入住我们重症监护病房（ICU）的需要原发性或继发性DC的重度TBI患者。评估了流行病学、临床和放射学变量。
在312例入住ICU的TBI患者中，72例接受了DC（45例原发性，33例继发性）。原发性DC在术中进行肿块清除时实施，未事先评估颅内压（ICP），而继发性DC用于治疗难治性颅内高压（ICH）。接受原发性DC的患者入院时显示出更严重的损伤迹象，这与更高的死亡率相关。
继发性DC患者的初始预后和ICU病程较好，可能是由于选择的病例病情较轻。原发性DC组较高的死亡率可能反映了初始损伤的更严重程度，而非早期干预的负面影响。一个纳入临床（血流动力学不稳定）和放射学（中脑周围脑池塌陷、中线移位）标准的预测模型可有效区分原发性DC候选者（AUC = 0.821，p < 0.0001）。
