Decompressive craniectomy at the National Hospital of Niamey: Prospective study of the epidemioclinical profile, indications, surgical techniques, and results in a context of limited resources

Abstract

Background: Decompressive craniectomy (DC) is a neurosurgical technique that is gaining renewed interest due to the worldwide resurgence of head injuries. We aimed to analyze the quality of management and prognosis of patients who underwent this surgery in the context of limited resources.

Methods: This was a prospective, longitudinal, descriptive, and analytical study following STROBE, lasting 36 months at the National Hospital of Niamey in patients who had undergone DC. P ≤ 0.05 was considered significant.

Results: During our study, we collected 74 cases of DC. The mean age was 32.04 years (10-75 years), with male predominance (91.89%). DC was mainly performed following head trauma (95.95%), the main cause of which was road traffic accidents (76%; 54/71). On admission, most patients presented with altered consciousness (95.95%) and pupillary abnormalities (62.16%). The average time between brain damage and brain scan was 31.28 h, with parenchymal contusion being the most frequent lesion (90.54%). The majority of patients (94.59%) underwent decompressive hemicraniectomy. Postoperative complications accounted for 71.62% of all cases, with 33.78% resulting in death. Among survivors, 55.10% had neurological sequelae at the last consultation (27/49). The main factors associated with the risk of death and morbidity were a Glasgow coma score ≤8, pupillary abnormality on admission, the presence of signs of brain engagement, and a long admission delay.

Conclusion: Our study shows that the impact of limited resources on our care is moderate. Future research will concentrate on long-term monitoring, particularly focusing on the psychosocial reintegration of patients post-DC.

Keywords: Craniocerebral trauma; Decompressive craniectomy; Developing countries; Infarction; Intracranial hypertension.

Figure 1:

Distribution of patients by trauma location.

Figure 2:

Iconograms of a 20-year-old patient who underwent decompressive craniectomy following a road traffic accident resulting in severe head trauma, the operative sequelae of which were complicated by major hydrocephalus. (a-c) Preoperative computed tomography images showing diencephalic contusions, acute subdural hematoma, and subarachnoid hemorrhage; (d and e) Intraoperative images showing cerebral contusions and duroplasty; (f) Late postoperative frontal photograph showing distension opposite the cranial flap (white arrows); (g and h) Postoperative control computed tomography images showing tetraventricular hydrocephalus with disconnection of the ventriculoperitoneal shunt.

Figure 3:

Iconograms of an adult patient who underwent decompressive craniectomy following a ballistic craniocerebral wound from firearm assault, with a favorable postoperative outcome. (a and b) Preoperative computed tomography (CT) images showing the tangential point of impact of the bullet (white arrow), a punch fracture and a focus of edematous-hemorrhagic contusion with intra-parenchymal bone fragments (red arrows); (c) Photograph in the operating room after the patient had been placed on the operating table, shaved and the incision line marked, showing the entrance wound (green arrow) and the exit wound (red arrow); (d and e) Intraoperative images after wide cranial flap, showing dural breach and focus of brain parenchyma mortification after durotomy (white arrow); (f) Photograph of patient 3 months after decompression surgery, showing healed wounds (red arrows); (g and h) Control CT images showing a large area of parieto-occipital ischemia (white arrow) and the cranial flap after cranioplasty (red arrows); (i) Photograph of the patient after cranioplasty, showing healed bullet entry and exit wounds (red arrows) and the healing wound from the second surgery (white arrow).