Long-Term Quality of Life after Decompressive Craniectomy in Severe Traumatic Brain Injury and Stroke

Research Article

Phys Med Rehabil Int. 2021; 8(3): 1186.

Long-Term Quality of Life after Decompressive Craniectomy in Severe Traumatic Brain Injury and Stroke

Vicino A1, Vuadens P2, Léger B3 and Benaim C3,4*

1Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland

2Department of Neurorehabilitation, Clinique Romande de Réadaptation, Sion, Switzerland

3Department of Medical Research, Clinique Romande de Réadaptation, Sion, Switzerland

4Department of Physical Medicine and Rehabilitaion, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland

*Corresponding author: Charles Benaim, Physical Medicine and Rehabilitation, Centre Hospitalier Universitaire Vaudois (CHUV), Avenue Pierre Decker 4, 1011 Lausanne, Switzerland

Received: June 21, 2021; Accepted: August 04, 2021;Published: August 11, 2021


Purpose: Decompressive Craniectomy (DC) can rapidly reduce intracranial pressure and save lives in the acute phase of severe Traumatic Brain Injury (TBI) or stroke, but little is known about the long-term outcome after DC. We evaluated Quality of Life (QoL) a few years after DC for severe TBI/stroke.

Methods: The following data were collected for stroke/TBI patients hospitalized for neurorehabilitation after DC: 1) at discharge, motor and cognitive sub-scores of the Functional Independence Measure (motor-FIM (score 13-91) and cognitive-FIM (score 5-35)) and 2) more than 4 years after discharge, the QOLIBRI health-related QoL (HR-QoL) score (0-100; <60 representing low or impaired QoL) and the return to work (RTW: 0%, partial, 100%).

Results: We included 88 patients (66 males, median age 38 (interquartile range 26.3-51.0), 65 with TBI/23 stroke); 46 responded to the HR-QoL questionnaire. Responders and non-responders had similar characteristics (age, sex, functional levels upon discharge). Median motor-FIM and cognitive- FIM scores were 85/91 and 27/35, with no significant difference between TBI and stroke patients. Long-term QoL was borderline low for TBI patients and within normal values for stroke patients (score 58.0 (42.0-69.0) vs. 67.0 (54.0- 81.5), p=0.052). RTW was comparable between the groups (62% full time).

Conclusion: We already knew that DC can save the lives of TBI or stroke patients in the acute phase and this study suggests that their long-term quality of life is generally quite acceptable.

Keywords: TBI; Stroke; Decompressive carniectomy; Quality of life


DC: Decompressive Craniectomy; FIM: Functional Independence Measure; HR-QoL: Health-Related Quality of Life; QoL: Quality of Life; RTW: Return to Work; TBI: Traumatic Brain Injury

Background and Purpose

Stroke and Traumatic Brain Injury (TBI) are among the leading causes of death and disability in developed countries. In Switzerland, they have an incidence of approximately 240/100,000 and 170/100,000 (8.2/100,000 considered severe) [1-3], and represent two of the leading causes of death, with mortality at 14.4% for stroke and 20% to 30% for TBI in the first year and 50% and 35% in the following 5 years. These two conditions also induce major chronic disability in the population, with a significant impact on quality of life (QoL) [4,5].

In severe stroke or TBI, high Intracranial Pressure (ICP) can be life-threatening. Decompressive Craniectomy (DC) is widely used to avoid refractory intracranial hypertension, one of the most common causes of death after stroke or TBI. As described by the Cochrane Collaboration in the 2016 Brain Trauma Foundation guidelines, DC is recommended as second-line treatment for TBI [6]. However, this latest version of these guidelines does not recommend DC to improve outcomes, although it acknowledges that the procedure is useful for rapidly reducing ICP and minimizing days spent in the intensive care unit. DC is recommended in Switzerland as Class I/ Level A management for middle cerebral artery stroke with altered consciousness and mass effect [7] and, according to the classification of the European Federation of neurological societies guidelines for therapeutic interventions, as Class III/Level C management for cerebellar infarction [8]. The exact proportion of patients requiring craniectomy after TBI or malignant ischemic stroke remains unknown because no national incidence data are available. In a Swiss cohort of 101 patients with TBI, 60 survived the accident and 9 (15%) underwent DC [1]. Despite immediate benefits in reduced ICP and mortality, the effect of DC on disability is still controversial.

We collected information on long-term (>4 years) health-related QoL (HR-QoL) and occupational outcomes in patients with stroke or TBI who underwent DC and were hospitalized in our rehabilitation clinic. Another objective was to compare HR-QoL and RTW in the two groups.


Study design and setting

This was a monocentric retrospective cross-sectional study conducted in the Clinique Romande de Réadaptation, a nationalreference rehabilitation center in Switzerland that receives patients who underwent DC after stroke or TBI.


Eligible patients were those admitted in our neurorehabilitation unit between 2003 and 2012 and had undergone DC for malignant stroke or TBI. Exclusion criteria was DC for another intracranial pathology (cancer, subarachnoid hemorrhage etc.). The study was approved by the state ethics committee (CER-VD, 2017-00458). All participants or their representatives gave their informed consent before the start of the enrolment.

Variables/data measurement

At discharge, the motor and cognitive sub-scores of the Functional Independence Measure (motor-FIM and cognitive-FIM) were used to characterize patients’ functional abilities [9]. Between 4 to 14 years after discharge from the clinic, patients were 1) invited by mail to complete the QOLIBRI questionnaire (HR-QoL) [10], a 37-item scale that assesses both physical- and psychological-related life satisfaction, resulting in an overall satisfaction score (0-100, 100 being the best possible QoL; a score <60 represents low or impaired QoL [11]) and 2) asked about their return to work (RTW), rated as 0%, partial or 100% if they returned to the occupation held before the stroke or TBI. Two reminders were sent after 2 and 4 weeks in case of non-response. Patients who still did not answer were contacted by phone after another 2 to 4 weeks.

Study size

Because of no previous data on the topic, we were unable to estimate a suitable number of participants needed for this study. Rather, we considered 40 to 50 participants as a reasonable sample size to estimate patient outcome after DC, given that this is a relatively rare surgery. To account for non-response, we set the total number of participants at 80.

Statistical methods

Differences between groups (responders/non-responders, stroke/ TBI) were analyzed with the non-parametric Wilcoxon rank-sum test for quantitative variables and chi-square test for categorical variables. Data were analyzed with NCSS Number Cruncher Statistical System (2013: Atlanta). P <0.05 was considered statistically significant.


Participants (Figure 1)

Citation: Vicino A, Vuadens P, Léger B and Benaim C. Long-Term Quality of Life after Decompressive Craniectomy in Severe Traumatic Brain Injury and Stroke. Phys Med Rehabil Int. 2021; 8(3): 1186.