- Department of Neurosurgery, National Hospital of Niamey, Niamey, Niger
- Department of Surgery and Surgical Specialties, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niamey, Niger
- Department of Radiology, General Hospital of Reference, Niamey, Niger
- Department of Psychiatry, National Hospital of Niamey, Niamey, Niger,
- Centre Medical Chirurgical Obstetrical Cote d’Opale, Saint Martin Boulogne, France.
Correspondence Address:
Ousmane Issoufou Hamma, Department of Neurosurgery, National Hospital of Niamey, Niamey, Niger.
DOI:10.25259/SNI_169_2024
Copyright: © 2024 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Ousmane Issoufou Hamma1, Aminath Bariath Kelani1,2, Souleymane Mahamadou Ango1, Tidjani Mahamat Hissene3, Salifou Mahamane Mobarak4, Yahouza Boka Tounga1, Assoumane Ibrahim Issa1,2, Gilbert Dechambenoit5. 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. 05-Jul-2024;15:235
How to cite this URL: Ousmane Issoufou Hamma1, Aminath Bariath Kelani1,2, Souleymane Mahamadou Ango1, Tidjani Mahamat Hissene3, Salifou Mahamane Mobarak4, Yahouza Boka Tounga1, Assoumane Ibrahim Issa1,2, Gilbert Dechambenoit5. 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. 05-Jul-2024;15:235. Available from: https://surgicalneurologyint.com/surgicalint-articles/12974/
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
INTRODUCTION
Refractory intracranial hypertension (RICH) is the main factor associated with an increased risk of death and/or morbidity in acute brain injury.[
The management of patients with DC necessitates a multidisciplinary approach. However, this approach faces many challenges at the National Hospital of Niamey (NHN). The main challenges are, first, the absence of universal health coverage to cover the cost of care, which is too high in relation to the average purchasing power of the Niger population. This cost is particularly high due to the need for a second cranioplasty surgery and rehabilitation care.[
Faced with these challenges, we conducted a study at NHN to analyze the quality of management and prognosis of patients with DC and to identify the impact of limited resources, typical of low-to-middle-income countries, on our management.
Context
Niger, with a surface area of 1,267,000 km2, is the largest country in West Africa. It is a landlocked country situated between latitudes 11°37 and 23°33 North and longitudes 0°06 and 16° East. It is bordered to the north by Algeria and Libya, to the east by Chad, to the south by Nigeria and Benin, and the west by Burkina Faso and Mali. Administratively, it is subdivided into 8 regions (Agadez, Dosso, Maradi, Tahoua, Tillabery, Zinder, Diffa and Niamey), which are divided into 67 departments. According to the latest data published in December 2022, Niger’s population was estimated at 23,591,983. The population is unevenly distributed across the country, with the highest average density in the capital (Niamey), at 5,356.6 inhabitants/km2, compared with an average density of 18.6 inhabitants/km2 nationwide. The population is also characterized by extreme youth (56.3% are under 15), and over 84% of the population lives in rural areas. The national electrification rate was 17.9%. On the economic front, the primary sector contributes 36.5% of the gross domestic product, which earned it 131st place in the “Doing Business 2021” ranking. On the health front, indicators show insufficient health coverage (53.2%), with 4051 registered health facilities and 1132 practicing doctors, giving a ratio of 20,841 inhabitants per doctor (the World Health Organization standard is one doctor per 10,000 inhabitants). Note that Niger’s health policy is mainly focused on the management of infectious diseases (malaria, tuberculosis, hepatitis, pneumonia, acquired immunodeficiency syndrome, etc.), childhood illnesses (infant malnutrition, diarrhea, vaccinations, etc.), and the activities of maternity units.[
The history of neurosurgery in Niger began with the return of the late Professor SANOUSSI Samuila from Strasbourg to NHN in the late 90s. He was instrumental in establishing the first neurosurgery department (36 beds) and installing the country’s first computed tomography (CT) scanner.[
MATERIALS AND METHODS
Patients and study design
We conducted a prospective, longitudinal, observational, descriptive, and analytical study at NHN following the strengthening of the reporting of observational studies in epidemiology (STROBE) guidelines over 36 months from October 2020 to October 2023. The neurosurgery, general intensive care, and emergency surgery departments were used as study settings.
This research represents a pilot clinical study of this surgical technique carried out in a neurosurgical department in Niger. For this initial study, we adopted a longitudinal, prospective design with both descriptive and analytical objectives. This methodology was chosen for its ease of implementation in a resource-limited context, particularly given the absence of certain professional roles such as neuroepidemiologists, data managers, clinical research coordinators, etc.
Inclusion and exclusion criteria
All patients admitted to NHN during our study period with a head injury, whether isolated or as part of a polytrauma, cerebrovascular syndrome, or brain tumor, and for whom DC was indicated, were included in our study.
We excluded from the study all patients admitted to NHN during our study period for whom DC was indicated but who:
Died on the operating table before closure; Had unusable data; Patients or legal guardians refused to participate in the study.
Judging criteria
The indication for surgery was based on a combination of information derived from the severity of the head injury (initial Glasgow Coma Scale [GCS], pupil status, pupil reactivity to light), time to admission to the surgical emergency department, Marshall’s CT score, and the presence of the signs of intracranial hypertension (ICH) intraoperatively. Postoperative assessment was performed according to the last Glasgow Outcome Scale (GOS) measured. The outcome was determined as follows:
Unfavorable outcome (GOS 1, GOS 2); Favorable outcome (GOS 3, GOS 4, and GOS 5).
To standardize our data, we decided not to use the modified Rankin score to assess the postoperative follow-up of patients who underwent DC following malignant middle cerebral artery (MCA) infarction. In addition, we used Marshall’s CT score for non-traumatic lesions, even though these scores are not specifically designed for this purpose.
Data collection methodology and software
We initially collected information using a paper questionnaire (epidemiological, clinical, paraclinical, operative, and postoperative data). We then stored and coded this information in a relational database using an input mask developed with Epi-info 7.5.2.0 software. This database was then exported to R × 64 4.3.2 statistical analysis software for descriptive analysis (tabulation and graphing) and univariate regression (logistic or linear). It should be noted that most of these variables were coded in the input mask as dichotomous variables (Yes/No), although some were coded as continuous variables (age, delay, etc.) and categorical variables (mode of admission, reason for admission, etc.).
Statistical analysis plan
Our descriptive analysis considered all variables, and we structured our variable distribution tables as follows:
Qualitative variables: In numbers (frequency [in %]); Quantitative variables: In mean (minimum-maximum).
Due to the lack of a control group and the size of our cohort, we were unable to conduct a robust multivariate regression. Consequently, we performed only univariate regressions during the inferential analysis.
Odds ratios (OR) in the analytical tables were calculated using logistic or linear univariate regression. This regression was performed after Pearson’s Chi-square test for comparison of proportions (morbimortality and independent variables) or Student’s t-test for comparison of means (performance indicators and independent variables). We considered P ≤ 0.05 significant and calculated their 95% confidence intervals.
For our univariate regression studies, we used all the independent variables contained within our descriptive analysis tables [
Ethical and administrative considerations
Research authorization was granted by the Dean of the Faculty of Health Sciences of the University of Niamey and the General Manager of NHN on written request. Data were collected after obtaining informed consent from the patients or their legal guardians. Patient anonymity was respected throughout the study.
RESULTS
Descriptive analysis
Epidemiological data
During our study, we recorded 74 cases of DC. The majority of patients, that is, 50% (37/74), were from the Niamey region, followed by the Tillabéri region, which accounted for 21.62% of patients (16/74) [
Clinical presentation
On admission, the altered consciousness was the predominant functional sign (95.95%; 71/74). The majority of patients were admitted with a GCS ≤8, that is, 62.16% (46/74), 31.08% of patients had GCS scores between 9 and 12 (23/74), and 6.76% had GCS scores between 13 and 15 (5/74). An ICH syndrome was noted in 81.08% of patients (60/74). More than half of our patients (62.16%; 46/74) had abnormal pupillary responses, with anisocoria predominating (47.83%; 22/46). In most patients, 89.19% (66/74) palpebral conjunctival color was normal. Patients with hemodynamic and ventilatory instability on admission accounted for 32.43% (24/74) [
Preoperative CT data
Our patients underwent a preoperative cerebral CT scan after an average of 31.28 hours. The most frequent CT scan lesion was parenchymal brain contusion, accounting for 90.54% of cases (67/74), followed by cerebral edema, 85.14% (63/74), subarachnoid hemorrhage, 83.78% (62/74), and acute subdural hematoma (SDH), 72.97% (54/74) [
Treatments characteristics
The majority of our patients, 94.59% (70/74), underwent decompressive hemicraniectomy. After durotomy, the brain parenchyma was predominantly hyperemic in 74.33% (55/74) of the patients. The flap was restored in 13.51% (10/74). Surgery was performed an average of 49.75 hours after the incident and lasted an average of 133 min. The direct cost of care averaged $636.15, that is, 393,150 FCFA (the XOF/USD exchange rate of 618.0169, which was recorded on October 30, 2023, the end of the study) [
Postoperative follow-up
Half of our patients (50%; 37/74) were taken directly to the intensive care unit after surgery, with an average stay of 8 days. A postoperative CT scan was performed in 51.35% of patients (38/74). Among these patients, 55.26% (21/38) experienced postoperative cerebral ischemia, 34.21% (13/38) developed postoperative subdural hygroma, 34.21% (13/38) had postoperative ventriculomegaly, and 7.89% (3/38) suffered from postoperative hydrocephalus. Notably, most of the latter required a ventriculoperitoneal shunt (66.67%; 2/3) [
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).
Inferential analysis
Variables associated with death
The main variables with a statistically significant association with an increased risk of death were as follows: GCS <9 (OR = 13; P = 0.001), hemodynamic and ventilatory instability (OR = 12.8; P < 0.001), and abnormal pupillary responses (OR = 7.64; P < 0.001) [
Variables associated with the risk of postoperative epilepsy
The main variables with a statistically significant association with an increased risk of postoperative epilepsy were as follows: neurological sequelae (OR = 41.9; P < 0.001), postoperative subdural hygroma (OR = 3.28; P = 0.022), and postoperative cerebral ischemia (OR = 9.78; P < 0.001) [
Variables associated with the risk of posttraumatic hydrocephalus
The main variables with a statistically significant association with an increased risk of posttraumatic hydrocephalus were as follows: postoperative meningitis (OR = 26.6; P < 0.012) and cranioplasty infection (OR = 140; P = 0.002) [
Variables associated with the risk of posttraumatic neurological sequelae
The main variables with a statistically significant association with an increased risk of neurological sequelae were as follows: postoperative epilepsy (OR = 41.9; P < 0.001) and postoperative ventriculomegaly (OR = 19.4; P = 0.007) [
DISCUSSION
Epidemiological data
In our study, 74 cases of DC were performed, mainly for TBIs (94.94%), the main cause of which was road traffic accidents (76.1%). The average age was 32.04 years, and the majority were male (91.89%). It is important to emphasize that the TBI situation in Niamey is alarming. Over 4000 cases were recorded during our study in the surgical emergency department of NHN alone, one of the city’s three national hospitals (1,365,927 inhabitants).[
Admission time
Several scientific studies have demonstrated a correlation between admission time and mortality. In Tau et al., patients with a delay of more than 7 h had less favorable outcomes.[
Surgical technique
DC is an ancient neurosurgical technique based on MonroKellie’s law. It consists of performing a large cranial flap followed by an enlarging duroplasty, thereby increasing cranial volume, reducing intracranial pressure (ICP), and avoiding secondary cerebral aggression and encephalic involvement.[
Surgical indications
At present, RICH related to TBI is the main indication for DC. In settings with limited resources and a lack of institutional facilities to provide adequate care, DC is sometimes used as a first-line treatment despite postoperative complications due to the high incidence (around 70%) of ICH in TBI.[
Malignant infarction of the MCA accounts for 10–15% of strokes. They cause massive cerebral edema and severe neurological deficits. DC can prevent fatal outcomes. Most patients (71.4% of cases) showed functional improvement after 6 months.[
Mortality
In South Africa, DC reduces mortality from severe DC by 90–50%.[
Postoperative epilepsy
Postoperative epilepsy is characterized by the onset of one or more convulsive seizures at least 1 week after a TBI, requiring antiepileptic treatment.[
Postoperative hydrocephalus
Postoperative hydrocephalus is defined as dilatation of the cerebral ventricles (Evans index >0.3) after DC.[
Postoperative infection
Major complications of surgical wounds after DC or cranioplasty include dehiscence, ulceration or necrosis, and infection.[
Postoperative neurological sequelae
In low-to-middle-income countries, TBI mainly affects the working population (aged 15–64). In Niger, this age group will represent 47.8% of the population in 2022.[
Prognostics factors
The GCS was measured after resuscitation, with studies showing a linear relationship between GCS and poor prognosis.[
Despite a higher frequency of postoperative complications such as hydrocephalus and epilepsy, mortality in children is lower after DC.[
Limitations of our study
Our study has several limitations. First, being an observational, longitudinal, prospective, and monocentric study carried out with a modestly sized population (<100 cases), it is complex to avoid certain biases inherent in the absence of a randomization process. Second, our study population is non-homogeneous because it includes patients with traumatic, tumor, and vascular brain lesions, and the evolution of these lesions is not necessarily superimposable. Third, our management protocol does not meet international standards, notably regarding systematic orotracheal intubation of all comatose patients (GCS <9/15), continuous ICP monitoring perioperatively, and successive follow-up brain CT scans immediately postoperatively. This situation stems from human and material resource constraints in relation to patient flow. The absence of a control group (sufficiently robust data) and the short duration of postoperative follow-up (<10 years) did not allow us to reach a sufficiently high level of evidence to draw up the first guidelines for cranial trauma in Niger. Further studies are therefore needed to collect sufficient data to adapt international neurosurgical guidelines to the realities of low- and middle-income countries. This adaptation of international guidelines will allow us to establish guidelines for neuro traumatology in Niger and sub-Saharan Africa, where the incidence could rise to 14 million per annum by 2050.[
CONCLUSION
Our study shows that DC is mainly performed at the NHN for TBIs. TBI remains a major public health problem, particularly in low-to-middle-income countries such as Niger. Our study demonstrates the efficacy of DC as a therapeutic measure for RICH in the context of limited resources, as the impact was moderate and the operative sequelae of our patients were generally favorable. Future studies will focus on long-term patient monitoring, emphasizing quality of life, successful rehabilitation, and psychosocial reintegration post-DC. This data will help us identify areas of care that need improvement beyond the acute surgical phase. We must also advocate for increased funding from policymakers to conduct multicenter studies to collect enough data for the adaptation of international neurosurgical guidelines to fit the realities of low-to-middle-income countries.
Ethical approval
The Ethics Committee of the National Hospital of Niamey approved the conduct of this study (Approval No. 00224/DG/HNN/DAF/SGRH, dated October 14, 2023).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
Acknowledgments
The authors are grateful to the following teacher-researchers: Pr. ABARCHI Habibou, the late Pr. SANOUSSI Samuila, Pr. SANI Rachid, Pr. SOUNA BADIO Seyni, Pr. CHAIBOU Mamane Sani, Pr. KADRE ALIO Kadre Ousmane and Dr. IDE Garba for their unconditional support.
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