Introduction: Traumatic brain injury (TBI) results in heterogeneous long-term sequels and approximately one-third of TBI patients present with ongoing functional and/or cognitive decline, suggesting a chronic and progressive pathophysiology. In contrast to stroke, decompressive craniectomy (DC) is not the first-line recommendation after TBI although very little is known about its long-term effects. Thus, we assessed health-related quality of life (HRQoL) to elucidate predicting factors for good long-term outcome in chronic TBI patients.
Methods: In this cross-sectional study, a representative sample of 135 out of 439 patients reported HRQoL up to 10 years after mild, moderate or severe TBI using the QOLIBRI questionnaire (Quality of Life after Brain Injury) with a total score of 0-100 representing lowest and best HRQoL, respectively. HRQoL was quantified (%; mean ± SD) and correlated to TBI severity, etiology, age at TBI, age at survey, sex, DC, ICP monitoring, tracheostomy, time to onset and duration of neurorehabilitation, and functional status (mobile/immobile: mRS 0-3/mRS 4-5) at admission/discharge (%) using multiple linear regression via backward selection. Numerical and categorical variables were analyzed using Wilcoxon-Mann-Whitney and Fisher test, respectively.
Results: TBI severity is not a strong predictor for HRQoL (p=0.04; adj. R2=0.02). 64% reported good HRQoL with a mean QOLIBRI total score of 65.5 ± 22.57 (± SD). 36% reported poor HRQoL (QOLIBRI total score <60) with an increased risk for one (20%) or two (16%) psychiatric comorbidities. 30% of TBI patients (n=41) underwent DC. 59% of non-craniectomized (DC-) and 76% of craniectomized patients (DC+) reported good HRQoL with a median QOLIBRI total score of 65 in DC- and 76 in DC+ patients (p=0.049). The most beneficial effect was observed in initially mild classified TBI patients with a QOLIBRI total score of 54 (DC-) and 84 (DC+) (p=0.001; adj. R2=0.45), during the first year after TBI with a score of 50 (DC-) and 76 (DC+) (p=0.13), and in the 61-85-year-olds with a score of 62 (DC-) and 79 (DC+), respectively (p=0.02). Risk for one or even two psychiatric comorbidities differed between DC- and DC+ groups: 22% (DC-) versus 15% (DC+) and 18% (DC-) versus 9% (DC+), respectively. Shorter neurorehabilitation correlated positive with a better HRQoL (p<0.001; r=0.037). Neurorehabilitation improved functional outcome (immobile at admission/discharge: 81%/33%; mobile at admission/discharge: 19%/67%).
Conclusion: TBI severity is not a strong predictor for HRQoL up to 10 years following TBI. DC and shorter duration of neurorehabilitation are associated with better HRQoL. DC particularly improves HRQoL in patients being prone to secondary brain injury. More than one-third of patients reported insufficient HRQoL. Thus, our data underline the relevance of DC for good long-term outcome following TBI and the need for an early psychiatric approach to improve HRQoL in chronic TBI patients.


Quality of Life Following Traumatic Brain Injury: CROCFLAME Decompressive Craniectomy and Neurorehabilitation Are Relevant for Good Outcome