Determinants of Outcomes Following Decompressive Craniectomy for Traumatic Brain Injury: A Multicenter Prospective Cohort Study in Addis Ababa, Ethiopia

Background: Traumatic brain injury (TBI) is a major cause of trauma-related mortality globally. The Brain Trauma Foundation recommends decompressive craniectomy (DC) as a last-resort intervention, particularly relevant in low- and middle-income countries (LMICs) like Ethiopia, where neuromonitoring is limited. This study aims to inform patient selection and improve outcomes. Objectives: This study aimed to assess outcomes and identify clinical and radiologic predictors among patients undergoing DC for TBI at major hospitals in Addis Ababa, Ethiopia. Methodology: A multicenter prospective cohort study was conducted from January 2023 to September 2024, enrolling 94 patients who underwent DC for TBI. Patients were followed for 90 days postoperatively. Outcomes were assessed at discharge, 30 days, and 90 days using the Extended Glasgow Outcome Score (EGOS), dichotomized as favorable (EGOS ≥5) or unfavorable. Statistical analysis included a chi-square test and binomial logistic regression, with variables showing p<0.25 in Bivariate analysis entered into multivariable models. Results: Of the 94 patients (80 males, 14 females; mean age 38.9±15.0 years), 41.5% presented with severe TBI (GCS <9). At 3-month follow-up, mortality was 30.9%, 55.3% achieved a favorable outcome, and 13.8% had an unfavorable outcome. Poor prognostic indicators included GCS <5 at presentation (p<0.001), non-reactive pupils (p=0.007), deranged emergency vital signs (p=0.018), poor response to osmotic diuretics (p=0.001), intraoperative hypotension (p=0.002), vasopressor requirement (p=0.008), and lower immediate postoperative GCS (p=0.007). Conclusion: Decompressive craniectomy remains a viable intervention for TBI in LMICs. Identifying poor prognostic factors can help optimize care and resource use in resource-limited settings