Decompressive Craniectomy in Diffuse Traumatic Brain Injury

Department of Intensive Care, Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia.
New England Journal of Medicine (Impact Factor: 54.42). 03/2011; 364(16):1493-502. DOI: 10.1056/NEJMoa1102077
Source: PubMed

ABSTRACT It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.
From December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final primary outcome was the score on the Extended Glasgow Outcome Scale at 6 months.
Patients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P=0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P=0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%).
In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.).

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Available from: Jennie Ponsford, Aug 09, 2015
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    • "Although the control of intracranial hypertension after severe TBI is important to prevent secondary brain ischemia and herniation, recent studies have suggested the need for additional therapies targeting other mechanisms of secondary damage. A multi-center randomized controlled trial (RCT) of decompressive craniectomy in adults with severe TBI (Cooper et al., 2011) showed that despite better control of raised ICP with surgical decompression, outcomes were worse vs. medical management – which unlike surgery, may be treating both ICP and other secondary injury mechanisms. Similarly, Mehta et al. (2010) reported that despite highly successful control of ICP in infants with severe TBI, ∼50% of children <2 years of age still had unfavorable long-term outcomes. "
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    Frontiers in Neurology 04/2013; 4:40. DOI:10.3389/fneur.2013.00040
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    • "A variety of factors contribute to practice patterns, and vary from surgeon to surgeon. While recent randomized trials have attempted to establish the efficacy of decompressive craniectomy in diffusely-injured states (Cooper et al., 2011), randomized trials for acute mass-occupying lesions such as acute subdural hematomas do not exist. Prognostic indicators, particularly in the preoperative evaluation, may be useful in determining which patients will benefit from surgical intervention. "
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    • "Our data are translationally relevant to TBI patients in the field or emergency department. Our data may also be relevant to patients undergoing decompressive craniectomy, who may have worse cognitive outcomes associated with this procedure (Cooper et al., 2011). Our data showing loss of benefit of LLLT in hidden platform trials in mice treated for 7 days versus 1 day after CCI highlight the need for further studies to establish rational dosing paradigms, determine the therapeutic window, and provide evidence of the safety of LLLT applied acutely after TBI. "
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