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decompressive_craniectomy_for_traumatic_brain_injury

Decompressive craniectomy for traumatic brain injury

Intracranial hypertension is the largest cause of death in young patients with severe traumatic brain injury 1).

The management of traumatic brain injury progressed significantly in the 1980s and 1990s due to advances in neuroimaging (widespread introduction of CT scanning), prehospital management, neurointensive care (widespread adoption of ICP monitoring and tiered therapeutic protocols) and rehabilitation. This led to a renaissance of interest in decompressive craniectomy (DC) with many uncontrolled studies reporting a survival benefit with DC 2) 3).

Since that time, DC has been increasingly studied in the setting of different conditions, including subarachnoid hemorrhage, and malignant middle cerebral artery infarction.

Furthermore, dural opening, usually followed by insertion of a dural graft (duraplasty), has meanwhile become an integral part of the decompressive surgery technique 4).

The 21st century, so far, has seen consistent efforts to improve the evidence base for DC following TBI with the conduct of randomized clinical trials 5).

In severely head injured children, a study has shown that decompressive craniectomy resulted in good recovery in all children in the study, suggesting the procedure has an advantage over non-surgical treatment in children.

In one of the largest studies on pediatric patients, Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients for accidental trauma after craniectomy when followed for more than five years. Only three patients were dependent on caregivers.

This is the only prospective randomised controlled study to date to support the potential benefit of decompressive craniectomy following traumatic brain injury.

Outcome

Early decompressive craniectomy (DC) has been used as the first stage treatment to prevent secondary injuries in cases of severe traumatic brain injury (TBI). Postoperative management is the major factor that influences outcome.

Intracranial pressure monitoring in conjunction with postoperative treatment, after early DC, is associated with a significantly reduced risk of death 6).

Patients surviving from DC need a second operation to repair the bone defect.

In the 2010s the use of decompressive craniectomy (DC) in everyday neurosurgical practice has largely increased, even though the effectiveness of this procedure is still uncertain 7).

Complications

Trials

The claim that decompressive craniectomy increases unfavourable outcome is overstated and not supported by the data presented in DECRA trial.

Sahuquillo et al. believe it premature to change clinical practice. Given the dismal outcome in these patients, it is reasonable to include this technique as a last resort in any type of protocol-driven management when conventional therapeutic measures have failed to control ICP, the presence of operable masses has been ruled out and the patient may still have a chance of a functional outcome. The main lesson to be learned from this study is that an upper threshold for ICP must be used as a cut-off for selecting decompressive craniectomy candidates 8).

see RescueICP Study.

Systematic review and meta-analysis

Although many studies have been conducted in this topic, there is still much uncertainty about the effectiveness of surgical treatment in TBI 9).

Zhang et al. aimed to perform a systematic review and metaanalysis to examine the prognostic value of decompressive craniectomy (DC) in patients with traumatic intracranial hypertension. PubMed, EMBASE, Cochrane Controlled Trials Register, Web of Science, http://clinicaltrials.gov/ were searched for eligible studies. Ten studies were included in the systematic review, with four randomized controlled trials involved in the meta-analysis, where compared with medical therapies, DC could significantly reduce mortality rate [risk ratio (RR), 0.59; 95% confidence interval (CI), 0.47-0.74, P < 0.001], lower intracranial pressure (ICP) [mean difference (MD), -2.12 mmHg; 95% CI, -2.81 to -1.43, P < 0.001], decrease the length of ICU stay (MD, -4.63 days; 95% CI, -6.62 to -2.65, P < 0.001) and hospital stay (MD, -14.39 days; 95% CI, -26.00 to -2.78, P = 0.02), but increase complications rate (RR, 1.94; 95% CI, 1.31-2.87, P < 0.001). No significant difference was detected for Glasgow Outcome Scale at six months (RR, 0.85; 95% CI, 0.61-1.18, P = 0.33), while in subgroup analysis, early DC would possibly result in improved prognosis (P = 0.04). Results from observational studies supported pooled results except prolonged length of ICU and hospital stay. Conclusively, DC seemed to effectively lower ICP, reduce mortality rate but increase complications rate, while its benefit on functional outcomes was not statistically significant 10).

Case series

2016

31 patients aged 16-72 of either sex who sustained a severe, non-penetrating TBI and underwent a unilateral DC for evacuation of parenchymal or extra-axial hematoma or for failure of medical therapy to control intracranial pressure (ICP).

Review of the electronic medical record of patients undergoing DC for severe TBI and assessment of extended Glasgow Outcome Score (e-GOS) at 6-months following DC.

The mean age was 39.3y ± 14.5. The initial GCS was 5.8 ± 3.2, and the ISS was 29.7 ± 6.3. Twenty-two patients underwent DC within the first 24 h, two within the next 24 h and seven between the 3rd and 7th day post injury. The pre-DC ICP was 30.7 ± 10.3 and the ICP was 12.1 ± 6.2 post-DC. Cranioplasty was performed in all surviving patients 1-4 months post-DC. Of the 29 survivors following DC, the e-GOS was 8 in seven patients, and 7 in ten patients. The e-GOS was 5-6 in 6 others. Of the 6 survivors with poor outcomes (e-GOS = 2-4), five were the initial patients in the series.

In patients with intractable cerebral hypertension following TBI, unilateral DC in concert with practice guideline directed brain resuscitation is associated with good functional outcome and acceptable-mortality 11).

2009

A case control study comparing a group of patients (n: 16) operated for severe TBI between January 2002 and July 2004 according to an institutional management protocol characterized by an early decompressive craniectomy (DC) approach versus a historical control group (n: 20) managed before the implementation of such protocol. Mortality and Glasgow Outcome Score (GOS) at 6 months were used as the main outcome variables.

An early DC protocol implemented within 12 hours from injury in 16 patients with severe isolated TBI and a Marshall score between III or IV was associated with a lesser mortality than the conventional approach with ventriculostomy and Intensive Care Unit (ICU) management alone. The GOS was significantly better in the DC group (p=0.0002) than in the control group.

The use of an early DC protocol for severe TBI patients (Glasgow Coma Scale <9) had a significantly improved outcome compared with the conventional approach with ventriculostomy and ICU management in Simòn Bolivar Hospital in Bogotá, Colombia 12).

1)
Alvis-Miranda H, Castellar-Leones SM, Moscote-Salazar LR. Decompressive Craniectomy and Traumatic Brain Injury: A Review. Bull Emerg Trauma. 2013 Apr;1(2):60-8. Review. PubMed PMID: 27162826; PubMed Central PMCID: PMC4771225.
2)
Polin RS, Shaffrey ME, Bogaev CA. et al.Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 19974184–92.92
3)
Whitfield PC, Patel H, Hutchinson PJ. et al.Bifrontal decompressive craniectomy in the management of posttraumatic intracranial hypertension. Br J Neurosurg 200115500–7.7
4)
Hutchinson P, Timofeev I, Kirkpatrick P. Surgery for brain edema. Neurosurg Focus.2007;22:E14
5)
Kolias AG, Adams H, Timofeev I, Czosnyka M, Corteen EA, Pickard JD, Turner C, Gregson BA, Kirkpatrick PJ, Murray GD, Menon DK, Hutchinson PJ. Decompressive craniectomy following traumatic brain injury: developing the evidence base. Br J Neurosurg. 2016 Apr;30(2):246-50. doi: 10.3109/02688697.2016.1159655. Epub 2016 Mar 14. PubMed PMID: 26972805; PubMed Central PMCID: PMC4841020.
6)
Kim DR, Yang SH, Sung JH, Lee SW, Son BC. Significance of intracranial pressure monitoring after early decompressive craniectomy in patients with severe traumatic brain injury. J Korean Neurosurg Soc. 2014 Jan;55(1):26-31. doi:10.3340/jkns.2014.55.1.26. Epub 2014 Jan 31. PubMed PMID: 24570814.
7)
Aarabi B, Hesdoffer DC, Ahn ES, Aresco C, Scalea TM, Eisenbergh HM: Outcome following decompres- sive craniectomy for malignant swelling due to se- vere head injury. J Neurosurg 104: 469–479, 2006
8)
Sahuquillo J, Martínez-Ricarte F, Poca MA. Decompressive craniectomy in traumatic brain injury after the DECRA trial. Where do we stand? Curr Opin Crit Care. 2013 Apr;19(2):101-6. doi: 10.1097/MCC.0b013e32835eba1a. Review. PubMed PMID: 23422159.
9)
Moon JW, Hyun DK. Decompressive Craniectomy in Traumatic Brain Injury: A Review Article. Korean J Neurotrauma. 2017 Apr;13(1):1-8. doi: 10.13004/kjnt.2017.13.1.1. Epub 2017 Apr 30. Review. PubMed PMID: 28512611; PubMed Central PMCID: PMC5432443.
10)
Zhang D, Xue Q, Chen J, Dong Y, Hou L, Jiang Y, Wang J. Decompressive craniectomy in the management of intracranial hypertension after traumatic brain injury: a systematic review and meta-analysis. Sci Rep. 2017 Aug 18;7(1):8800. doi: 10.1038/s41598-017-08959-y. PubMed PMID: 28821777.
11)
Grindlinger GA, Skavdahl DH, Ecker RD, Sanborn MR. Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis. Springerplus. 2016 Sep 20;5(1):1605. doi: 10.1186/s40064-016-3251-9. eCollection 2016. PubMed PMID: 27652178; PubMed Central PMCID: PMC5028365.
12)
Rubiano AM, Villarreal W, Hakim EJ, Aristizabal J, Hakim F, Dìez JC, Peña G, Puyana JC. Early decompressive craniectomy for neurotrauma: an institutional experience. Ulus Travma Acil Cerrahi Derg. 2009 Jan;15(1):28-38. PubMed PMID: 19130336; PubMed Central PMCID: PMC3413286.
decompressive_craniectomy_for_traumatic_brain_injury.txt · Last modified: 2017/08/23 23:02 by administrador