There is now no little doubt that decompressive craniectomy can reduce mortality following severe traumatic brain injury. However the concern has always been that the reduction in mortality comes at the cost of an increase in the number of survivors with severe neurological disability. It was these concerns that prompted investigators to conduct a number of large multicentre randomised trials investigating surgical efficacy of the procedure. Whilst the results of these trials have confirmed the survival benefit that can be achieved this has only been achieved by increasing the number of survivors with severe disability and dependency. Whilst these findings may be difficult to accept they do not necessarily mean that use of the procedure should be abandoned but rather a more nuanced and patient centred debate regarding the acceptability or otherwise of survival with severe disability is required. In addition the use of long term observation outcome studies in combination accurate outcome prediction models in combination with may be used to highlight those patients likely to benefit from surgical decompression and facilitate discussions regarding realistic outcome expectations 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).
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.
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.
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).
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.
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).
A retrospective study included all patients undergoing DC for sTBI from 2003 to 2011. The 6-month outcome, assessed using the Glasgow Outcome Scale (GOS), was dichotomized into favorable (GOS 4-5) and unfavorable (GOS 1-3) outcome. Predictors of outcome were identified by uni and multivariate analysis.
190 patients who underwent DC for sTBI were included in this study. 60 patients (31,6%) died within 30 days after DC. Independent prognostic factors for survival after 30-days were GCS at admission > 5 (p=0,002) and bilateral pupils reactivity (p<0,0001). After 30 days from DC, 67 patients (51,5%) out of 130 had unfavorable outcome (GOS 1-3) and 63 patients (49,5%) presented favorable outcome (GOS 4-5). The independent pre-operative prognostic factors for poor outcome were age over 65 years (p < 0,0001) and bilateral absence of pupil reactivity (p = 0,0165). After DC, onset of postoperative hydrocephalus and delayed cranioplasty (3 months after DC) were associated with unfavorable outcome at multivariate analysis (p= 0,002 and p < 0,0001).
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 12).
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 13).