Removal of a section of skull bone (decompressive craniectomy) after a severe traumatic brain injury in patients with raised intracranial pressure that has not responded to conventional medical treatments

An injury to the brain may cause it to swell. Pressure within the skull then increases as the brain has no room to expand; this excess pressure, known as intracranial pressure, can cause further brain injury. High intracranial pressure (ICP) is the most frequent cause of death and disability in brain-injured patients. If high ICP cannot be controlled using general or first-line therapeutic measures such as adjusting body temperature or carbon dioxide levels in the blood and sedation, second-line treatments are initiated. One of these is a procedure called decompressive craniectomy (DC). DC involves the removal of a section of skull so that the brain has room to expand and the pressure decrease. There is however clinical uncertainty regarding the use of DC and a lack of consensus on the optimal management of traumatic brain injury.

This review looked at all high quality trials investigating the effectiveness of DC, compared to conventional medical treatments, on survival and neurological outcomes for patients over the age of 12 months who had a raised ICP after traumatic brain injury (TBI). Only one trial was identified. This trial involved 27 pediatric patients (less than 18 years old). The results indicate that the risk of death and disability was moderately reduced when DC was used. No trials investigating the effectiveness in adults were found.

The authors of the review conclude that there is no evidence to support the routine use of DC to improve mortality and quality of life in brain-injured adults with high ICP. DC may improve survival and neurological outcomes in brain-injured pediatric patients with raised ICP for whom other medical treatments had failed. This one trial involved only a small number of patients and further studies are needed before applying DC as a routine treatment.

Two trials of DC are currently in progress, the results from which may allow further conclusions regarding the effectiveness of the procedure in adults. These will be incorporated into the review when they are completed.

Authors' conclusions: 

There is no evidence from randomized controlled trials that supports the routine use of secondary decompressive craniectomy to reduce unfavorable outcomes in adults with severe TBI and refractory high ICP. In the study with a pediatric population, decompressive craniectomy reduced the risk of death and unfavorable outcomes. Despite the wide CI for death and the small sample size of this one identified study, the treatment may be justified in patients below the age of 18 years when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of decompressive craniectomy (RescueICP and DECRA) that will allow further conclusions on the efficacy of this procedure in adults.

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Background: 

High intracranial pressure (ICP) is the most frequent cause of death and disability after a severe traumatic brain injury (TBI). High ICP is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail to control high ICP, second-line therapies are initiated. Of these, barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (decompressive craniectomy) are used.

Objectives: 

To assess the effects of secondary decompressive craniectomy on outcomes and quality of life for patients with severe TBI in whom conventional medical therapeutic measures have failed to control a raised ICP.

Search strategy: 

We searched the following electronic databases: Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, PubMed, EMBASE, ZETOC, CINAHL, and Controlled Trials metaRegister (www.controlled-trials.com/mrct/search). We searched the Internet using Google Scholar (http://scholar.google.com) and handsearched relevant conference proceedings. We also contacted experts in the field and authors of included studies. The searches were last conducted in May 2008.

Selection criteria: 

Randomized or quasi-randomized studies assessing patients over the age of 12 months with severe TBI who underwent decompressive craniectomy to control ICP refractory to conventional medical treatments.

Data collection and analysis: 

The electronic search and handsearching results were examined for reports of potentially relevant trials, which were then retrieved in full. The selection criteria were applied, data extraction performed, and studies assessed for methodological quality.

Main results: 

We found only one trial with 27 participants, conducted in a pediatric population. Decompressive craniectomy was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72) and a RR of 0.54 (95% CI 0.29 to 1.01) for an unfavorable outcome (death, vegetative status, or severe disability 6 to 12 months after injury). To date, no results are available to confirm or refute the effectiveness of decompressive craniectomy in adults.

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