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Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injurySahuquillo J, Arikan F
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SummaryDoes a procedure that involves removing a section of skull improve the outcome of brain injured patients with raised intracranial pressure (excess pressure within the skull), who have not responded to conventional medical treatments?An injury to the brain may cause it to swell. In such cases pressure within the skull increases as the brain has no room to expand; this excess pressure (known as intracranial pressure) can cause further 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 maneuvers or first-line therapeutic measures, second-line treatments are initiated. One such second-line measure 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 ICP can reduce. 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, in terms of the survival and neurological outcome of patients, over the age of 12 months, with raised ICP after traumatic brain injury (TBI). Only one high quality trial was identified; which involved 27 pediatric patients (less than 18 years old) with TBI, who received either DC or conventional treatment. 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. Evidence from one trial indicates that DC may improve survival and neurological outcomes in brain injured pediatric patients with raised ICP, for whom other medical treatments have failed. However, as this one trial involved only a small number of patients, 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, and will be incorporated into the review on their completion.
This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 3, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
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January 25. 2006 AbstractBackgroundHigh intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). High ICP is treated by 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 started. Among these, second line therapies such as barbiturates, hyperventilation, moderate hypothermia or removal of a variable amount of skull bone (known as decompressive craniectomy) are used. ObjectivesTo assess the effects of secondary decompressive craniectomy (DC) on outcome and quality of life in patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. Search strategyWe searched the Cochrane Injuries Group's Trial Register, CENTRAL, MEDLINE, EMBASE, Best Evidence, Clinical Practice Guidelines, PubMed, CINAHL, the National Research Register and Google Scholar. We also handsearched relevant conference proceedings and contacted experts in the field and the authors of included studies. Selection criteriaRandomized or quasi-randomized studies assessing patients over the age of 12 months with a severe TBI who underwent DC to control ICP refractory to conventional medical treatments. Data collection and analysisTwo authors independently examined the electronic search results for reports of possibly relevant trials and for retrieval in full. One author applied the selection criteria, performed the data extraction and assessed methodological quality. Study authors were contacted for additional information. Main resultsWe found one trial with 27 participants conducted in the pediatric population (>18 years). DC was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72), and RR of 0.54 for death, vegetative status or severe disability 6 to 12 months after injury (95% CI 0.29 to 1.07). Authors' conclusionsThere is no evidence to support the routine use of secondary DC to reduce unfavourable outcome in adults with severe TBI and refractory high ICP. In the pediatric population DC reduces the risk of death and unfavourable outcome. Despite the wide confidence intervals for death and the small sample size of the only study identified, this treatment maybe justified in patients below the age of 18 when maximal medical treatment has failed to control ICP. To date, there are no results from randomised trials to confirm or refute the effectiveness of DC in adults. However, the results of non-randomized trials and controlled trials with historical controls involving adults, suggest that DC may be a useful option when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of DC (Rescue ICP and DECRAN) that may allow further conclusions on the efficacy of this procedure in adults. |