Decompressive craniectomy: Surgical control of traumatic intracranial hypertension may improve outcome
Introduction
Following severe traumatic brain injury (TBI), brain oedema and intracranial hypertension (ICH) may lead to secondary brain damage. In addition, ICH is the most frequent cause of death and disability following severe TBI.9, 18, 21, 23, 28 The Brain Trauma Foundation (BTF) guidelines, have been established to guide the management of and indications for surgical decompression in TBI patients.6, 11 Within these guidelines, decompressive craniectomy (DC) is considered in two different situations; either it is performed prophylactically at the time of evacuation of a space occupying intracerebral haemorrhage or it is performed in patients with diffuse brain swelling and ICH after maximal medical treatment.6, 24, 25 Despite improvement in medical treatment modalities and neuromonitoring, including aggressive medical intervention such as barbiturate coma showed no improvement in outcomes for these patients.7, 13, 14, 18, 22
Decompressive craniectomy in the absence of a space occupying haemorrhage is currently regarded as a rescue therapy. The success rates of DC to restore normal ICP-levels and its impact on the outcomes, however, remain highly controversial.3, 4, 15, 16, 18, 20, 22, 23, 24, 26, 29, 30, 31, 32, 33 In addition, the optimal time point for this procedure is unclear. It appears that there may be a trend towards improved outcomes the earlier DC is performed.4, 8, 15, 19, 26, 29 Chibbaro and Tacconi found a survival rate with good neurological outcome in 18 of 48 patients when DC was performed within the first 16 h.8 These are the earliest DC patients published in the literature; however, this cohort also included patients with space occupying haemorrhages. In contrast, Aarabi et al. retrospectively investigated a homogeneous group of patients without space occupying haemorrhage. He reported a favourable outcome in 13 of 17 patients, when the decompression was performed within 48 h.3 The role of early DC to decrease ICP in TBI patients is of high interest. Currently, there are two randomised controlled trials ongoing: in Europe the RescueICP and in Australia the DECRA as well as a multicentre, retrospective trial in the United States to assess neurological outcome after DC.1, 2, 17
The purpose of this study was to investigate the outcome of patients who underwent early DC for intractable ICH in the absence of a space occupying haemorrhage and to delineate the impact of timing of DC on mortality.
Section snippets
Patients and methods
After Institutional Review Board (IRB) approval, patients who underwent DC at the Los Angeles County+University of Southern California Medical Centre from January 2004 to December 2008 were retrospectively reviewed. All patients with an AIS head >2 were pulled from the trauma registry to identify all patients who potentially underwent DC. Patients who required DC due to intracranial hypertension refractory to maximal medical treatment without space occupying haemorrhage on the CT scan were
Results
During the 5-year study period 1955 patients were admitted with severe TBI (AIS head ≥3). Overall, 106 patients (5.4%) underwent DC. Of those, 43 patients (40.6%) underwent DC for decompression of ICH without space occupying haemorrhage (Fig. 2).
In the 43 patients included in our study the mean age and ISS ± SD were 35.7 ± 15.0 years and 24.3 ± 7.6. The mean GCS ± SD was 8.6 ± 4.5 on admission. The majority (79.1%) of patients were males. A total of 83.3% sustained blunt head trauma, and 16.7% (7 of 43)
Discussion
The purpose of this study was to investigate the role of DC for intractable traumatic ICH in the absence of a space occupying haemorrhage. In this scenario DC is currently regarded as a rescue therapy in cases where herniation is expected. The success rates of DC to restore normal ICP-levels, its impact on the outcomes, and the optimal time point for this procedure remains highly controversial and the available recommendations are based on Levels II and III evidence. In particular, the role of
Conclusion
Decompressive craniectomy for isolated ICH is not a hopeless intervention. The present study is the largest published to date studying the outcome of DC performed within 24 h on patients with elevated ICP who have no space occupying haemorrhage. DC is a heroic procedure that has the potential to improve both survival and functional outcome in a selected group of patients. In particular patients, whose ICP is lowered by surgical intervention when medical management has not been successful, have a
Conflict of interest
There are no conflicts of interest to disclose.
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