Jury out on decompressive craniectomy for intracranial hypertension
medwireNews: In patients with refractory intracranial hypertension after traumatic brain injury (TBI), decompressive craniectomy is associated with a lower mortality rate than medical management, show trial findings.
However, a larger proportion of the survivors in the surgical versus medical group were less able to care for themselves independently, as shown by the higher rates of vegetative state and lower and upper severe disability on the 8-point Extended Glasgow Outcome Scale (GOS-E) in surgically treated patients.
This result “emphasizes the fact that lifesaving procedures may not ensure a return to normal functioning”, say Lori Shutter (University of Pittsburgh, Pennsylvania, USA) and Shelly Timmons (Penn State University Milton S Hershey Medical Center, USA) in an editorial accompanying the research in The New England Journal of Medicine.
They continue: “The findings of this trial argue for more investigation into the nuances of selecting patients for decompressive craniectomy after traumatic brain injury and for the development of more refined clinical decision-making tools.”
The Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) trial included 398 TBI patients with elevated intracranial pressure (>25 mmHg) that persisted for 1–12 hours despite interventions such as ventilation, sedation and ventriculostomy. Participants were assigned to either undergo decompressive craniectomy – either unilateral hemicraniectomy or bifrontal craniectomy at the surgeon’s discretion – or receive ongoing medical care, with the added option of barbiturates.
At 6 months, death was less common among the 201 patients who underwent depressive craniectomy than the 188 who received medical care, at 26.9% versus 48.9%.
But the rate of individuals judged to be in a vegetative state was higher in the craniectomy arm, at 8.5% and 2.1%, respectively. This was also the case for the lower severe disability (ie, dependent on others for care) and upper severe disability (ie, independent at home but not outside the home) ratings, with corresponding rates of 21.9% versus 14.4% and 15.4% versus 8.0%.
The proportion of patients with moderate disability and those deemed to have made a good recovery were comparable between the groups.
Lead author Peter Hutchinson (University of Cambridge, UK) and team report that the findings were similar at the 12-month timepoint.
They add that surgical management led to significantly better control of intracranial hypertension than medical management, as assessed by, for instance, a shorter duration of intracranial pressure over 25 mmHg after randomisation (median 5 vs 17 hours).
However, adverse events occurred significantly more frequently among surgically treated than medically managed participants (16.3 vs 9.2%).
The researchers point out that patients in the medical care arm were permitted to undergo decompressive craniectomy in case of treatment failure, an option taken up for “a relatively large proportion” (37%) of those in the medical group, which “may have diluted the observed treatment effect”.
Shutter and Timmons also note: “In comparison, only 9% of patients in the surgical group did not have their intracranial pressure controlled and required barbiturate infusion.
“These results suggest that maximal medical therapy is often not adequate to control intracranial pressure.”
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