Decompressive Craniectomy in Diffuse Traumatic Brain Injury

Elevated intracranial pressure (ICP) has been associated with poor outcomes in patients suffering traumatic brain injury (TBI). However, the optimal treatment for ICP as a result of TBI remains unclear. In this randomized controlled prospective trial, the authors examined the effect of early decompressive craniectomy vs. standard medical therapy in patients with refractory elevated ICP after TBI. Refractory ICP was defined as ICP > 20 mm Hg for more than 15 min, persisting after first-line treatment including pharmacologic sedation, normalization of arterial carbon dioxide pressure, mannitol, hypertonic saline, neuromuscular blockade, and external ventricular drainage. Early decompressive craniectomy was defined as bilateral craniectomy within 72 h of presentation, and standard medical therapy involved options for barbiturates, mild therapeutic hypothermia, and life-saving decompressive craniectomy, if indicated. Patients eligible for inclusion were between 15 and 59 years of age, had non-penetrating TBI, an initial Glasgow Coma Scale score of 3–8, and were excluded if they had focal lesions amenable to surgery, fixed dilated pupils on presentation, spinal cord injury, or cardiac arrest at the scene. One hundred fifty-five patients in Australia, New Zealand, and Saudi Arabia met inclusion criteria and were enrolled in the study. The primary outcome was unfavorable neurologic outcome as defined by mortality, vegetative state, or severe disability. Mortality was similar between both groups (19% in the craniectomy group vs. 18% in the standard therapy group), and neurologic outcomes at 6 months, as defined by the Extended Glasgow Outcome Scale (EGOS) were significantly worse in the early decompressive group (EGOS median score of 3, with 70% unfavorable scores) vs. the standard medical therapy group (EGOS median score 4, with 51% unfavorable scores). However, early decompressive craniectomy subjects had significantly fewer days of mechanical ventilation, days of intensive care unit stay, days of hospitalization, and fewer hours with elevated ICP.