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Decompressive Craniectomy in Diffuse Traumatic Brain Injury

Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R; the DECRA Trial Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group.

N Engl J Med. 2011 Apr 21;364(16):1493-502.

Link to free article.

It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.

From December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final primary outcome was the score on the Extended Glasgow Outcome Scale at 6 months.

Patients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P=0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P=0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%).

In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617 .).


Address: From the Departments of Intensive Care (D.J.C., L.M., A.R.D.) and Neurosurgery (J.V.R.), Alfred Hospital; the Departments of Epidemiology and Preventive Medicine (D.J.C., L.M., A.R.D., J.P., R.W.) and Surgery (J.V.R.), Monash University; the Neurosciences Clinical Institute (P.D.) and the Monash-Epworth Rehabilitation Research Centre (J.P.), Epworth Healthcare; and the Epworth Hospital (T.K.) - all in Melbourne, VIC; the Department of Intensive Care Medicine, Nepean Hospital, University of Sydney, Sydney, NSW (I.S.); and the Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, SA (P.R.) - all in Australia; and the Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (Y.M.A.).

PMID: 21434843

Comments (2)Add Comment

First randomized study about craniectomy and TBI
written by Thomas S, April 01, 2011
This is the first large randomized study about decompressive craniectomy in adult patients with diffuse traumatic brain injury. 155 adults with refractory intracranial hypertension were randomized to craniectomy within 72 h or standard care.
Interestingly patients undergoing craniectomy had worse outcome at 6 months with a greater risk of unfavourable outcome. Rates of death were similar in the two groups.

According to the poll on NEUROSURGIC in July 2010 a majority of our visitors use decompressive craniectomy in TBI patients. (See poll http://neurosurgic.com/index.p...raniectomy)

Will this study change the way you treat these patients?
written by Jan, April 02, 2011
Dr Servadei has written an interesting editorial also published in NEJM (http://www.nejm.org/doi/full/10.1056/NEJMe1102998).

He raises some concerns about the study:
- Refractory intracranial hypertension was defined as ICP > 20 mmHg for more than 15 min - most neurosurgeons would not perform craniectomy so early and aggressively.
- Only 155 patients of 3478 screened patients were enrolled - this may indicate that only a restricted subpopulation of TBI patiens were enrolled.

Dr Servadei conclude that the results from the present DECRA study should not stop the ongoing RESCUEicp study since it has a different design.

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