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.
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.).