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COMMENTARY
Year : 2019  |  Volume : 67  |  Issue : 5  |  Page : 1233--1234

To Do or not to Do the Good and Bad about Decompressive Craniectomy

Dhaval Shukla 
 Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Dhaval Shukla
Department of Neurosurgery, NIMHANS, Bengaluru - 560 029, Karnataka
India




How to cite this article:
Shukla D. To Do or not to Do the Good and Bad about Decompressive Craniectomy.Neurol India 2019;67:1233-1234


How to cite this URL:
Shukla D. To Do or not to Do the Good and Bad about Decompressive Craniectomy. Neurol India [serial online] 2019 [cited 2020 Jan 22 ];67:1233-1234
Available from: http://www.neurologyindia.com/text.asp?2019/67/5/1233/271264


Full Text



Decompressive craniectomy (DC), which was described more than a century earlier, is now gaining a resurgence but is mired in debate and controversy. It is used as a last resort to treat refractory intracranial hypertension. In this issue ---, et al. did a meta-analysis of randomized controlled trials of decompressive craniectomy in traumatic brain injury.[1] The meta-analysis is largely based on two big trials DECRA and Rescue ICP.[2],[3] The authors have also included a smaller study for meta-analysis and a study on DC in children with TBI for readership. Though both DECRA and Rescue ICP trials were done to determine the outcome of DC in patients with severe traumatic brain injury (TBI), there were a lot of differences between them which makes collective conclusions difficult.

The major differences were the technique and type of DC and the stage at which DC was offered. All patients in DECRA trial and 63% patients in Rescue ICP trial were treated with a bifrontal technique. The results were not presented related to specific techniques. However, in clinical practice, a hemicraniectomy is often performed when there is persistent brain swelling after evacuation of traumatic intradural hematoma. Such DC is termed as primary DC, whereas the Rescue ICP trial included only patients who underwent secondary DC and excluded 240 patients who underwent primary DC. The second difference was the stage at which DC was offered. In DECRA trial the DC was offered as second tier treatment, and in Rescue trial as third tier treatment. A DC for patients with refractory ICP without significant traumatic mass lesions is often performed as a salvage procedure, not an upfront procedure. The outcome in group of patients that failed medical treatment and underwent DC would be more useful for clinicians who counsel the patients in daily practice before offering DC as a salvage procedure. The outcome of such patients was not available from these two trials. The results of DECRA and Rescue ICP are not exactly applicable for patients treated with DC for TBI in routine practice. The indications of DC in practice are not congruent with those evaluated in clinical trials. In one study, it was shown that out of 644 consecutive patients with severe TBI, 51 (8%) were treated with DC. The ICP measurements influenced the decision to perform DC in only 18% of patients. The decision to perform DC was based on compression of basal cisterns, presence of midline shift, and lack of pupillary light reflex.[4]

The meta-analysis by no authors, et al. concluded that there is a mortality benefit by performing a DC over best medical management in adult patients. In patients surviving following DC, a higher incidence of poor neurological outcome is noted.[1] One more meta-analysis by Zhang, et al. concluded that the DC effectively lowers ICP and reduces mortality rate, but also increases complications rate, while its benefit on functional outcomes is not statistically significant.[5]

In the recent edition of guidelines for the management of severe traumatic brain injury by the Brain Trauma Foundation (BTF), DC was included as a new topic. The results of Rescue ICP trial were still awaited at the time of publication of the guidelines. The BTF has not updated the recommendation of DC for TBI after the results of Rescue ICP trial, and meta-analyses of DC. An international consensus meeting on the role of DC in the management of TBI was held in Cambridge in September 2017. The updated recommendations from the BTF and the consensus meeting may influence the practice of DC in future.

DC should not be interpreted as an alternative procedure to medical treatment but as a sequential procedure of medical treatment. A practical study would be the one that compares the outcome of patients who undergo most aggressive medical treatment with the other group that opts for DC as a salvage treatment in case of failure of medical treatment. The practical question would be whether addition of DC as a treatment option offers a favorable outcome to a patient with severe TBI whose medical treatment has failed to reduce the ICP.

References

1Garg K, Singh PM, Singla R, Aggarwal A, Borle A, Singh M, et al. Role of decompressive craniectomy in traumatic brain injury – A meta-analysis of randomized controlled trials. Neurol India 2019;67;1225-32.
2Cooper DJ, Rosenfeld J V, Murray L, Arabi YM, Davies AR, D'Urso P, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;364:1493-502.
3Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 2016;375:1119-30.
4Kramer AH, Deis N, Ruddell S, Couillard P, Zygun DA, Doig CJ, et al. Decompressive craniectomy in patients with traumatic brain injury: Are the usual indications congruent with those evaluated in clinical trials? Neurocrit Care 2016;25:10-9.
5Zhang D, Xue Q, Chen J, Dong Y, Hou L, Jiang Y, et al. Decompressive craniectomy in the management of intracranial hypertension after traumatic brain injury: A systematic review and meta-analysis. Sci Rep 2017;7:8800.