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Table of Contents    
LETTER TO EDITOR
Year : 2020  |  Volume : 68  |  Issue : 5  |  Page : 1243

Reply to letter - Role of Decompressive Craniectomy in Traumatic Brain Injury - A Meta-analysis of Randomized Controlled Trials


1 Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
2 Department of Anesthesia, Washington University, Saint Louis, MO, USA
3 Department of Radiodiagnosis, All India Institute of medical Sciences, New Delhi, India

Date of Web Publication27-Oct-2020

Correspondence Address:
Dr. Kanwaljeet Garg
Room No 716, Cardio-Neuro Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.294545

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How to cite this article:
Garg K, Singh PM, Singla R, Aggarwal A, Borle A, Singh M, Chandra P S, Kale SS, Mahapatra AK. Reply to letter - Role of Decompressive Craniectomy in Traumatic Brain Injury - A Meta-analysis of Randomized Controlled Trials. Neurol India 2020;68:1243

How to cite this URL:
Garg K, Singh PM, Singla R, Aggarwal A, Borle A, Singh M, Chandra P S, Kale SS, Mahapatra AK. Reply to letter - Role of Decompressive Craniectomy in Traumatic Brain Injury - A Meta-analysis of Randomized Controlled Trials. Neurol India [serial online] 2020 [cited 2020 Dec 4];68:1243. Available from: https://www.neurologyindia.com/text.asp?2020/68/5/1243/294545




We thank the author for reading our article with great interest. We completely agree with the author that all cases included in the decompressive craniectomy (DECRA) trial were diffuse lesions after traumatic brain injury (TBI) while 20% of patients in the RESCUE intracranial pressure (ICP) trial had some mass lesion in computed tomography (CT) and had undergone evacuation.[1],[2] We have also commented on this aspect in our article (page no 1230, column 2, line 6-–).[3]

There are other differences in the DECRA and RESCUE ICP trials also.[1],[2],[4] The most important difference is the stage at which decompressive craniectomy was done in these two trials. DECRA trial “aimed to assess the effectiveness of early craniectomy offered as a stage 2 treatment”. In contrast, the RESCUE ICP “aimed to assess the effectiveness of decompressive craniectomy offered as the last-tier treatment (stage 3)”.[4] Similarly, the ICP threshold at which decompressive craniectomy was offered was higher in RESCUE ICP trial (ICP threshold: >25 mm Hg for 1 to 12 h) than in DECRA trial (ICP threshold: >20 mm Hg for 15 min within a 1-h period, continuous or cumulative). Accordingly, all patients were enrolled within 72 h of trauma in the DECRA trial while 44% of patients were enrolled after 72 h after injury in the RESCUE ICP trial. All these differences can be explained by the fact at what stage was the decompressive craniectomy offered.

Another point of difference was the technique of decompressive craniectomy used in these trials - while all patients underwent bilateral decompressive craniectomy in the DECRA trial, 37% of patients underwent unilateral decompressive craniectomy in RESCUE ICP trial.

These all can be a source of potential bias; however, it is not possible to ascertain the exact effect of these factors. One would like to have a perfect comparison in this era of evidence-based medicine. Having said this, it is very difficult to do randomized controlled trials in this field and we will have to try to be wise based on the results of trials we have.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cooper DJ, Rosenfeld JV, 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.  Back to cited text no. 1
    
2.
Hutchinson 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.  Back to cited text no. 2
    
3.
Garg 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. Neurology India 2019;67:1225-32.  Back to cited text no. 3
    
4.
Sharma R, Garg K. Letter: Role of decompressive craniectomy in traumatic brain injury—How much wiser are we after randomized evaluation of surgery with craniectomy for uncontrollable elevation of intracranial pressure trial? Neurosurgery 2017;81:E58-60.  Back to cited text no. 4
    




 

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