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Cooper DJ, Rosenfeld JV, Murray LB, et al. DECRA Trial Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group. N Eng J Med 2011; 364:1493-1502.
In a nutshell
Sixty per cent of patients hospitalised with severe traumatic brain injury die or are severely disabled. Raised Intracranial Pressure (ICP) from brain swelling causes secondary brain insult. Medical therapies often inadequately control raised ICP, but does Decompressive Craniectomy (DC) help? One hundred and fifty-five adults (15-60 years old) with severe (GCS 3-8) non-penetrating head injury were recruited from 15 referral centres. ICP treated medically >20mm Hg (e.g optimising sedation, normalising PaCO2, mannitol) and deemed refractory if elevated for <15 minutes (continuously or intermittently) within a one-hour period, despite optimised interventions. Those with mass lesions were excluded.
Patients randomised to bifrontotemporoparietal DC with dural opening, or standard treatment (mild hypothermia [35°C], barbiturates). Bone flaps replaced after 2-3 months. Eighteen per cent of the non-treatment group crossed over to DC 72 hours after admission. The final primary outcome was Extended Glasgow Outcome Scale (EGOS) at six months. The craniectomy group had reduced ICP levels (P<0.001), fewer ICP treatments (P<0.02), and fewer intensive care days (P<0.001), but worse EGOS scores. DC shifted survivors from a favourable outcome to an unfavourable outcome, it did not simply increase survival of severely injured patients; death rates were similar (craniectomy [19%] vs standard-care [18%]).
Second opinion
Enhancements in intensive care monitoring and treatment have not impacted significantly on severe traumatic brain injury (TBI) outcomes, so the potential of DC is a hot topic. The authors expected to show improved outcomes with the intervention and their findings contrast results from some non-randomised studies, as well as trials for brain swelling from malignant cerebral artery infarction where DC appears valuable to some patients. Indeed, when faced with refractory raised ICP, it may seem ‘easier’ to do something rather than nothing, so this study is extremely valuable.
If DC is at best no worse than medial treatment alone, if it improves survival but not function, we risk generating a cohort of extremely disabled patients; patients and their families need to know this. All may not be lost though for the DC; type and extent of craniectomy may be important. A UK study into DC in TBI (RescueICP) is ongoing despite the DECRA trial outcomes, because its protocol is subtly different; e.g. refractory ICP ? 25mmHg. We should keep an open mind until RescueICP reports.
The verdict
- DC for diffuse traumatic brain injury and raised ICP refractory to maximal medical treatment lowers ICP but does not appear to improve patient outcomes at six months
- Patient’s families need to be properly counselled as to the implications of this study
- The results of the RescueICP study of DC in traumatic brain injury are keenly awaited.
Paul Brennan, Clinical Lecturer and Honorary SpR Neurosurgery, Edinburgh Cancer Research Centre, Western General Hospital, Edinburgh
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