Surgery for Brain Edema

Peter Hutchinson, F.R.C.S.(SN); Ivan Timofeev, M.R.C.S.; Peter Kirkpatrick, F.R.C.S.(SN)

Disclosures

Neurosurg Focus. 2007;22(5):E14 

In This Article

Traumatic Brain Injury

For many years, decompressive craniectomy has been applied in patients with TBI. Within the past 10 years, the modern era of neurointensive care, there have been several observational studies. In one of the first analyses,[54] authors from Charlottesville compared the results in patients undergoing decompressive craniectomy with historical control data from the National Traumatic Coma Data bank. They reported good outcomes in 37% of the patients as opposed to 16% in controls, with better results if de compression was performed within 48 hours of injury and if ICP at the time of decompression was less than 40 mm Hg. From Wurzburg, Kunze et al.[45] reported a favorable outcome rate of 56% and a mortality rate of 11%, with later de compressions averaging 68 hours postinjury in 28 patients. Similar results have been reported from Griefs wald by Guerra et al.:[29] a favorable outcome rate of 58% and mortality rate of 19%. In 2000, De Luca et al.[17] reported a 41% favorable outcome rate and an 18% mortality rate in a series of 22 patients. In a study conducted in Hungary, investigators reported a favorable outcome in 38% of patients whose initial Glasgow Coma Scale score had been 3 or 4 and a high mortality rate of 43%.[15] In a small series from Thessaloniki (nine patients) there was a 66% favorable outcome rate, 22% mortality rate, and 11% severe disability rate.[44] Data from other studies have shown less favorable results, including one by Meier et al.[47] (19 patients, 26% favorable outcome rate, and 43% mortality rate) and by Munch et al.,[50] who reported improvements in CT appearance after decompression but no beneficial effect on patient outcome. Schneider and associates[62] reported ICP reductions following decompressive craniectomy, but favorable outcomes in only 29% of patients and a 22.5% mortality rate.

More recently, Albanese et al.[3] from Marseille have re ported good recovery in 38% of patients and a mortality rate of 23% among a series of 40 patients; Skoglund et al.[65] from Goteborg, a favorable outcome in 68% and a mortality rate of 11% among a series of 19 patients; Ucar et al.[69] from Antalya, a favorable outcome in only 16% among a series of 100 patients; and Aarabi et al.[1] from Baltimore, a favorable outcome in 40% and a mortality rate of 28% among a series of 50 patients. Our initial experience with decompressive craniectomy in TBI in Cambridge, described in 2001,[73] demonstrated a favorable outcome in 69% of patients among a cohort of 26. A study in a second cohort of 49 patients[68] yielded a favorable outcome in 61%.

In summary, the literature demonstrates a wide range of clinical outcomes, with no clear consensus regarding the indications for surgery. What are the current recommendations for the role of decompressive craniectomy in TBI? In Europe, Sahuquillo and Arikan[60] have published a Cochrane review. These authors have concluded that there is no evidence to support the routine use of decompressive craniectomy to reduce unfavorable outcomes in adults with severe TBI and medically refractory elevated ICP. In the pediatric population, decompressive craniectomy reduces the risk of death and unfavorable outcome.[67] How ever, the results of nonrandomized trials and controlled trials with historical controls involving adults have suggested that decompressive craniectomy may be a useful option when maximal medical treatment has failed to regulate ICP. The American Brain Trauma Foundation guidelines[9] state that bifrontal decompressive craniectomy with in 48 hours of injury is a treatment option in patients with diffuse, medically refractory, posttraumatic cerebral edema and resultant intracranial hypertension. With no clear consensus, proposals for randomized studies have been offered to obtain Class I evidence ( Table 1 ). In 2001, a small randomized study originating from the Royal Child ren's Hospital in Melbourne was published.[67] Patients were randomized to standard treatment alone or with decompression. Those in the standard treatment group had a mean ICP reduction of 3.7 mm Hg and a favorable outcome (normal or mild disability) in 14%; patients in the standard treatment plus decompression (performed at 19 hours postinjury) group had a mean ICP reduction of 8.9 mm Hg and a favorable outcome rate of 54%. This difference did not quite reach significance. There were several problems with this study—sample size, outcome evaluation, and prolonged duration (7 years)—and the authors recognized these limitations. Two multicenter prospective randomized studies are ongoing: the RESCUEicp study[35] and the DECRA study.

The RESCUEicp is a multicenter randomized trial in which decompressive craniectomy will be compared with medical management coordinated by the University of Cam bridge, UK, and the European Brain Injury Consortium. Patients (50 for the pilot phase and 600 for the main study) with TBI and elevated ICP (. 25 mm Hg) refractory to initial treatment measures are eligible for the study. Patients are randomized to one of two arms: continuation of optimal medical management (including barbiturates) and surgery (decompressive craniectomy). Outcome will be assessed using the extended GOS and 36-Item Short Form Health Survey at 6 months posttreatment, with additional surrogate end points (ICP control and duration of stay in the intensive therapy unit). The pilot phase of the study has been completed and has demonstrated that randomizing patients with TBI to decompressive craniectomy as opposed to optimal medical management is feasible. Whether this operation is effective and safe remains to be seen. The main phase of the study continues, and interested centers are welcome to join the trial.

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