Juan Sahuquillo1, Francisco Martínez-Ricarte, Maria-Antonia Poca. 1. Department of Neurosurgery and Neurosurgery and Neurotraumatology Research Unit (UNINN), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain. sahuquillo@neurotrauma.net
Abstract
PURPOSE OF REVIEW: The results of the multicentre, randomized, controlled trial to test the effectiveness of decompressive craniectomy in adults with traumatic brain injury and high intracranial pressure (Decompressive Craniectomy, DECRA) were published in 2011. DECRA concluded that decompressive craniectomy decreased intracranial pressure (ICP) but was associated with more unfavourable outcomes. Our review aims to put the DECRA trial into context, comment on its findings and discuss whether we should include decompressive craniectomy in our clinical armamentarium. RECENT FINDINGS: The key message that DECRA conveys is that decompressive craniectomy significantly lowers ICP and shortens the length of the stay in the ICU. However, neither mortality nor unfavourable outcome was reduced when adjusting the significant baseline covariates. SUMMARY: The claim that decompressive craniectomy increases unfavourable outcome is overstated and not supported by the data presented in DECRA. We believe it premature to change clinical practice. Given the dismal outcome in these patients, it is reasonable to include this technique as a last resort in any type of protocol-driven management when conventional therapeutic measures have failed to control ICP, the presence of operable masses has been ruled out and the patient may still have a chance of a functional outcome. The main lesson to be learned from this study is that an upper threshold for ICP must be used as a cut-off for selecting decompressive craniectomy candidates.
RCT Entities:
PURPOSE OF REVIEW: The results of the multicentre, randomized, controlled trial to test the effectiveness of decompressive craniectomy in adults with traumatic brain injury and high intracranial pressure (Decompressive Craniectomy, DECRA) were published in 2011. DECRA concluded that decompressive craniectomy decreased intracranial pressure (ICP) but was associated with more unfavourable outcomes. Our review aims to put the DECRA trial into context, comment on its findings and discuss whether we should include decompressive craniectomy in our clinical armamentarium. RECENT FINDINGS: The key message that DECRA conveys is that decompressive craniectomy significantly lowers ICP and shortens the length of the stay in the ICU. However, neither mortality nor unfavourable outcome was reduced when adjusting the significant baseline covariates. SUMMARY: The claim that decompressive craniectomy increases unfavourable outcome is overstated and not supported by the data presented in DECRA. We believe it premature to change clinical practice. Given the dismal outcome in these patients, it is reasonable to include this technique as a last resort in any type of protocol-driven management when conventional therapeutic measures have failed to control ICP, the presence of operable masses has been ruled out and the patient may still have a chance of a functional outcome. The main lesson to be learned from this study is that an upper threshold for ICP must be used as a cut-off for selecting decompressive craniectomy candidates.
Authors: Angelos G Kolias; Hadie Adams; Ivan S Timofeev; Elizabeth A Corteen; Iftakher Hossain; Marek Czosnyka; Jake Timothy; Ian Anderson; Diederik O Bulters; Antonio Belli; C Andrew Eynon; John Wadley; A David Mendelow; Patrick M Mitchell; Mark H Wilson; Giles Critchley; Juan Sahuquillo; Andreas Unterberg; Jussi P Posti; Franco Servadei; Graham M Teasdale; John D Pickard; David K Menon; Gordon D Murray; Peter J Kirkpatrick; Peter J Hutchinson Journal: JAMA Neurol Date: 2022-07-01 Impact factor: 29.907