Andreas H Kramer1,2,3, Nathan Deis4,5, Stacy Ruddell4, Philippe Couillard4,5,6, David A Zygun7, Christopher J Doig4,8, Clare Gallagher4,5,6. 1. Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada. andreas.kramer@albertahealthservices.ca. 2. Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada. andreas.kramer@albertahealthservices.ca. 3. Hotchkiss Brain Institute, Calgary, AB, Canada. andreas.kramer@albertahealthservices.ca. 4. Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada. 5. Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada. 6. Hotchkiss Brain Institute, Calgary, AB, Canada. 7. Department of Medicine, University of Alberta, Edmonton, AB, Canada. 8. Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
Abstract
BACKGROUND: In patients with traumatic brain injury (TBI), multicenter randomized controlled trials have assessed decompressive craniectomy (DC) exclusively as treatment for refractory elevation of intracranial pressure (ICP). DC reliably lowers ICP but does not necessarily improve outcomes. However, some patients undergo DC as treatment for impending or established transtentorial herniation, irrespective of ICP. METHODS: We performed a population-based cohort study assessing consecutive patients with moderate-severe TBI. Indications for DC were compared with enrollment criteria for the DECRA and RESCUE-ICP trials. RESULTS: Of 644 consecutive patients, 51 (8 %) were treated with DC. All patients undergoing DC had compressed basal cisterns, 82 % had at least temporary preoperative loss of ≥1 pupillary light reflex (PLR), and 80 % had >5 mm of midline shift. Most DC procedures (67 %) were "primary," having been performed concomitantly with evacuation of a space-occupying lesion. ICP measurements influenced the decision to perform DC in 18 % of patients. Only 10 and 16 % of patients, respectively, would have been eligible for the DECRA and RESCUE-ICP trials. DC improved basal cistern compression in 76 %, and midline shift in 94 % of patients. Among patients with ≥1 absent PLR at admission, DC was associated with lower mortality (46 vs. 68 %, p = 0.03), especially when the admission Marshall CT score was 3-4 (p = 0.0005). No patients treated with DC progressed to brain death. Variables predictive of poor outcome following DC included loss of PLR(s), poor motor score, midline shift ≥11 mm, and development of perioperative cerebral infarcts. CONCLUSIONS: DC is most often performed for clinical and radiographic evidence of herniation, rather than for refractory ICP elevation. Results of previously completed randomized trials do not directly apply to a large proportion of patients undergoing DC in practice.
BACKGROUND: In patients with traumatic brain injury (TBI), multicenter randomized controlled trials have assessed decompressive craniectomy (DC) exclusively as treatment for refractory elevation of intracranial pressure (ICP). DC reliably lowers ICP but does not necessarily improve outcomes. However, some patients undergo DC as treatment for impending or established transtentorial herniation, irrespective of ICP. METHODS: We performed a population-based cohort study assessing consecutive patients with moderate-severe TBI. Indications for DC were compared with enrollment criteria for the DECRA and RESCUE-ICP trials. RESULTS: Of 644 consecutive patients, 51 (8 %) were treated with DC. All patients undergoing DC had compressed basal cisterns, 82 % had at least temporary preoperative loss of ≥1 pupillary light reflex (PLR), and 80 % had >5 mm of midline shift. Most DC procedures (67 %) were "primary," having been performed concomitantly with evacuation of a space-occupying lesion. ICP measurements influenced the decision to perform DC in 18 % of patients. Only 10 and 16 % of patients, respectively, would have been eligible for the DECRA and RESCUE-ICP trials. DC improved basal cistern compression in 76 %, and midline shift in 94 % of patients. Among patients with ≥1 absent PLR at admission, DC was associated with lower mortality (46 vs. 68 %, p = 0.03), especially when the admission Marshall CT score was 3-4 (p = 0.0005). No patients treated with DC progressed to brain death. Variables predictive of poor outcome following DC included loss of PLR(s), poor motor score, midline shift ≥11 mm, and development of perioperative cerebral infarcts. CONCLUSIONS: DC is most often performed for clinical and radiographic evidence of herniation, rather than for refractory ICP elevation. Results of previously completed randomized trials do not directly apply to a large proportion of patients undergoing DC in practice.
Authors: P J Hutchinson; E Corteen; M Czosnyka; A D Mendelow; D K Menon; P Mitchell; G Murray; J D Pickard; E Rickels; J Sahuquillo; F Servadei; G M Teasdale; I Timofeev; A Unterberg; P J Kirkpatrick Journal: Acta Neurochir Suppl Date: 2006
Authors: A Taylor; W Butt; J Rosenfeld; F Shann; M Ditchfield; E Lewis; G Klug; D Wallace; R Henning; J Tibballs Journal: Childs Nerv Syst Date: 2001-02 Impact factor: 1.475
Authors: D James Cooper; Jeffrey V Rosenfeld; Lynnette Murray; Yaseen M Arabi; Andrew R Davies; Paul D'Urso; Thomas Kossmann; Jennie Ponsford; Ian Seppelt; Peter Reilly; Rory Wolfe Journal: N Engl J Med Date: 2011-03-25 Impact factor: 91.245
Authors: Bizhan Aarabi; Dale C Hesdorffer; Edward S Ahn; Carla Aresco; Thomas M Scalea; Howard M Eisenberg Journal: J Neurosurg Date: 2006-04 Impact factor: 5.115
Authors: Regan F Williams; Louis J Magnotti; Martin A Croce; Brinson B Hargraves; Peter E Fischer; Thomas J Schroeppel; Ben L Zarzaur; Michael Muhlbauer; Shelly D Timmons; Timothy C Fabian Journal: J Trauma Date: 2009-06
Authors: S M Toutant; M R Klauber; L F Marshall; B M Toole; S A Bowers; J M Seelig; J B Varnell Journal: J Neurosurg Date: 1984-10 Impact factor: 5.115
Authors: Thomas Beez; Christopher Munoz-Bendix; Sebastian Alexander Ahmadi; Hans-Jakob Steiger; Kerim Beseoglu Journal: Childs Nerv Syst Date: 2019-07-20 Impact factor: 1.475
Authors: Andreas H Kramer; Philippe L Couillard; David A Zygun; Marcel J Aries; Clare N Gallagher Journal: Neurocrit Care Date: 2019-02 Impact factor: 3.210
Authors: Teodor Svedung Wettervik; Samuel Lenell; Lena Nyholm; Tim Howells; Anders Lewén; Per Enblad Journal: Acta Neurochir (Wien) Date: 2017-12-12 Impact factor: 2.216
Authors: Shannon M Fernando; Alexandre Tran; Wei Cheng; Bram Rochwerg; Monica Taljaard; Kwadwo Kyeremanteng; Shane W English; Mypinder S Sekhon; Donald E G Griesdale; Dar Dowlatshahi; Victoria A McCredie; Eelco F M Wijdicks; Saleh A Almenawer; Kenji Inaba; Venkatakrishna Rajajee; Jeffrey J Perry Journal: BMJ Date: 2019-07-24