Decompressive craniectomy dca surgical procedure that involves removal of part of the skullhas been used for many years in the management of patients with brain. Traumatic intracerebral hemorrhage tich represents approximately %48% of the lesions after a traumatic brain injury tbi, and hemorrhagic progression hp occurs in 38%63% of cases. Decompressive craniectomy for traumatic intracranial. In this study, 155 patients with refractory icps 20 mmhg for 15 min within. Review article intracranial hypertension is the largest cause of death in young patients with severe traumatic brain injury. One of these is a procedure called decompressive craniectomy dc. Traumatic brain injury tbi is associated with elevated intracranial pressure icp, primarily as a result of cerebral edema, and can lead to a decrease of cerebral blood flow and brain stem herniation, and is the most common cause of death and disability after severe tbi. Decompressive craniectomy for the treatment of refractory. The current status of decompressive craniectomy in traumatic brain injury angelos g. The decompressive craniectomy in diffuse traumatic brain injury decra randomized trial unexpectedly found that decompressive craniectomy dc surgery effectively controlled icp but increased the proportion of vegetative survivors, and decreased the proportion of independent functioning survivors. Decompressive craniectomy dc for the management of severe traumatic brain injury tbi has a long history but remains controversial. There is however clinical uncertainty regarding the use of dc and a lack of consensus on the optimal management of traumatic brain injury. However, risk factors predicting contusion expansion after dc are still.
The effectiveness of hinge craniotomy for increased. The development or expansion of a cerebral hemorrhagic contusion after decompressive craniectomy dc for traumatic brain injury tbi occurs commonly and it can result in an unfavorable outcome. While decompressive craniectomy following severe diffuse traumatic brain injury has been shown to reduce intracranial pressure and thereby facilitate maintenance of cerebral perfusion, the optimal timing, target population, and effect on survivor outcome of. The aim of our study was to evaluate the impact of decompressive craniectomy in severe traumatic brain injury tbi in children, focusing on short and longterm neurological and neuropsychological. The primary outcome was the rating on the extended glasgow outcome scale gose an 8point scale, ranging from death to upper good recovery no injury related problems at 6 months. Decompressive craniectomy for severe diffuse tbi 201105. Predicting longterm neurological outcomes after severe.
Hemorrhagic contusions hc represent a common consequence of traumatic brain injury tbi and usually evolve during the first 12 h after trauma. Craniectomy in diffuse traumatic brain injury request pdf. Among adults with severe diffuse traumatic brain injury and refractory intracranial hypertension in the icu, we found that decompressive craniectomy decreased intracranial pressure, the duration of mechanical ventilation, and the time in the icu, as compared with standard care. Lowpressure fluid percussion minimally adds to the sham. Decompressive craniectomy is part of the second level measures for the. The decompressive craniectomy in diffuse traumatic brain injury decra study was the first randomized study to address this issue and the randomized evaluation of surgery with craniectomy for uncontrollable elevation of intracranial pressure rescueicp study has recently been published. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension.
A craniectomy is a surgery done to remove a part of your skull in order to relieve pressure in that area when your brain swells. Effect of decompressive craniectomy in the postoperative. Cooper dj, rosenfeld jv, murray l, arabi ym, davies ar, durso p, kossmann t, ponsford j, seppelt i, reilly p, wolfe r 2011 decompressive craniectomy in diffuse traumatic brain injury. In the decra trial, patients were randomly allocated 1. Pdf decompressive craniectomy and traumatic brain injury. Patient outcomes at twelve months after early decompressive craniectomy for diffuse traumatic brain injury in the randomized decra clinical trial d.
Cooper dj1, rosenfeld jv, murray l, arabi ym, davies ar, durso p, kossmann t, ponsford j. In the setting of traumatic brain injury, the procedure has remained controversial a difficulty. A craniectomy is usually performed after a traumatic brain injury. Decompressive craniectomy can be proposed in the management of severe traumatic brain injury.
Predicted unfavorable neurologic outcome is overestimated by the marshall computed tomography score, corticosteroid randomization after significant head injury crash, and international mission for prognosis and analysis of clinical trials in traumatic brain injury impact models in patients with severe traumatic brain injury managed with early decompressive craniectomy. This metaanalysis examined whether early decompressive craniectomy dc can improve control of intracranial pressure icp and mortality in patients with traumatic brain injury tbi. There continues to be considerable interest in the use of decompressive craniectomy in the management of severe traumatic brain injury tbi, and stroke, and more recently in the context of subarachnoid haemorrhage, cerebrovenous thrombosis, severe intracranial infection, inflammatory demyelination, and encephalopathy. High intracranial pressure is the most frequent cause of mortality and disability after severe traumatic brain injury tbi which is treated. Guidelines for the management of severe traumatic brain injury. As bone and arachnoid trabeculae share the same collagen type, we investigated possible connections between the skull hounsfield unit hu values and shuntdependent. Several studies have indicated that decompressive craniectomy dc for traumatic brain injury tbi is lifesaving. Davies, 1 jennie ponsford, 6, 7 ian seppelt, 8 peter reilly, 9 eveline wiegers, 1, 10 and rory.
On behalf of the section on neurotrauma and critical care of the american association of neurological surgeons and the congress of neurological surgeons, we register our concern with the recently published article decompressive craniectomy in diffuse traumatic brain injury by cooper et al. The objective of this retrospective study was to evaluate the results of all decompressive craniectomies performed between 2005 and 2011 for. Although dc has been shown to improve both survival and functional outcome in patients with malignant cerebral infarctions, evidence of benefit in patients with tbi is decidedly more mixed. Outcomes of early decompressive craniectomy versus. The decompressive craniectomy decra in diffuse traumatic brain injury study published in 2011 randomized tbi patients to craniectomy vs maximal medical therapy. As per the decompressive craniectomy in diffuse traumatic brain injury decra trial, early bifrontotemporoparietal dc was found to decrease icp 14. On behalf of the section on neurotrauma and critical care of the american association of neurological surgeons and the congress of neurological surgeons, we register our concern with the recently published article decompressive craniectomy in diffuse traumatic brain injury. Technical considerations in decompressive craniectomy in the. Does the skull hounsfield unit predict shunt dependent.
Intracranial hypertension is the largest cause of death in young patients with severe traumatic brain injury. Role of decompressive craniectomy in diffuse traumatic. The decra decompressive craniectomy in diffuse traumatic brain injury trial published by cooper et al. The aim of the present study was to evaluate the impact of dc on hc evolution. It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and.
Functional outcomes at twelve months were a secondary outcome of the randomized decra trial of early decompressive craniectomy for severe diffuse traumatic brain injury and refractory intracranial. Dc involves the removal of a section of skull so that the brain has room to expand and the pressure decrease. Decompressive craniectomy is an emergency operation in case of severe traumatic primary brain injury as well as a secondline therapy to prevent secondary brain damage due to refractory elevated. Although many studies have been conducted in this topic, there is still much uncertainty about the effectiveness of surgical treatment in tbi. Frontiers new or blossoming hemorrhagic contusions after. Decompressive craniectomy in patients with severe brain injury causes a significant decrease in midline shift. Decompressive craniectomy in diffuse traumatic brain injury. It is a leading cause of mortality and disability across the globe, with low and middleincome countries lmics facing the greatest disease burden 1. Decompressive craniectomy in traumatic brain injury.
The relationship between decompressive craniectomy dc and evolution of the post traumatic hc is still unclear. What is new in decompressive craniectomy in neurological. Decompressive craniectomy in the management of traumatic brain. Functional outcomes at 12 months were a secondary outcome of the randomized decra trial of early decompressive craniectomy for severe diffuse traumatic brain injury tbi and refractory intracranial hypertension.
The current status of decompressive craniectomy in. Decompressive craniectomy an overview sciencedirect topics. Craniectomy in diffuse traumatic brain injury nejm. Timing of decompressive craniectomy for ischemic stroke. Hence, these complications often occur at the chronic traumatic phase, i. Decompressive craniectomy dc is used to improve the brain herniation or increased intracranial pressure caused by brain swelling as the result of severe traumatic brain injury or severe acute stroke. Decompressive craniectomy for severe traumatic brain. Is decompressive craniectomy a good idea for the management of intracranial hypertension in patients with diffuse traumatic brain injury. The role of decompressive craniectomy in the context of severe traumatic brain injury. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure. Role of decompressive craniectomy in traumatic brain.
In previous studies, decompressive craniectomy dc has been characterized as a risk factor in the hp of tich. Intracranial hypertension is a compartment syndrome, and it seems natural to surgically relieve this abnormal pressure as. The role of decompressive craniectomy in traumatic brain. Do traumatic brain contusions increase in size after. In the context of traumatic brain injury tbi, decompressive craniectomy dc is used as part of tiered therapeutic protocols for patients with intracranial hypertension secondary or protocoldriven dc. Rubiano, 2, 4 hadie adams, 1 tariq khan, 2, 5 deepak gupta, 2, 6 amos adeleye, 2, 7, 8 corrado iaccarino, 9 franco servadei, 10 bhagavatula indira devi, 2, 11 and peter j. Decompressive craniectomy is part of the second level measures for the management of increased intracranial pressure refractory to medical management as moderate hypothermia and barbiturate coma. Current studies report mixed results, preventing any clear conclusions on the place of decompressive craniectomy in traumatology. Request pdf on jul 28, 2011, olaf l cremer and others published craniectomy in diffuse traumatic brain injury find, read and cite all the research you need on researchgate. Brain swelling and intracranial hypertension are wellrecognized secondary insults associated with increased mortality and poorer outcomes. However, there is lack of level 1 evidence to define the role of dc in tbi. From december 2002 through april 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to firsttier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. We performed a metaanalysis of all the randomized controlled trials rcts published so far on the role of dc in adult patients with tbi. Mild traumatic brain injury mtbi is the most common form of tbi and accounts for up to 80% of clinical patients bruns jr and hauser, 2003.
Functional outcomes at 12 months were a secondary outcome of the randomized decra trial of early decompressive craniectomy for severe diffuse traumatic brain injury. Traumatic brain injury tbi is one of the high priority areas of causality care practice within the military as well as the civilian population. The importance of treating traumatic brain injury tbi is well known worldwide. The decra decompressive craniectomy in patients with severe traumatic brain injury compared early decompressive craniectomy for diffuse traumatic brain injury with standard medical therapy and found that patients in the surgical arm of the trial had worse outcomes than those treated medically. Decompressive craniectomy in children neurosurgery. Our results suggest that the distance of the lower border of the decompressive craniectomy from the temporal cranial base is more important for a beneficial effect than the size of the craniectomy.
1482 78 1586 645 705 1419 892 1253 948 805 1579 876 1294 725 919 1192 1004 257 1585 437 1290 1189 1111 273 1448 1219 1536 595 415 725 946 1162 1231 461 850 951 784 222 312 1121 840 385 1047 1405 799 1467 387