Decompressive craniectomy reduces death in traumatic brain injury

By Gene Emery

NEW YORK (Reuters Health) - A new study of more than 400 cases of severe traumatic brain injury has concluded that decompressive craniectomy dramatically reduces the risk of death by nearly half in patients with intracranial pressures >25 mmHg after conventional medical therapy.

But the survivors are more likely to be left in a vegetative state or have a high degree of severe disability than patients who received ongoing medical care.

The international study, known as the RESCUEicp Trial, was reported online September 7 in The New England Journal of Medicine.

Chief author Dr. Peter Hutchinson, a neurosurgeon at the University of Cambridge, said the findings would probably apply to about 10% of patients with brain swelling following non-penetrating head trauma. In the remaining cases, drugs can usually relieve the pressure.

"People perform the operation but nobody really knows whether it is benefiting the patient even though it's lowering the brain pressure," he told Reuters Health in a telephone interview. "What's always been uncertain is the effect on immediate clinical outcomes and further down the line."

"What the result shows is there is a very dramatic effect on mortality," said Dr. Hutchinson. But the surgery also increases the chance of a person being in a vegetative state or severely disabled.

The 408 patients from 20 countries were enrolled from 2004 through 2014. They were evaluated at 6 and 12 months on the 8-point Extended Glasgow Outcome Scale.

With decompressive craniectomy, the one-year survival rate was 69.6%, versus 48.1% with ongoing medical care in which barbiturates were used after randomization.

On the other hand, surgery nearly quadrupled the odds of ending up in a vegetative state one year after surgery: 6.2% after surgery compared to 1.7% for patients who didn't have the surgery.

In addition, 30.3% were dependent on others for care at the 6-month mark versus 16.5% with nonsurgical management. At the 12-month mark, the ratios shrank a bit; 24.2% in the surgical group were dependent compared to 15.6% in the medical group.

After the first six months, "What we see is surgical patients do improve with time such that an increasing number are living independently. At 12 months nearly half of the patients - 45 percent - were at least independent at home as compared to 32 percent who had the medical treatment," Dr. Hutchinson said.

Outcome rates at the one-year mark for surgery patients were 30.4% for death, 6.2% for vegetative state, 31.4% for severe disability, 22.2% for moderate disability, and 9.8% for good recovery.

Corresponding rates in the control group were 52.0% for death, 1.7% for vegetative state, 17.9% for severe disability, 20.1% for moderate disability, and 8.4% for good recovery.

Bifrontal craniectomy was used 63% of the time. Only bone from one side of the skull was removed in the remaining instances.

In addition, 37% of patients in the medical group underwent decompression anyway because their condition deteriorated so severely.

"This is the first time we've shown a really clear survival benefit. But I think it shows we need to be very honest with families about the level of disability," Dr. Hutchinson said. "What's encouraging is that between the 6-12 months there is improvement."

SOURCE: https://bit.ly/2bZ13NT

N Engl J Med 2016.