Information sourced from NEJM Journal Watch:
Delayed Decompressive Craniectomy After Traumatic Brain Injury
In the long-awaited RESCUEicp trial, decompressive craniectomy led to a 22% absolute decrease in mortality, a 6% increase in vegetative state, a 19% increase in survival with disability, and similar rates of full recovery.
In 2011, the DECRA trial showed that early decompressive craniectomy for brain swelling after traumatic brain injury (TBI) was not only ineffective but worsened outcomes. Nevertheless, craniectomy remains in use as salvage therapy for patients at imminent risk of fatal brainstem herniation. Investigators now report on the RESCUEicp trial comparing salvage craniectomy versus continued medical management alone.
Between 2004 and 2014, 52 centers in 20 countries enrolled 408 TBI patients between the ages of 10 and 65 years. Key eligibility requirements were an abnormal computed tomographic (CT) scan and persistently elevated intracranial pressure (>25 mm Hg for >1 hour) despite standard medical therapies except for barbiturates. Patients were randomly assigned to decompressive craniectomy versus barbiturate infusion. (Ultimately, 37% of those randomized to barbiturates also underwent craniectomy.) The primary outcome was the Extended Glasgow Outcome Scale (GOS-E) at 6 months.
At 6 months, GOS-E scores differed significantly between the two groups, but not in a linear way. Craniectomy significantly increased survival (49% vs. 27%) but not rates of functional independence (both 27%). At 12 months, there was again no significant difference in independent function (22% vs. 21%). Rates of a good outcome, defined by the authors as at least independent functioning at home while requiring help with travel or shopping, were significantly higher in the craniectomy group (43% vs. 35% at 6 months; 45% vs. 32% at 12 months).
DECRA showed that early craniectomy after TBI is harmful, probably because many patients could have been medically managed. RESCUEicp shows that craniectomy for truly refractory cerebral edema is life-saving (and given that many control patients underwent craniectomy, the trial likely underestimates the mortality benefit of the procedure). However, craniectomy increases the chance of being left vegetative or severely disabled and does not increase the chance of a good enough recovery to return to independent living. We must ensure that these facts are clearly communicated to and understood by patients’ surrogates so that life-or-death decisions about craniectomy align with patients’ values.
Hooman Kamel, MD reviewing Hutchinson PJ et al. N Engl J Med 2016 Sep 22. Shutter LA and Timmons SD. N Engl J Med 2016 Sep 22.
Hutchinson PJ et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 2016 Sep 22; 375:1119.
Shutter LA and Timmons SD. Intracranial pressure rescued by decompressive surgery after traumatic brain injury. N Engl J Med 2016 Sep 22; 375:1183.
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