ARTICLE REVIEW
Intracranial hypertension following traumatic brain injury (TBI) has been associated with increased mortality and recently published international guidelines [1] recommend treating intracranial pressure (ICP) >22mmHg to minimise the risk of secondary brain injury. The previously published DECRA study [2] recruited 155 patients with TBI and ICP >20mmHg for >15 minutes despite optimal medical therapy and randomised them to receive decompressive craniectomy or standard care alone. In the DECRA study significantly more patients in the craniectomy group had an unfavourable neurological outcome at 6 months (70% vs. 51%, p=0.02) whilst mortality was similar (19% vs. 18%, p>0.05).
The Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of intracranial pressure (RESCUEicp) trial [3] is a prospective multi-centre randomised controlled trial, recruiting from 24 countries (71% of patients recruited from the United Kingdom). Like the DECRA trial patients with TBI and refractory intracranial hypertension were randomised to receive either surgery and optimal medical therapy, or optimal medical therapy alone. The study recruited older children (age ≥10) and adults (age ≤65) with severe TBI from centres that could offer around-the-clock neurosurgical services. Patients with fixed dilated pupils, bleeding diathesis or an injury which was deemed unsurvivable were excluded.
Surgery (either unilateral frontotemporoparietal hemi-craniectomy or bifrontal craniectomy, depending on the pattern of injury and at the discretion of the surgical team) was considered a ‘last tier’ intervention and to be eligible for randomisation patients needed to have ICP >25mmHg for >1 hour (but <12 hours) despite stage 1 and stage 2 medical therapies. The use of barbiturates were prohibited in stage 1 and stage 2 medical therapies, but permitted in the group randomised to non-surgical management. Crossover (i.e. craniectomy in the medical group and barbiturates in the surgical group) was permitted in the event of further deterioration of the patient’s condition.
408 patients were randomised and following exclusion of patients for whom there was no valid consent (n=10) or were lost to follow-up (n=9) 389 patients could be included in the primary intention to treat analysis. Patients were predominantly young (mean age 33.5 years) and male (81%). In the surgical group craniectomy was performed in 93% of patients, whilst 87% of patients in the medical group received barbiturates. More than a third of patients in the medical group had a subsequent decompressive craniectomy (37%).
At 6 months there was a trend towards more favourable neurological outcome (Extended Glasgow Outcome Scale score 4-8) in the surgical group (42.8% vs. 34.6%, p=0.12). The secondary outcome of favourable neurological outcome at 12 months was significantly more common in the surgical group (45.4% vs. 32.4%, p=0.01) and there was significantly lower mortality at both 6 and 12 months in the surgical group (26.9% vs. 48.9% and 30.4% vs. 52.0% respectively).
In this well conducted randomised controlled trial patients randomised to decompressive craniectomy for refractory intracranial hypertension following severe TBI were significantly less likely to die, whilst rates of vegetative state and severe disability were greater. The authors estimate that for every 100 patients treated with surgical intent there would be an additional 22 survivors, however only 8 of these survivors would recover adequately to be able to live independently within their own home.
This article review was submitted by ESICM Journal Review Club member Dr Richard Fisher.
References
1. Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. 4th edition. 2016.
2. Cooper DJ et al. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med. 2011;364:1493-502.
3. Hutchinson PJ et al. Trial of Decpmressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med. 2016;375:1119-30.
