Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury
Editorial Group: Cochrane Injuries Group
Published Online: 25 JAN 2006
Assessed as up-to-date: 28 MAY 2008
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Sahuquillo J. Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD003983. DOI: 10.1002/14651858.CD003983.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 25 JAN 2006
High intracranial pressure (ICP) is the most frequent cause of death and disability after a severe traumatic brain injury (TBI). High ICP is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail to control high ICP, second-line therapies are initiated. Of these, barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (decompressive craniectomy) are used.
To assess the effects of secondary decompressive craniectomy on outcomes and quality of life for patients with severe TBI in whom conventional medical therapeutic measures have failed to control a raised ICP.
We searched the following electronic databases: Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, PubMed, EMBASE, ZETOC, CINAHL, and Controlled Trials metaRegister (www.controlled-trials.com/mrct/search). We searched the Internet using Google Scholar (http://scholar.google.com) and handsearched relevant conference proceedings. We also contacted experts in the field and authors of included studies. The searches were last conducted in May 2008.
Randomized or quasi-randomized studies assessing patients over the age of 12 months with severe TBI who underwent decompressive craniectomy to control ICP refractory to conventional medical treatments.
Data collection and analysis
The electronic search and handsearching results were examined for reports of potentially relevant trials, which were then retrieved in full. The selection criteria were applied, data extraction performed, and studies assessed for methodological quality.
We found only one trial with 27 participants, conducted in a pediatric population. Decompressive craniectomy was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72) and a RR of 0.54 (95% CI 0.29 to 1.01) for an unfavorable outcome (death, vegetative status, or severe disability 6 to 12 months after injury). To date, no results are available to confirm or refute the effectiveness of decompressive craniectomy in adults.
There is no evidence from randomized controlled trials that supports the routine use of secondary decompressive craniectomy to reduce unfavorable outcomes in adults with severe TBI and refractory high ICP. In the study with a pediatric population, decompressive craniectomy reduced the risk of death and unfavorable outcomes. Despite the wide CI for death and the small sample size of this one identified study, the treatment may be justified in patients below the age of 18 years when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of decompressive craniectomy (RescueICP and DECRA) that will allow further conclusions on the efficacy of this procedure in adults.
Plain language summary
Removal of a section of skull bone (decompressive craniectomy) after a severe traumatic brain injury in patients with raised intracranial pressure that has not responded to conventional medical treatments
An injury to the brain may cause it to swell. Pressure within the skull then increases as the brain has no room to expand; this excess pressure, known as intracranial pressure, can cause further brain injury. High intracranial pressure (ICP) is the most frequent cause of death and disability in brain-injured patients. If high ICP cannot be controlled using general or first-line therapeutic measures such as adjusting body temperature or carbon dioxide levels in the blood and sedation, second-line treatments are initiated. One of these is a procedure called decompressive craniectomy (DC). DC involves the removal of a section of skull so that the brain has room to expand and the pressure decrease. There is however clinical uncertainty regarding the use of DC and a lack of consensus on the optimal management of traumatic brain injury.
This review looked at all high quality trials investigating the effectiveness of DC, compared to conventional medical treatments, on survival and neurological outcomes for patients over the age of 12 months who had a raised ICP after traumatic brain injury (TBI). Only one trial was identified. This trial involved 27 pediatric patients (less than 18 years old). The results indicate that the risk of death and disability was moderately reduced when DC was used. No trials investigating the effectiveness in adults were found.
The authors of the review conclude that there is no evidence to support the routine use of DC to improve mortality and quality of life in brain-injured adults with high ICP. DC may improve survival and neurological outcomes in brain-injured pediatric patients with raised ICP for whom other medical treatments had failed. This one trial involved only a small number of patients and further studies are needed before applying DC as a routine treatment.
Two trials of DC are currently in progress, the results from which may allow further conclusions regarding the effectiveness of the procedure in adults. These will be incorporated into the review when they are completed.
高顱內壓(intracranial pressure (ICP))是嚴重腦外傷(traumatic brain injury (TBI))後最常見的死亡與失能的原因。高ICP以一般策略(常溫，鎮靜等)與一連串的第一線治療方式(適當的低碳酸血，mannitol等)加以治療。當這些方法無法控制高ICP時，便開始採用第二線治療。其中，第二線治療如使用barbiturates，過度換氣，適當的低溫或移除一部分可變動的顱骨(稱為減壓性顱骨切除術)。
傳統醫學治療策略無法控制TBI患者其嚴重升高的ICP時，評估次級的減壓性顱骨切除術(decompressive craniectomy (DC))對病患結果與生活品質的效果。
我們檢索the Cochrane Injuries Group's Trial Register，CENTRAL，MEDLINE，EMBASE，Best Evidence，Clinical Practice Guidelines，PubMed，CINAHL，the National Research Register與Google Scholar。我們也人工檢索相關的會議記錄並連絡該領域的專家與納入研究的作者。
我們發現一篇建立於兒童族群(超過18歲)的試驗，包括27名研究對象。DC患者其死亡的相對風險(risk ratio (RR))為0.54(95% CI為0.17至1.72)，且其死亡，呈植物人狀態或受傷後六至十二月嚴重失能的RR為0.54(95% CI 0.29至1.07)。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。