Intervention Review

Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury

  1. Juan Sahuquillo*

Editorial Group: Cochrane Injuries Group

Published Online: 25 JAN 2006

Assessed as up-to-date: 28 MAY 2008

DOI: 10.1002/14651858.CD003983.pub2


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.

Author Information

  1. Vall d'Hebron University Hospital, Department of Neurosurgery, Barcelona, Barcelona, Spain

*Juan Sahuquillo, Department of Neurosurgery, Vall d'Hebron University Hospital, Paseo Vall d'Hebron 119 - 129, Barcelona, Barcelona, 08035, Spain. sahuquillo@neurotrauma.net.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 25 JAN 2006

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

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.

Objectives

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.

Search methods

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.

Selection criteria

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.

Main results

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.

Authors' conclusions

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

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

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.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

腦外傷病患中用於治療難治之高顱內壓的減壓性顱骨切除術

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)。

目標

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。

搜尋策略

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。

選擇標準

評估一歲以上之嚴重TBI患者其施行DC以控制傳統醫學治療策略所無法控制之ICP的隨機或類隨機研究。

資料收集與分析

兩名作者分別評估電子檢索結果以篩選可能相關試驗的報告並取得全部。一名作者應用篩選標準,進行資料摘錄並評估方法學品質。聯絡研究的作者以了解更多的資訊。

主要結論

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)。

作者結論

沒有證據支持常規使用次級的DC可以減少嚴重TBI與難治之高ICP不利的結果。兒童族群中,DC可以減少死亡風險與不利的結果。儘管死亡的信賴區間寬鬆且只有少量樣本數的研究被確定,但當所有的醫學治療無法控制ICP時這種治療也許對於18歲以下的病患也許是合理的。至今,隨機試驗的結果無法推斷或反對DC對於成人的效果。然而,有關成人之歷史對照組的非隨機試驗與對照試驗的結果認為,當所有的醫學治療無法控制ICP時DC也許是一個有利的選擇。目前有兩篇持續進行的DC(Rescue ICP與DECRAN)隨機對照試驗,其也許可以進一步推論關於這種手術對於成人的效益。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於傳統醫學治療沒有反應的顱內壓,移除一部分顱骨的手術可以改善腦外傷患者升高的顱內壓(過高的顱內壓)?腦部受傷也許會造成其腫脹。在這種案例中因為腦部沒有擴張的空間使得顱內的壓力增加;這種過度的壓力(稱為顱內壓)會造成進一步傷害。高顱內壓(ICP)是腦部受傷病患最常見的死亡與失能的原因。如果高ICP無法使用一般策略或第一線治療方法獲得控制,則開始第二線的治療。其中一種第二線治療方法是稱為減壓性顱骨切除術(DC)的手術。DC包含移除一部分的顱骨以使腦部的空間擴張因而減少ICP。然而,DC的使用具有臨床的不確定性,且缺少腦外傷適當處置的共識。這篇回顧觀察所有調查DC相較於傳統醫學治療之高品質的試驗,依據腦外傷(TBI)後ICP升高的一歲病患其存活與神經學結果。只有確定一篇高品質的試驗;其包含27名有TBI的兒童病患(18歲以下),其接受DC或傳統治療。研究結果指出使用DC時可以適度減少死亡與失能風險。沒有發現試驗研究成人的效果。回顧的作者推論沒有證據可以支持常規使用DC以改善高ICP的腦受傷病患的死亡率與生活品質。一篇試驗的證據指出其他醫學治療對於高ICP失敗時,DC也許可以改善ICP升高的腦受傷兒童病患其存活與神經學結果。然而,因為這一篇試驗只包含少量的病患,因此應用DC作為常規治療之前還需要進一步的研究。目前有兩篇試驗正在進行中,其結果也許可以進一步推論手術對於成人的效果,且它們的成果可以整合到回顧中。