Abstract
BackgroundTwo randomised controlled trials (RCTs) of decompressive craniectomy (DC) in traumatic brain injury (TBI) have shown poor outcome, but there are considerations of how these protocols relate to real practice. The aims of this study were to evaluate usage and outcome of DC and thiopental in a single centre.MethodThe study included all TBI patients treated at the neurointensive care unit, Akademiska sjukhuset, Uppsala, Sweden, between 2008 and 2014. Of 609 patients aged 16 years or older, 35 treated with DC and 23 treated with thiopental only were studied in particular. Background variables, intracranial pressure (ICP) measures and global outcome were analysed.ResultsOf 35 DC patients, 9 were treated stepwise with thiopental before DC, 9 were treated stepwise with no thiopental before DC and 17 were treated primarily with DC. Six patients received thiopental after DC. For 23 patients, no DC was needed after thiopental. Eighty-eight percent of our DC patients would have qualified for the DECRA study and 38% for the Rescue-ICP trial. Favourable outcome was 44% in patients treated with thiopental before DC, 56% in patients treated with DC without prior thiopental, 29% in patients treated primarily with DC and 52% in patients treated with thiopental with no DC.ConclusionsThe place for DC in TBI management must be evaluated better, and we believe it is important that future RCTs should have clearer and less permissive ICP criteria regarding when thiopental should be followed by DC and DC followed by thiopental.
Highlights
Traumatic brain injury (TBI) continues to cause substantial morbidity and mortality
In the DECRA (Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury) study [2], traumatic brain injury (TBI) patients with intracranial pressure (ICP) over 20 mmHg continuously or intermittently for 15 min during an hour and who did not respond to first line ICP treatment were randomised to either decompressive craniectomy (DC) or continuing standard medical care with addition of mild hypothermia followed by barbiturates
The current study investigates the usage of DC and long-term global outcome in a single centre, both when DC is used as a late step in an escalated management protocol that includes both thiopental as well as DC to reduce refractory elevated ICP, and when DC is done at the time of mass lesion evacuation
Summary
Traumatic brain injury (TBI) continues to cause substantial morbidity and mortality. The annual incidence is estimated at 260 per 100,000 in Europe, with a fatality rate between 0.9 and 7.6% [14]. In the DECRA (Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury) study [2], TBI patients with ICP over 20 mmHg continuously or intermittently for 15 min during an hour and who did not respond to first line ICP treatment were randomised to either DC (bifrontotemporoparietal) or continuing standard medical care with addition of mild hypothermia followed by barbiturates. In the Rescue-ICP study [8], patients with ICP above 25 mmHg for 1–12 h, refractory to first- and second-line treatment, were randomised to either barbiturates or DC (unilateral frontotemporoparietal or bifrontal). The DECRA study showed better global outcome in the group treated with standard. Two randomised controlled trials (RCTs) of decompressive craniectomy (DC) in traumatic brain injury (TBI) have shown poor outcome, but there are considerations of how these protocols relate to real practice. Favourable outcome was 44% in patients treated with thiopental before DC, 56% in patients treated with DC without prior thiopental, 29% in patients treated primarily with DC and 52% in patients treated with thiopental with no DC
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