Skull removal surgery for traumatic brain injury
A recent article published in the New England Journal of Medicine1, “Decompressive craniectomy in diffuse traumatic brain injury”, seeks to define the utility of removing a part of the skull for treatment of severe brain injury with abnormally high pressure within the cranium. The surgical procedure to remove part of the skull, called a craniectomy, is intended to allow the swelling injured brain room to expand and avoid the deleterious effects of high pressure induced by swelling. There have been published reports demonstrating the value of such a procedure in the treatment of brain swelling with posttraumatic brain injury and strokes.
The present study was a randomized clinical trial consisting of 155 patients with severe brain injury. They were randomized to receive the standard medical treatment for increased intracranial pressure versus proceeding with surgery to remove a part of the skull, decompressive craniectomy. The trigger for randomization to surgery or nonsurgical treatment was intracranial pressure rising above the normal value for more than 15 minutes despite what was considered optimal interventions.
The results were that those undergoing a decompressive craniectomy successfully had lower intracranial pressure, less time on the mechanical ventilator and shorter stay in the intensive care unit. However, they were more likely to have fluid buildup in the brain, called hydrocephalus, and more likely to have medical and surgical complications. Although the surgery patient had a shorter stay in the intensive care unit, they did not have a shorter hospital stay. In fact, the outcomes for mortality and disability were worse for the craniectomy group unless adjustments were made for the neurologic function at the time of randomization to treatment.
The conclusion of the study is that patients with severe head injury undergoing a craniectomy for increased intracranial pressure after brain injury had a worse outcome. However, there were many patients from an additional group of 3478 excluded from participation in this clinical trial which was narrowed down to 155 patients. The results may not be generalizable since such a narrow group may not represent the typical severe headache the patient for which the decision may need to be made about a decompressive craniectomy. Also, the time of 15 minutes of elevated intracranial pressure as a trigger for randomization to surgery is a much shorter time than is customarily allowed for other medical interventions before surgery is considered. Thus, it remains to be further elucidated by other clinical trials if this procedure improves outcomes when it is more widely applied to victims of severe head injury who have high intracranial pressure not responding to standard therapy.
1) Decompressive Craniectomy in Diffuse Traumatic Brain Injury; Cooper et al.;
New England Journal of Medicine March 25, 2011