Will Decompressive Craniectomies Lead to Worse Outcomes for TBI Victims?
Decompressive craniectomies are an aggressive surgical strategy increasingly used at trauma centers for victims of diffuse traumatic brain injury. Although surgical methods vary, the decompressive craniectomy involves temporarily removing a portion of the skull to relieve the pressure from the swelling of the injured brain.
As recently reported in the New England Journal of Medicine, results of a randomized trial show that although decompressive craniectomy reduced intracranial pressure and the length of stay in the intensive care unit, it was also associated with a greater risk for unfavorable outcome at 6 months for patients with diffuse traumatic brain injury (TBI) compared with standard care. The standard care involves lowering the patient's body temperature and administering barbiturates.Rates of death didn't differ between groups, but scores on the Extended Glasgow Outcomes Scale were lower in the group undergoing bifrontotemporoparietal craniectomy, and there was a significant increase in risk, more than double, for an unfavorable outcome on that same scale, the researchers report. The unfavorable outcomes included vegetative state and conscious but disabled.
Our findings differ from those of most nonrandomized studies and are contrary to our hypothesis," the researchers, with lead study author D. James Cooper, MD, from the Department of Intensive Care at Alfred Hospital, Monash University, in Melbourne, Australia, acknowledge. " Our unexpected findings underscore the critical importance of performing such trials to test common therapies, particularly in patients with complex critical illnesses."
Experts stress that that the procedure should not be abandoned on the basis of these results. Surgeons must think more carefully about the risks and benefits of the decompressive craniectomy before performing the procedure and must work to further define appropriate clinical settings for this procedure.
