September 2016
Patients with traumatic brain injury and raised intracranial pressure who underwent decompressive craniectomy — in which a large section of the skull is removed to allow the brain to expand — had a far lower mortality rate but were more likely to be left with severe disability than those treated medically, according to a new randomized study.

The results, from the Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) trial, were published online in The New England Journal of Medicine on September 7.

“This is groundbreaking as it is the first intervention that has shown a major difference in outcome in this population — in particular a large and dramatic survival benefit,” lead author, neurosurgeon Peter Hutchinson, FRCS, commented to Medscape Medical News.

Mortality was reduced from 48.9% in the control group to 26.9% in the surgery group.

However, the concern is that patients whose lives have been saved by this procedure are generally left with a severe level of disability, with more patients in a vegetative state or with lower severe disability (dependent on others for care) or upper severe disability (able to live independently but requiring support to go out), Professor Hutchinson added.

The rates of moderate disability and good recovery were similar in the two groups, he said, “so the big question is, ‘Is it worth it?’ That is the fundamental issue.”

“There is no doubt this surgery saves lives — but we have to look very carefully at the quality of survival to give information to families on the pros and cons of performing this surgery,” he said. “This is not a black and white decision. This surgery is already taking place in practice, but now we have more information to guide our decisions. The data are now out there and can be discussed, and the neurosurgeons need to interpret it for themselves. I believe some will take this study as a reason to do more of these procedures. Others may be more concerned about the increase in patients left in a vegetative state and decide to do less.”
He noted that these patients have sustained traumatic brain injury mainly as a result of road traffic accidents, falls, or assaults. They are generally young — the median age was 33 years (range, 10 to 65 years). They had refractory elevated intracranial pressure (>25 mm Hg) for 1 to 12 hours.

So far, no treatment has shown evidence of benefit in terms of outcome for these patients, he said. “We try to bring intracranial pressure down with drugs such as barbiturates, but this has not been tested in an outcomes study. Decompressive surgery is also performed in some cases, but again there has been no evidence of benefit until now in an outcomes study.”

Professor Hutchinson explained that that there are two types of decompressive surgery: primary (hematoma is removed on admission and part of the skull is not replaced after the operation) and secondary (conducted later when there is diffuse brain swelling despite medical treatment).

“This trial tested secondary surgery,” he said. “All patients received medical treatment. If this did not work and the brain was still swollen, then the surgery was performed.”


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