The case for decompressive craniectomy versus medical care for… : Neurology Today

By Mary Beth Nierengarten

July 21, 2022


Article in brief

A new analysis found that people who had depressive craniectomy for traumatic brain injury with elevated intracranial pressure were more likely to improve at 24 months, compared to those who received standard medical treatment. Those who underwent the surgery survived with moderate to severe disability, although the disability improved over time.

Patients who underwent decompressive craniectomy for severe traumatic brain injury with elevated intracranial pressure were twice as likely to improve up to 24 months after surgery, compared to patients treated with standard medical care.

A pre-specified secondary analysis from the Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEICP) trial, published June 9 in JAMA Neurologyfound that the reduction in mortality in surgical patients was maintained for up to 24 months.

“We estimate that for every 100 patients treated with surgical rather than medical intent, there will be 21 additional survivors,” said study lead author Angelos Kolias, MD, PhD, consultant neurosurgeon at the University of Cambridge at UK. The results support the use of decompressive craniectomy in the management of patients with refractory post-traumatic intracranial hypertension, he said.

Dr. Kolias, however, pointed out that patient outcomes include a range of possibilities beyond mortality that could affect patients’ quality of life. The study found higher rates of vegetative state and varying levels of disability in patients who underwent surgery: either patients needed help with independent daily activities (rated with low severe disability ), or they could be independent at home for at least eight hours (higher serious condition). disability), or they may be independent at home and away but with some physical or mental disability (lower moderate disability) or independent at home and away but with less disturbance (upper moderate disability).

Of the 21 out of 100 patients who survive decompressive craniectomy, he said, six would be dependent, seven could be independent at home and eight would be independent outside their home and could eventually return to work.

“Survivors have a range of possible outcomes, including addiction,” he said. “Therefore, an open discussion with families is crucial, as becoming dependent may be unacceptable for some patients.”

Study details

The pre-specified secondary analysis of the RESCUEicp trial included 206 operated patients and 202 treated medically and with barbiturate infusion as last resort treatment for refractory post-traumatic intracranial hypertension.

Patients from 52 centers in 20 countries were recruited into the study between January 2004 and March 2014, and data were analyzed between 2018 and 2021. All patients in the study were between the ages of 10 and 65 and had blood pressure sustained refractory high intracranial. (> 25 mm Hg) for one to 12 hours after CT-confirmed head trauma despite intracranial pressure control measures. Eighty percent were men; the group who underwent surgery were on average 32 years old, compared to 35 years old among those who received standard medical care.

The study reported functional outcomes at 24 months on the Extended Glasgow Outcome Scale (GOS-E). It found that the reduction in mortality in the surgical group compared to those receiving medical care at six and 12 months was maintained at 24 months (33.5% and 54%, respectively). However, at 24 months, surgical patients had significantly higher rates of being in a vegetative state and had greater disability.

“The results provide a general framework when discussing treatment with families and their surrogates, including surgery, to convey a more realistic recovery trajectory from which families/surrogates can make informed decisions with their multidisciplinary team that correspond to the wishes and values ​​of their loved one. ”—DR. EMILY J. GILMORE

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“Survivors have a range of possible outcomes, including addiction. Therefore, an open discussion with families is crucial, as becoming dependent may be unacceptable for some patients. —DR. ANGELOS G. KOLIAS

Looking at changes in GOS-E over time, however, surgical patients were more likely to improve than medical patients. The study found that 30.4% of surgical patients improved by at least 1 point on the GOS-E scale from six to 24 months, compared to 14.5% of medical patients.

Study lead author Peter Hutchinson, MBBS, PhD, professor of neurosurgery at the University of Cambridge, pointed out that the results show that decompressive craniectomy has a clear role to play in the management of traumatic intracranial hypertension. refractory, but he warned that it is not a panacea.

The improvement seen in surgical patients could be related to the fact that these patients underwent cranioplasty to reconstruct the cranial defect between six and 12 months after the decompression craniectomy, he explained.

“It is important to better understand the potential negative effects of living with a cranial abnormality in terms of neurological but also psychosocial disability,” he said, adding that prospective studies are needed to examine whether performing cranioplasty earlier in these patients (less than three months after craniectomy) might mitigate these negative effects.

Expert commentary

In addition to providing a stronger argument for the use of decompressive craniectomy, the longer follow-up results provide insight into what patients’ ultimate trajectory might look like once they have completed rehabilitation and reached a plateau in their recovery, said Wendy Ziai, MD, MPH, professor of neurology, neurosurgery, anesthesiology and critical care medicine at Johns Hopkins University School of Medicine.

“Between 12 and 24 months, changes in the distribution of GOS-E scores were not different for medical or surgical groups, suggesting that further improvements in recovery become less likely beyond the first year” , said Dr. Ziai. “However, significant differences were observed between GOS-E results at six and 24 months in the surgical group that were not observed in the medical group or between other time points.”

Dr. Ziai said decompressive craniectomy should remain in the clinical arsenal of neurosurgeons as a life-saving treatment for patients with traumatic intracranial hypertension refractory to first-line therapy. But she added that the challenge is to define which patients are most likely to benefit from surgery.

Dr. Ziai noted that many patients who undergo decompressive craniectomy in clinical practice have characteristics that would have excluded them from the current trial. “This suggests the need for further comparative efficacy research to determine whether patients selected for surgery in clinical practice achieve similar outcomes to those studied in trials,” she said.

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“Between 12 and 24 months, changes in the distribution of GOS-E scores were not different for medical or surgical groups, suggesting that further improvements in recovery become less likely beyond the first year. However, significant differences were observed between GOS-E results at 6 and 24 months in the surgical group that were not observed in the medical group or between other time points.”—DR. WENDY ZIAÏ

She pointed out that “accepting potentially poor functional outcomes for survival benefit” presents an ethical dilemma. Additionally, she added that it was important to consider individual patient preferences regarding quality of life in clinical decision-making.

Emily J. Gilmore, MD, director of the Neuroscience Intensive Care Unit and co-director of neurotrauma, neurology and neurosurgery at Yale School of Medicine, agreed that the findings were key to better understanding the recovery trajectory. of these patients.

“The results provide a general framework when discussing treatment with families and their surrogates, including surgery, to convey a more realistic recovery trajectory from which families/surrogates can make informed decisions with their multidisciplinary team that align with the wishes and values ​​of their loved one,” she said, adding that it is important for clinicians to recognize the limitations of the data from which prognostic predictions are made while balancing expectations regarding results, extended recovery times and quality of life.

Dr. Gilmore also highlighted the need to better understand the nuances of patient selection for decompressive craniectomy in this setting. She noted the challenge of applying the study results to patients whose characteristics do not match those of the trial participants. “There is still a lot of work to be done to appreciate the different endophenotypes of traumatic brain injury,” she said.

Disclosures

None of the cited sources had disclosures.

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