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Decompressive craniectomy in traumatic brain injury after the DECRA trial. Where do we stand?
Juan Sahuquillo1, Francisco Martínez-Ricarte, Maria-Antonia Poca
1Department of Neurosurgery and Neurosurgery and Neurotraumatology Research Unit (UNINN), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain. sahuquillo@neurotrauma.net
Insights
Decompressive craniectomy effectively lowers intracranial pressure (ICP) in traumatic brain injury patients. However, current evidence does not support claims of increased unfavorable outcomes, suggesting its use as a last resort.
Area of Science:
- Neurosurgery
- Critical Care Medicine
- Trauma Surgery
Background:
- Decompressive craniectomy is a surgical procedure to reduce elevated intracranial pressure (ICP).
- The 2011 Decompressive Craniectomy (DECRA) trial evaluated its effectiveness in adults with traumatic brain injury (TBI).
- DECRA reported decreased ICP but raised concerns about unfavorable outcomes.
Purpose of the Study:
- To contextualize the DECRA trial findings.
- To critically analyze the implications of decompressive craniectomy for TBI management.
- To discuss the role of decompressive craniectomy in clinical practice.
Main Methods:
- Review and analysis of the DECRA trial data.
- Discussion of the clinical significance of the trial's results.
- Evaluation of decompressive craniectomy as a treatment option.
Main Results:
- Decompressive craniectomy significantly reduces ICP and intensive care unit (ICU) length of stay.
- The trial did not find a reduction in mortality or unfavorable outcomes after adjusting for baseline covariates.
- The association between decompressive craniectomy and unfavorable outcomes is considered overstated.
Conclusions:
- It is premature to alter clinical practice based solely on the DECRA trial.
- Decompressive craniectomy may be considered a last resort in protocol-driven management for refractory ICP.
- Establishing an ICP threshold for patient selection is crucial for optimizing outcomes.
Purpose Of Review:
The results of the multicentre, randomized, controlled trial to test the effectiveness of decompressive craniectomy in adults with traumatic brain injury and high intracranial pressure (Decompressive Craniectomy, DECRA) were published in 2011. DECRA concluded that decompressive craniectomy decreased intracranial pressure (ICP) but was associated with more unfavourable outcomes. Our review aims to put the DECRA trial into context, comment on its findings and discuss whether we should include decompressive craniectomy in our clinical armamentarium.
Recent Findings:
The key message that DECRA conveys is that decompressive craniectomy significantly lowers ICP and shortens the length of the stay in the ICU. However, neither mortality nor unfavourable outcome was reduced when adjusting the significant baseline covariates.
Summary:
The claim that decompressive craniectomy increases unfavourable outcome is overstated and not supported by the data presented in DECRA. We believe it premature to change clinical practice. Given the dismal outcome in these patients, it is reasonable to include this technique as a last resort in any type of protocol-driven management when conventional therapeutic measures have failed to control ICP, the presence of operable masses has been ruled out and the patient may still have a chance of a functional outcome. The main lesson to be learned from this study is that an upper threshold for ICP must be used as a cut-off for selecting decompressive craniectomy candidates.
