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Balancing the short-term benefits and long-term outcomes of decompressive craniectomy for severe traumatic brain
1Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Perth, Western Australia, Australia.
Insights
Decompressive craniectomy can reduce mortality in neurological emergencies but may increase severe disability. The procedure should be reserved for intractable intracranial hypertension, with careful patient-centered discussions about outcomes.
Area of Science:
- Neurosurgery
- Critical Care Medicine
Background:
- Decompressive craniectomy is used for neurological emergencies to reduce intracranial pressure.
- Concerns exist regarding increased severe disability despite potential mortality reduction.
Purpose of the Study:
- Analyze recent randomized controlled trials on decompressive craniectomy efficacy.
- Evaluate the procedure's impact on short-term mortality and long-term functional outcomes.
Main Methods:
- Review of recent randomized controlled trials.
- Analysis of mortality rates and functional outcomes post-procedure.
Main Results:
- Decompressive craniectomy can reduce intracranial pressure.
- Evidence on improving functional outcomes remains debated, with potential for increased severe disability.
Conclusions:
- Clinical decision-making should reserve decompressive craniectomy for intractable intracranial hypertension in non-survivable cases.
- Patient-centered discussions are crucial regarding the risks and benefits, including survival with severe neurocognitive impairment.
Abstract:
Introduction: The role of decompressive craniectomy in the management of neurological emergencies remains controversial. There is evidence available that it can reduce intracranial pressure, but it will not reverse the effects of the pathology that precipitated the neurological crisis, so there has always been concern that any reduction in mortality will result in an increase in the number of survivors with severe disability.Areas covered: The results of recent randomised controlled trials investigating the efficacy of the procedure are analyzed in order to determine the degree to which the short-term goals of reducing mortality and the long-term goals of a good functional outcome are achieved.Expert opinion: Given the results of the trials, there needs to be a change in the clinical decision-making paradigm such that decompression is reserved for patients who develop intractable intracranial hypertension and who are thought unlikely to survive without surgical intervention. In these circumstances, a more patient-centered discussion is required regarding the possibility and acceptability or otherwise of survival with severely impaired neurocognitive function.
