Critically evaluate the role of Decompressive Craniectomy (DC) following traumatic brain injury.
The main role of DC in TBI is reduction of ICP and prevention of herniation, aggravated by haematoma and brain swelling. Use of this technique is controversial and its efficacy in TBI is uncertain despite recent trials. Two main techniques widely used for DC in TBI are unilateral frontotemporoparietal craniectomy and bifrontal craniectomy
In a decompressive craniectomy, a substantial portion of the skull is removed in order to reduce increased ICP. This can be done in combination with an evacuation procedure or as a primary treatment for increased ICP. The rationale of DC is based in the Monro-Kellie Doctrine. The skull is a rigid unexpandable structure, opening the cranial vault by DC increases the volume available to the intracranial contents and reduces ICP. Current Brain Trauma Foundation guidelines suggested the ICP lower than 20 mmHg after TBI. Patients with well-controlled ICP under the threshold appear to have improved outcomes.
Published by Cooper et al. in 2011- 155 patients with TBI and either GCS score lower than 8 or CT demonstrating moderate diffuse brain injury were enrolled. Patients with refractory ICP (ICP>20 mmHg for 15 minutes) within a 1-hour period were randomized to one of two groups.
DC decreased ICP and the length of stay in the intensive care unit but was associated with more patients with unfavourable neurological outcomes.
Criticisms of DECRA:
Higher ICP threshold should be used before performing DC in TBI.
The period of medical management with high ICP was too short prior to randomisation.
More patients who had non-reactive pupil were enrolled in the DC group (27%) only 12% in medical therapy group.
The choice of surgical method- only bifrontal DC without falx sectioning allowed.
No standardised rehabilitation
Long enrolment period
Less emphasis on CPP.
Multicentre (48 centre, 19 countries) RCT
408 patients (age, 10-65 years) with TBI and refractory elevated ICP (>25 mmHg) were randomized to undergo DC or receive ongoing medical care.
The primary outcome was the Extended Glasgow Outcome Scale (GOS-E) at 6 months.
At 6 months patients in DC group resulted in lower mortality and higher rates of vegetative state, lower severe disability and upper severe disability than ongoing medical care group. The rates of moderate disability and good recovery were similar in the two groups.
A relatively large proportion of patients in the medical group underwent DC
• Reduces ICP
• Increases survival
• Decreases ICU length of stay
ICP reduction may not necessarily result in better clinical outcomes
Potentially increased numbers of severely debilitated survivors
Surgical complications potentially include:
• Axonal stretch
• Aggravated brain oedema
• Haematoma expansion or bleeding
• CSF leakage
• Syndrome of the trephined
We utilise decompressive craniectomy in our unit in young patients with TBI, refractory intracranial hypertension and relatively early in their course prior to irreversible secondary injury
Clinicians and family members will need to be aware of the risks when potentially employing this strategy.
Probably useful if mass lesion (excluded in DECRA)
There is a growing body of literature with conflicting results.
Decompressive craniectomy decreases ICP and leads to improved survival. The quality of that survival is the issue, so careful procedure selection, patient population selection and overall situation appreciation are important
The level of detail of the studies given in the template was not required.
Most candidates answered the question as asked, but several wasted efforts explaining other methods of controlling ICP or describing DC use in non-TBI situations. Candidates are reminded to read the stem carefully.
This SAQ is entirely unlike Question 9 from the first paper of 2009, where the focus was more on indications complications and outcomes. This one required some additional depth of analysis, of which probably the most sophisticated area involved the interpretation and presentation of the results of two major trials in TBI management. In spite of the dyssynchronous-sounding "wasted efforts" mentioned by the college, clearly many of the trainees (at least 67.2% of them) have at least a workmanlike knowledge of these issues.
Advantages of decompression in TBI include
This section should probably be written delicately. Among the examiners, there is clearly substantial heterogeneity of beliefs regarding this intervention. The "own practice" answer should be sufficiently conservative to please the haters of decompressive craniectomy, while acknowledging that it is difficult to present improved survival as a bad thing. Thus, something like:
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