August 17, 2022

Healty

Slick Healthy

The Case for Decompressive Craniectomy vs. Medical Care

By Mary Beth Nierengarten

July 21, 2022


Article In Brief

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

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

A prespecified secondary analysis of the Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEICP) trial, published June 9 in JAMA Neurology, found that reduced mortality for surgical patients was sustained for up to 24 months.

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

Dr. Kolias stressed, however, that outcomes for patients include a range of possibilites beyond mortality that could affect the quality of life of patients. The study found higher rates of vegetative state and varied levels of disability in the patients who underwent surgery—either patients required help in independent daily activities (as assessed with lower severe disability) or could be independent at home for at least eight hours (upper severe disability), or they could be independent at home and outside the home but with some physical or mental disability (lower moderate disability) or independent at home and outside the home but with less disruption (upper moderate disability).

Of the 21 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 of their home and possibly could return to work.

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

Study Details

The prespecified secondary analysis of the RESCUEicp trial included 206 patients who had surgery and 202 who were treated medically and with barbiturate infusion as their last-tier treatment for refractory post-traumatic intracranial hypertension.

Patients from 52 centers in 20 countries were enrolled in the study between January 2004 and March 2014, and the data were analyzed between 2018 and 2021. All patients in the study were between 10- and 65 years of age and had sustained refractory elevated intracranial pressure (>25 mm Hg) for one to 12 hours after CT-confirmed traumatic brain injury despite measures to control intracranial pressure. Eighty percent were male; the group who received surgery were on average 32 years old, compared with 35 years old in those receiving standard medical care.

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

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“The results provide a broad framework when talking with families and their surrogates about treatment, including surgery, to convey a more realistic recovery trajectory from which families/surrogates can make informed decisions with their multidsiplinary team that align with their loved one wishes and values.”—DR. EMILY J. GILMORE

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

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

The senior author of the study Peter Hutchinson, MBBS, PhD, professor of neurosurgery at Cambridge University, emphasized that the results show that decompressive craniectomy has a clear role to play in managing refractory traumatic intracranial hypertension, but he cautioned that it is not a panacea.

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

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

Expert Commentary

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

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

Dr. Ziai said that decompressive craniectomy should remain in the clinical armament of neurosurgeons as a life-saving treatment for patients with traumatic intracranial hypertension refractory to first-line treatment. But she added that the challenge is to define which patients are most likely to benefit from the 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 a need for further comparative effectiveness research to determine whether patients selected for surgery in clinical practice achieve similar results to those studied in the trials,” she said.

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“Between 12 to 24 months, changes in GOS-E outcome distribution were not different for either medical or surgical groups, suggesting that further improvements in recovery become less likely beyond the first year. However, significant differences were observed between six- and 24-month GOS-E outcomes in the surgical group that were not seen in the medical group or between other time points.”—DR. WENDY ZIAI

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

Emily J. Gilmore, MD, director of the neurosciences intensive care unit and co-director of neurotrauma, neurology and neurosurgery at Yale School of Medicine, agreed that the findings were critical to better understand the trajectory of recovery for these patients.

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

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

Disclosures

None of the sources quoted had disclosures.