Early Decompressive Craniectomy Does Not Improve 12-Month Outcomes Among Patients With Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is a serious condition that often requires intensive in-hospital treatment. One of the most common health crises after a severe TBI is elevated intracranial pressure (ICP), which occurs when cerebrospinal fluid exerts excess pressure on the brain and the skull, often leading to permanent brain damage. Given that 60% of patients with severe TBI die or are permanently disabled as a result of their injuries, clinicians are motivated to develop effective treatments that improve patient outcomes by managing ICP immediately after injury.

One such intervention is called early decompressive craniectomy, a high-risk procedure in which a surgeon removes a portion of the patient’s skull to relieve pressure on the brain. Despite some evidence that decompressive craniectomy is an effective treatment for severe TBI, many clinicians believe that the risks and recovery associated with neurosurgery outweigh the benefits of the procedure, preferring to manage elevated ICP with other therapies. Additionally, there is controversy about the most effective timing of decompressive craniectomy: some clinicians prefer to perform the surgery early (within 72 hours of TBI), while others argue that the patient needs more time to stabilize before the procedure is safe.

A research team sought to resolve this controversy by studying outcomes among severe TBI patients who underwent early decompressive craniectomy to reduce elevated ICP. The researchers used data from the DECompressive CRAniectomy (DECRA) trial, which included 155 adults with TBI and elevated ICP, half of whom received standard intensive medical care (such as barbiturate infusions) and half of whom received early decompressive craniectomy in addition to standard care. The DECRA trial then assessed outcomes (such as motor skills and eye movement) among patients who survived for at least 12 months after their TBI, finding that:

  • At six months after injury, there were no functional differences between patients who received early decompressive craniectomy and those who only received standard care.
  • At twelve months after injury, decompressive craniectomy did not increase chances of survival compared to standard care.
  • Patients who received early decompressive craniectomy were more likely to be in a vegetative state and were less likely to have good functional outcomes compared to patients who received standard care.

Despite evidence that early decompressive craniectomy is an effective short-term treatment to reduce elevated ICP after head injury, the results of this study suggest that (compared to standard care) this surgical procedure does not improve survival rates or positive outcomes among patients who survive at least one year after TBI. In fact, patients who received early decompressive craniectomy were more likely to remain in a permanent vegetative state at the one-year mark, suggesting that long-term complications of the surgery outweigh the short-term benefits.

Cooper DJ, Rosenfeld JF, Murray L, et al. Patient outcomes at twelve months after early decompressive craniectomy for diffuse traumatic brain injury in the randomized DECRA clinical trial. Neurotrauma. (March 2020).

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