- Department of Neurosurgery, Stanford Univ. Medical School, Stanford, USA
Department of Neurosurgery, Stanford Univ. Medical School, Stanford, USA
DOI:10.4103/2152-7806.96150Copyright: © 2012 Torres R. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Torres R. DECRA…Where do we go from here?. Surg Neurol Int 14-May-2012;3:54
How to cite this URL: Torres R. DECRA…Where do we go from here?. Surg Neurol Int 14-May-2012;3:54. Available from: http://sni.wpengine.com/surgicalint_articles/decrawhere-do-we-go-from-here/
In the United States, about two million head injuries of all types (including skull and facial fractures) occur each year (175 to 200 per 100,000 population), with the annual cost around $80 billion dollars.
It has been a year since the results of the randomized Decompressive Craniectomy (DECRA) trial were published on March 25 in the New England Journal of Medicine,New Engl J Med. Published online March 25, 2011. Since then, it has stirred up controversy in a number of circles amongst our colleagues. Over a period of eight years, the DECRA trial, identified 155 patients from 3478 screened, with severe diffuse TBI and intracranial hypertension refractory to first-tier therapies. These 155 were randomly assigned to either early decompressive craniectomy or standard of care therapy.
Patients in the craniectomy group, were found to have less time with intracranial pressures above the treatment threshold (20 mm.hg.), fewer interventions for elevations in intracranial pressure (ICP), and shorter lengths of stay (l.o.s), in the intensive care unit (ICU). Unfortunately however, patients that underwent decompressive hemi-craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care and ultimately greater risk of an unfavorable outcome. Rates of death at 6 months were similar in the craniectomy group (19%) vs. the standard-care group (18%).
The authors concluded that in adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy[
Their conclusions have raised a lot of eyebrows and significant criticism including senior members from the Section on Neurotrauma,[
Since this study seems to focus primarily on intracranial pressure, it is also important to point out, that most Neurosurgeons and Neuro-intensivists that manage traumatic brain injury would rarely if ever entertain decompressive craniectomy in patients with an ICP of 20 mm Hg for such brief duration. Studies recording ICP following head injury show that thresholds of 25 mm Hg determine outcome,[
What this study does suggest is that the normalization of ICP achieved with decompressive craniectomy may not be the key to managing patients with diffuse, severe traumatic brain injury.
When ICP and cerebral perfusion pressure(CPP) are normalized, patients with severe traumatic brain injury often have severe cerebral hypoxia, with reduced oxygen tension in brain tissue, which may explain their poor outcome[
Brain ischemia/hypoxia is a key factor in Neurologic outcome following severe traumatic brain injury, Unfortunately, no concomitant measurements of cerebral blood flow (CBF), brain tissue oxygenation(Pbt02), microdyalisis or bio-markers were used while ICP was increasing.[
Unfortunately, the DECRA study leaves us with little evidence that aggressive Neurosurgical intervention aimed at reducing ICP, improves outcome. In closing, I would caution the readers not to close the door on this topic but rather, support work which will help define the optimal clinical setting for this procedure. We await the results of the other ongoing trial of craniectomy for head injury called the Randomized Evaluation of Surgery with Craniectomy for uncontrollable Elevation of Intracranial Pressure(RESCUEicp), which has several differences in their design as compared to DECRA.
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