Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury

Abstract

Background Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Patient Outcomes at Twelve Months after Early Decompressive Craniectomy for Diffuse Traumatic Brain Injury in the Randomized DECRA Clinical Trial

“…International consensus guidelines concerning decompressive craniectomy in the management of patients with TBI were recently published. 24 Future potential modifications of the craniectomy surgery technique are unlikely to change our results: hinged craniotomy, [25][26][27] unilateral craniectomy, or even not opening the dura at all are strategies that limit brain herniation, but were not tested in the DECRA trial. DECRA excluded patients with intracranial hematomas (mass lesions) as these patients often require craniectomy to evacuate hemorrhage, and it also did not include patients with penetrating gunshot or blast craniocerebral injury.…”

“…Finally, most patients in DECRA were from high-income countries, and the results are not generalizable to conditions in low-income countries with more limited facilities. 24 Both trials used primary intention-to-treat analyses, because alternative per-protocol analyses may be complicated by inevitable baseline severity imbalances.…”

Targeted Perfusion Therapy in Spinal Cord Trauma

“…These observations suggest that the dura may play a major, but unappreciated, role in spinal cord compression after TSCI. The idea that the dura causes CNS compression is established in TBI; thus, decompressive craniectomy involves removing skull and opening dura to allow outward herniation of brain to reduce ICP and increase CPP [16,39]. In a randomized controlled trial, decompressive craniectomy significantly reduced mortality though most surviving patients had severe disabilities [16].…”

A comparison of publication to TBI burden ratio of low- and middle-income countries versus high-income countries: how can we improve worldwide care of TBI?

“…The production of suggestions on TBI management based on consensus conferences is a good way to include neurosurgeons from all over the world both in the discussion and in publications. 13 Their views on indications are different from neurosurgeons in HICs and must be taken into account, such as the use of decompression as a "preventive" measure to avoid subsequent intracranial hypertension. The inclusion of some LMICs in large international databases of TBI 17 is a good example of how to compare data from these areas with American and European patients.…”