Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension

Hutchinson, Peter J.; Kolias, Angelos G.; Timofeev, Ivan; Corteen, Elizabeth A.; Czosnyka, Marek; Timothy, Jake; Anderson, Ian; Bulters, Diederik; Belli, Antonio; Eynon, C. Andrew; Wadley, John; Mendelow, AD; Mitchell, Patrick; Wilson, Mark; Critchley, Giles; Sahuquillo, Juan; Unterberg, Andreas; Servadei, Franco; Teasdale, Graham M.; Pickard, John D.; Menon, David; Murray, Gordon; Kirkpatrick, Peter J.

doi:10.1056/nejmoa1605215

Cited by 955 publications

(669 citation statements)

References 19 publications

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“…The RESCUEicp study (Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of intracranial pressure) to assess the effectiveness of DC as last-tier intervention in patients with TBI and refractory ICH has been published last year [21]. DC resulted in lower mortality and higher rates of vegetative state, severe disability than medical care.…”

Section: Discussionmentioning

confidence: 99%

Relationship between Intracranial Pressure or Cerebral Perfusion Pressure and Prognosis in Patients with Severe Traumatic Brain Injury Treated with Mild Hypothermia

Hayakawa¹,

Tasaki²,

Iwamura³

et al. 2017

J Trauma Treat

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Aims: The purpose of this study was to predict the clinical course by intracranial pressure (ICP) or cerebral perfusion pressure (CPP) in the acute phase and prognosis in patients with severe head trauma who underwent therapeutic mild hypothermia (HT). Methods:A consecutive 143 patients treated with HT for intracranial hypertension (ICH) in two trauma centers were included in this study. The pressure measured after computed tomography scanning was defined as the initial ICP or CPP. Outcome was assessed at 6 months according to the Glasgow Outcome Scale. ROC analysis was performed to clarify the threshold value of ICP/CPP predictive of ICP uncontrollable by HT. Results:The cutoff value of ICP for uncontrollable ICP obtained from ROC analysis was 32.5 mmHg (sensitivity: 0.545, specificity: 0.875), and that for CPP was 56.5 mmHg (sensitivity: 0.813, specificity: 0.663). Fifty-three (96.4%) of 55 patients whose initial ICP was greater than 32.5 mmHg and 67 (95.7%) of 70 patients whose initial CPP was less than 56.5 mmHg had developed uncontrollable ICP. Conclusion:The cutoff values predictive of ICP uncontrollable by HT from ROC analysis were 32.5 mmHg for ICP and 56.5 mmHg for CPP. For those patients with initial ICP greater than the cutoff value or an initial CPP less than the cutoff value, it may be harmful to prolong HT. The knowledge obtained from this study may be useful for considering the treatment strategy for severe traumatic brain injury.

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Section: Discussionmentioning

confidence: 99%

Relationship between Intracranial Pressure or Cerebral Perfusion Pressure and Prognosis in Patients with Severe Traumatic Brain Injury Treated with Mild Hypothermia

Hayakawa¹,

Tasaki²,

Iwamura³

et al. 2017

J Trauma Treat

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“…In their 2013 review on managing intracranial hypertension in aSAH, Mak et al supported a future RCT involving decompressive craniectomy for medically refractory intracranial hypertension in aSAH. 40,51 Matched case-control studies can be performed when randomized studies are not feasible to potentially identify whether ICP monitoring or strict ICP control leads to better functional outcomes in patients presenting with various grades of hemorrhages. Lastly, because the definitions of "normal" and "elevated" ICP in aSAH have traditionally been translated directly from studies on TBI, they may need to be adjusted considering the significant differences in pathophysiology.…”

mentioning

confidence: 99%

Management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage: time for a consensus?

Alotaibi

Wang

Pasarikovski

et al. 2017

Neurosurgical Focus

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Elevated intracranial pressure (ICP) is a well-recognized phenomenon in aneurysmal subarachnoid hemorrhage (aSAH) that has been demonstrated to lead to poor outcomes. Despite significant advances in clinical research into aSAH, there are no consensus guidelines devoted specifically to the management of elevated ICP in the setting of aSAH. To treat high ICP in aSAH, most centers extrapolate their treatment algorithms from studies and published guidelines for traumatic brain injury. Herein, the authors review the current management strategies for treating raised ICP within the aSAH population, emphasize key differences from the traumatic brain injury population, and highlight potential directions for future research in this controversial topic.

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“…As many as three consensus conferences have tried to address this and other controversies and uncertainties [2,3,8]. One of the recommendations was that BICP monitoring is generally recommended following a secondary decompressive craniectomy (DC) in order to assess the effectiveness of DC, in terms of ICP control, and guide further therapy^ [8].Indeed there exists plentiful information from recent trials (DECRA and RESCUEicp) about situations where DC was employed to control rising ICP refractory to maximal medical therapy [4,6]; this being secondary DC.One of the gaps in our knowledge, and the main objective of the featured study by Picetti et al [7], was to explore the role of ICP monitoring in traumatic brain injury (TBI) patients after primary decompressive craniectomy. BPrimary^in this context refers to DC during evacuation of an intracranial lesion in the acute phase.…”

mentioning

confidence: 99%

“…Indeed there exists plentiful information from recent trials (DECRA and RESCUEicp) about situations where DC was employed to control rising ICP refractory to maximal medical therapy [4,6]; this being secondary DC.…”

mentioning

confidence: 99%

Intracranial pressure monitoring after primary decompressive craniectomy: is it useful?

Demetriades

2017

Acta Neurochir

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Intracranial hypertension is an important secondary insult after traumatic brain injury, and its control is considered to be of benefit to our patients. Intracranial pressure (ICP) monitoring is considered standard practice, at least in the developed world, in the modern neurosurgical management of traumatic brain injury. ICP waveform analysis and understanding has improved tremendously over the last few decades. However, there is still a lack of Bclass I^evidence in support of superiority of treatment based on intracranial-pressure monitoring over treatment guided by neurological testing and serial computed tomography imaging in improving short-term or longterm recovery in the general population of patients with severe traumatic brain injury [1].In settings such as the developing world, where ICP monitoring may come with equipoise, controversies exist, including the use of postoperative ICP monitoring. As many as three consensus conferences have tried to address this and other controversies and uncertainties [2,3,8]. One of the recommendations was that BICP monitoring is generally recommended following a secondary decompressive craniectomy (DC) in order to assess the effectiveness of DC, in terms of ICP control, and guide further therapy^ [8].Indeed there exists plentiful information from recent trials (DECRA and RESCUEicp) about situations where DC was employed to control rising ICP refractory to maximal medical therapy [4,6]; this being secondary DC.One of the gaps in our knowledge, and the main objective of the featured study by Picetti et al. [7], was to explore the role of ICP monitoring in traumatic brain injury (TBI) patients after primary decompressive craniectomy. BPrimary^in this context refers to DC during evacuation of an intracranial lesion in the acute phase.Worded differently, there has been controversy as to whether ICP monitoring is futile after such primary DC.Recent data on this topic suggest that ICP monitoring after primary DC for head-injured patients significantly decreases in-hospital mortality and should be implemented in neurocritical care to ensure the highest chances of surviving TBI [5].Picetti et al. [7] provide further useful information on this topic. They selected and analysed data from 34 patients, out of a database of 880. The vast majority (26/34; 77%) were cases of acute subdural haematoma. The authors report that despite decompressive craniectomy, ICP may still rise to dangerous levels in most cases; furthermore, one-third of ICP monitoring days revealed at least one episode of intracranial hypertension. Intracranial hypertension was high enough to affect a reduction in cerebral perfusion pressure (CPP) of less than 60 mmHg in 1-6 days monitored. Despite decompressive craniectomy, patients needed ICP-and CPP-driven escalation therapy and monitoring assistance in taking decisions.This study is one of the first to specifically address the clinical utility of ICP monitoring after primary decompressive craniectomy.The message is clear:-Intracranial hypertension associated with ...

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Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension

Cited by 955 publications

References 19 publications

Relationship between Intracranial Pressure or Cerebral Perfusion Pressure and Prognosis in Patients with Severe Traumatic Brain Injury Treated with Mild Hypothermia

Relationship between Intracranial Pressure or Cerebral Perfusion Pressure and Prognosis in Patients with Severe Traumatic Brain Injury Treated with Mild Hypothermia

Management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage: time for a consensus?

Intracranial pressure monitoring after primary decompressive craniectomy: is it useful?

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