DECOMPRESSIVE CRANIECTOMY IN DIFFUSE TRAUMATIC BRAIN INJURY PDF
PDF | It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and. The Decompressive Craniectomy in Diffuse Traumatic Brain Injury or DECRA trial was the first neurosurgical randomized controlled trail that sought to answer. BACKGROUND It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory.
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Undoubtedly, it is one of the most encouraging clinical researches in the field of TBI in the past five years.
Decompressive Craniectomy in Diffuse Traumatic Brain Injury: An Industrial Hospital Study
The results showed that, in contrast to medical brin, decompressive craniectomy DC in patients with TBI and refractory intracranial hypertension can not only immediately and constantly reduce intracranial pressure ICP but, even more importantly, result in a nearly 20 percent reduction in mortality at 6 and 12 months. Unfortunately, DC also caused higher rates of vegetative state, lower severe disability, and upper severe disability than medical care.
Therefore, the long-awaited large tarumatic will again provoke some new thoughts about the role of DC in the management of refractory hypertension after TBI. DC is a straightforward procedure that for more than a century has been widely used to treat medically refractory intracranial hypertension of patients with severe TBI 2. Although a series of clinical studies demonstrated that DC is the most effective treatment in reducing ICP, the effect on outcome of severe TBI has yet to be clearly established 34.
In the 4th injuey guidelines of management of severe TBI that just emerged on September of this year, DC as a new topic was included for the first time 5.
Decompressive Craniectomy in Diffuse Traumatic Brain Injury: The DECRA Trial – Oxford Medicine
However, there were some inherent differences between these two diffjse. Second, timing of DC. The RESCUEicp study used more reasonable surgical options according to tomographic imaging and at the discretion of the surgeon bifrontal DC or hemi-craniectomy versus bifrontal DC alone.
At last stage of the protocol of the RESCUEicp trial, patients in medical management group received continued medical therapy with the option of adding barbiturates to reduce the ICP. Therefore, all above differences might be the main reasons of different conclusions in these two studies.
Would decompressive craniectomy really bring the hope to severe traumatic brain injury?
In addition, the main similarity between the results of these traumaic studies was that DC reduced ICP effectively but increase larger proportion of survivors in the vegetative state and severe disability significantly.
Therefore, we have to ask ourselves: We will further discuss the uncertainty of the effect of DC on TBI patients through above four questions.
craniectmoy First, suitable population for DC. The scoring range can be used as a reference indicator for the severity of TBI extremely severe: Whether DC is too radical for mild TBI patients or has been already powerless for extremely severe TBI deserves further investigation by subgroup analysis.
Second, the optimal timing of DC.
Therefore, we believed that DC might be too invasive to benefit the patients with less pronounced elevation of ICP e. The other question is what other indicators need established in order to evaluate DC timing. However, some studies suggested that high ICP was not the most powerful predictor of neurological worsening, and models used to predict outcome adopted age, motor response in GCS, pupil reactivity and some characteristics of the initial computed tomography CT scan as input variables In addition, evidences also suggest that low cerebral perfusion pressure CPP at levels below 50—55 mmHg is one of the major contributors to unfavourable clinical outcome, so modern intensive-care management of severe TBI can also base on CPP-driven therapeutic protocol 14 Therefore, whether we need to combine the ICP thresholds for defining medically refractory intracranial hypertension with other indicators warrants consideration.
Third, the proper method of DC. However, to date adequately powered clinical studies testing the effect of these two DC methods on TBI patients are lacking. Fourth, the barbiturate coma.
Decompressive craniectomy in diffuse traumatic brain injury. – Semantic Scholar
At last stage of the protocol of the RESCUEicp trial, patients were randomly assigned to undergo DC with medical therapy or to receive continued medical therapy with the option of adding barbiturates to reduce the ICP. Although barbiturates are included in level II recommendations of TBI guideline 5a Cochrane systematic review concluded that barbiturates may reduce ICP but do not reduce decompressivee or improve outcome in ddcompressive TBI survivors In conclusion, aforementioned questions have yet to be addressed.
For DC, we cannot give it up too early or cannot stick to it too blindly. Exploring the beneficiary patient population and operation timing remain the prime concerns. N Engl J Med ; Cite this article as: Would decompressive craniectomy really bring the hope to severe traumatic brain injury? J Thorac Ibjury ;8