Decompressive craniectomy linked to lower mortality, improved recovery

Patients with posttraumatic refractory intracranial hypertension treated with decompressive craniectomy showed reduced mortality and improved recovery at 24 months compared with standard care, per a study published in JAMA Neurology.

“Decompressive craniectomy is a life-saving procedure to reduce critically elevated intracranial pressure among patients with traumatic brain injury,” Angelos G. Kolias, MD, PhD, of the department of clinical neurosciences, University of Cambridge in the United Kingdom, and colleagues wrote. “The optimal timing, indications and functional outcome benefits associated with decompressive craniectomy have been widely debated.”

Researchers sought to evaluate 24-month outcomes for patients with traumatic intracranial hypertension treated with either decompressive craniectomy or standard medical care. They performed prespecified secondary analysis of the Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure randomized clinical trial data, which included 408 participants with traumatic intracranial hypertension (>25 mm Hg) from 52 centers in 20 countries. Patients, who were enrolled in the study between January 2004 and March 2014, were randomly assigned on a 1:1 basis to receive either decompressive craniectomy with standard care (surgical group n = 206) or ongoing medical treatment with the option to add barbiturate infusion (medical group n = 202). The primary outcome was measured with the eight-point Extended Glasgow Outcome Scale (where a score of 1 indicates death and 8 denotes upper good recovery), and the 6- to 24-month outcome trajectory was subsequently examined. Data were analyzed between 2018 and 2021.

Results showed at 24 months, patients in the surgical group experienced reduced mortality (61 [33.5%] vs. 94 [54%]; absolute difference, 20.5 [95% CI, 30.8 to 10.2]) as well as higher rates of vegetative state (absolute difference, 4.3 [95% CI, 0 to 8.6]), lower or upper moderate disability (4.7 [0.9 to 10.3] vs 2.8 [4.2 to 9.8]) and lower or upper severe disability (2.2 [5.4 to 9.8] vs. 6.5 [1.8 to 11.2]).

Data additionally revealed that rates of lower and upper good recovery were similar for the surgical and medical groups (20 [11%] vs. 19 [10.9%]), and significant differences in net improvement (1 grade) were observed between 6 and 24 months (55 [30%] vs. 25 [14%]).

“These findings support the notion that careful patient selection, following the principles of multidisciplinary consensus and shared decision-making with the closest relatives, is required,” Kolias and colleagues wrote.