The Brain Trauma Foundation (BTF) released the 4th Edition of the Guidelines for the Management of Severe Traumatic Brain Injury in September 2016 to help guide physicians in evidence-based care of traumatic brain injuries. The document provided recommendations only when there was evidence to support them and stratified the evidence and recommendations based on key criteria. Each recommendation was given a level of recommendation depending on the quality of the body of evidence, combined with the class of the studies.
Last year, I did my best to condense this 244-page document into this tightly-packed 12 pages, summarizing the BTF guidelines for severe TBI:
This series of posts is intended to cover some of the most important aspects of TBI management and the updated literature to support the best management, starting with DECOMPRESSIVE CRANIECTOMY (DC).
Rational for DC in TBI
Cerebral edema can result from primary or secondary injury in TBI. The edema can ultimately cause brain tissue displacement and hernia, as well as regional ischemia. DC can relieve intracranial pressure (ICP) and prevent herniation. There are a few different methods of performing DC; here is the bifrontotemporoparietal technique.
4th Edition BTF Guidelines
- Bifrontal DC may reduce ICP and days in the ICU but does not improve outcomes as measured by Glasgow Outcome Scale-Extended (GOSE) at 6 months (Level IIA)
- DECRA study (PMID: 21434843) found that early (<3 days) bifrontotemporoparietal DC decreased ICP and ICU LOS but was also associated with worse scores on GOSE. However, the study had issues with randomization and a high crossover rate; post hoc adjustment for difference in pupil reactivity at admission resulted in some outcome differences that were no longer significant. “A beneficial effect of craniectomy was excluded.” Furthermore, the threshold for inclusion in this study was very low, and many of the patients who were enrolled may have benefitted from more aggressive non-invasive measures and may not have needed a DC. More on that from the EM Nerd on EMCrit.org.
- “Any potential improvement obtained by surgical decompression may well be offset by surgical morbidity.” (PMID: 23022646)
- “On the basis of its findings, we are able to conclude that bifrontal DC should not be used as a neuroprotective measure for moderate posttraumatic intracranial hypertension in well-resourced settings.” (PMID: 30473990)
- Large frontotemporoparietal (FTP) DC is recommended over small frontotemporoparietal DC for reduced mortality and improved neurologic outcomes (Level IIA)
- Larger FTP DC had lower rates of poor neuro function (GOS 1 to 3) and higher rates of good neuro function (GOS 4 or 5) compared to smaller FTP DC (PMID: 15941372)
- Larger DC improved outcomes but resulted in higher rates of complications, including delayed intracranial hematoma and subdural effusion (PMID: 19930556).
- RESCUEicp trial (PMID: 27602507): international, multicenter, randomized controlled trial showed that DC (within 10 days) can improve mortality but increases rates of vegetative state and severe disability at 6 months compared to medical care alone. However, they used an unconventional dichotomy between good and poor neurological outcomes, making it challenging to interpret the results in the same context of other studies.
- No recommendations on DC vs craniotomy due to low-quality studies that reported lower but not statistically significant, mortality rates and conflicting findings about function and complications (PMID: 19061378, PMID: 12516810)
- No recommendations on timing due to conflicting studies
2020 Update of the Decompressive Craniectomy Recommendations
- The 12-month outcome data from the DECRA trial was published in 2020
- Fewer good outcomes in survivors with DC: 0.33 (95% CI 0.12 to 0.91)
- More vegetative outcomes in survivors with DC: 5.12 (95% CI 1.04 to 25.2)
- Other than that update to the DECRA study, there hasn’t been much more new data on this topic
Here are the new recommendations in 2020:
- In the above recommendations, the authors specify early (within 3 days) vs late (within 10 days) refractory ICP elevation and recommend DC only for late refractory ICP elevation.
- They also state that secondary DC, for either early or late refractory ICP, can reduce ICP and ICU length of stay, but the effect of DC on favorable outcomes is still uncertain.
- Cerebral edema can cause brain tissue displacement and hernia, as well as regional ischemia. DC can relieve ICP and prevent herniation.
- The DECRA and RESCUEicp trials currently provide the best evidence about DC but the effect of DC on favorable outcomes is still uncertain.
- The latest guidelines for DC in severe TBI recommend secondary DC (via a large frontotemporoparietal DC) for late refractory ICP elevation.
- Hawryluk GWJ, Rubiano AM, Totten AM, O’Reilly C, Ullman JS, Bratton SL, Chesnut R, Harris OA, Kissoon N, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Lumba-Brown A, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations. Neurosurgery. 2020 Sep 1;87(3):427-434. doi: 10.1093/neuros/nyaa278. PMID: 32761068; PMCID: PMC7426189.
- Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi: 10.1227/NEU.0000000000001432. PMID: 27654000.
- Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R; DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011 Apr 21;364(16):1493-502. doi: 10.1056/NEJMoa1102077. Epub 2011 Mar 25. Erratum in: N Engl J Med. 2011 Nov 24;365(21):2040. PMID: 21434843.
- Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ; RESCUEicp Trial Collaborators. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med. 2016 Sep 22;375(12):1119-30. doi: 10.1056/NEJMoa1605215. Epub 2016 Sep 7. PMID: 27602507.