title: Decompressive craniectomy in diffuse traumatic brain injury.
abstract: BACKGROUND
  It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.
  
  
  METHODS
  From December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final primary outcome was the score on the Extended Glasgow Outcome Scale at 6 months.
  
  
  RESULTS
  Patients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P=0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P=0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%).
  
  
  CONCLUSIONS
  In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.).
authors: Department of Intensive Care, Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. jamie.cooper@monash.edu
authors: D James
authors: DJ
authors: Cooper
authors: Jeffrey V
authors: JV
authors: Rosenfeld
authors: Lynnette
authors: L
authors: Murray
authors: Yaseen M
authors: YM
authors: Arabi
authors: Andrew R
authors: AR
authors: Davies
authors: Paul
authors: P
authors: D'Urso
authors: Thomas
authors: T
authors: Kossmann
authors: Jennie
authors: J
authors: Ponsford
authors: Ian
authors: I
authors: Seppelt
authors: Peter
authors: P
authors: Reilly
authors: Rory
authors: R
authors: Wolfe
mesh_terms: D000293:Adolescent; D000328:Adult; D001930:Brain Injuries / Q000150:complications / Q000503:physiopathology / Q000601:surgery* / Q000628:therapy; D056424:Decompressive Craniectomy; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000601:surgery; D007427:Intracranial Pressure; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D059039:Standard of Care; D016896:Treatment Outcome; D055815:Young Adult