title: Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis.
abstract: BACKGROUND
  Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH.
  
  
  METHODS
  Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls.
  
  
  RESULTS
  There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher.
  
  
  CONCLUSIONS
  Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy.
  
  
  METHODS
  Therapeutic care/management, level III.
authors.affiliation: From the University of Utah (R.N., D.M., T.G., M.M., L.S.), Salt Lake City, Utah; University of Maryland Medical Center (T.M.S., D.M.S.), Baltimore, Maryland; University of Tennessee (L.J.M.), Memphis, Tennessee; University of Washington (G.J.J.), Seattle, Washington; Emory University (G.V.), Atlanta, Georgia; University of Southern California-Los Angles County Medical Center (D.D.), Los Angeles; University of California Davis (L.A.S.), Sacramento; and University of California, San Diego (R.C.), San Diego, California; University of Pittsburgh Medical Center (A.P., J.S.), Pittsburgh, Pennsylvania; University of Colorado (K.B., S.B.), Denver Health, Denver, Colorado; and Maricopa Integrated Health Systems (IF-E, P.O.), Phoenix, Arizona.
authors.forename: Ram
authors.initials: R
authors.lastname: Nirula
authors.forename: D
authors.initials: D
authors.lastname: Millar
authors.forename: Tom
authors.initials: T
authors.lastname: Greene
authors.forename: Molly
authors.initials: M
authors.lastname: McFadden
authors.forename: Lubdha
authors.initials: L
authors.lastname: Shah
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Stein
authors.forename: Louis J
authors.initials: LJ
authors.lastname: Magnotti
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Jurkovich
authors.forename: Gary
authors.initials: G
authors.lastname: Vercruysse
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
authors.forename: Lynette A
authors.initials: LA
authors.lastname: Scherer
authors.forename: Andrew
authors.initials: A
authors.lastname: Peitzman
authors.forename: Jason
authors.initials: J
authors.lastname: Sperry
authors.forename: Kathryn
authors.initials: K
authors.lastname: Beauchamp
authors.forename: Scott
authors.initials: S
authors.lastname: Bell
authors.forename: Iman
authors.initials: I
authors.lastname: Feiz-Erfan
authors.forename: Patrick
authors.initials: P
authors.lastname: O'Neill
authors.forename: Raul
authors.initials: R
authors.lastname: Coimbra
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D056424:Decompressive Craniectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015601:Injury Severity Score; D019586:Intracranial Hypertension / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D007427:Intracranial Pressure; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome