title: Decompressive Craniectomy in Patients with Traumatic Brain Injury: Are the Usual Indications Congruent with Those Evaluated in Clinical Trials?
abstract: In patients with traumatic brain injury (TBI), multicenter randomized controlled trials have assessed decompressive craniectomy (DC) exclusively as treatment for refractory elevation of intracranial pressure (ICP). DC reliably lowers ICP but does not necessarily improve outcomes. However, some patients undergo DC as treatment for impending or established transtentorial herniation, irrespective of ICP.
  
  
  
  We performed a population-based cohort study assessing consecutive patients with moderate-severe TBI. Indications for DC were compared with enrollment criteria for the DECRA and RESCUE-ICP trials.
  
  
  
  Of 644 consecutive patients, 51 (8 %) were treated with DC. All patients undergoing DC had compressed basal cisterns, 82 % had at least temporary preoperative loss of ≥1 pupillary light reflex (PLR), and 80 % had >5 mm of midline shift. Most DC procedures (67 %) were "primary," having been performed concomitantly with evacuation of a space-occupying lesion. ICP measurements influenced the decision to perform DC in 18 % of patients. Only 10 and 16 % of patients, respectively, would have been eligible for the DECRA and RESCUE-ICP trials. DC improved basal cistern compression in 76 %, and midline shift in 94 % of patients. Among patients with ≥1 absent PLR at admission, DC was associated with lower mortality (46 vs. 68 %, p = 0.03), especially when the admission Marshall CT score was 3-4 (p = 0.0005). No patients treated with DC progressed to brain death. Variables predictive of poor outcome following DC included loss of PLR(s), poor motor score, midline shift ≥11 mm, and development of perioperative cerebral infarcts.
  
  
  
  DC is most often performed for clinical and radiographic evidence of herniation, rather than for refractory ICP elevation. Results of previously completed randomized trials do not directly apply to a large proportion of patients undergoing DC in practice.
authors.affiliation: Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada. andreas.kramer@albertahealthservices.ca.|Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada. andreas.kramer@albertahealthservices.ca.|Hotchkiss Brain Institute, Calgary, AB, Canada. andreas.kramer@albertahealthservices.ca.
authors.forename: Andreas H
authors.initials: AH
authors.lastname: Kramer
authors.affiliation: Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.|Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.
authors.forename: Nathan
authors.initials: N
authors.lastname: Deis
authors.affiliation: Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.
authors.forename: Stacy
authors.initials: S
authors.lastname: Ruddell
authors.affiliation: Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.|Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.|Hotchkiss Brain Institute, Calgary, AB, Canada.
authors.forename: Philippe
authors.initials: P
authors.lastname: Couillard
authors.affiliation: Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: David A
authors.initials: DA
authors.lastname: Zygun
authors.affiliation: Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.|Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Doig
authors.affiliation: Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.|Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.|Hotchkiss Brain Institute, Calgary, AB, Canada.
authors.forename: Clare
authors.initials: C
authors.lastname: Gallagher
mesh_terms: D000328:Adult; D000070642:Brain Injuries, Traumatic / Q000000981:diagnostic imaging* / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D002986:Clinical Trials as Topic; D015331:Cohort Studies; D056424:Decompressive Craniectomy / Q000379:methods*; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D055815:Young Adult
keywords: Cerebral edema; Decompressive craniectomy; Intracranial pressure; Midline shift; Pupillary light reflex; Transtentorial herniation