Evaluation of the Immediate and Early Role of Decompressive Craniectomy in the Treatment of Refractory ICP in Cases of STBI in Egypt: A Clue for Responders

Mini Review

Austin Neurosurg Open Access. 2015; 2(4): 1040.

Evaluation of the Immediate and Early Role of Decompressive Craniectomy in the Treatment of Refractory ICP in Cases of STBI in Egypt: A Clue for Responders

Mohamed El-Fiki*

Professor of Neurosurgery, University Of Alexandria, Egypt

*Corresponding author: Mohamed El-Fiki, Professor of Neurosurgery, University Of Alexandria, 63 Sidi Gaber Street, Cleopatra, Alexandria, Egypt

Received: August 21, 2015; Accepted: September 23, 2015; Published: September 28, 2015

Abstract

Introduction: Decompressive craniotomy may be performed in several indications including severe traumatic brain injuries. To date, there is no specific drug treatment and many promising agents in pre-clinical animal models have failed in clinical trials. Evidence-based guidelines for traumatic brain injury management have not made a major impact on recovery. Decompressive craniectomy procedure was successful in decreasing intracranial pressure in most cases but has failed to change prognosis. Selecting patients who may improve using new selection criteria will increase the procedure acceptance and define criteria for success.

Patients and Methods: Alexandria study recruited 80 patients with severe traumatic brain injuries & increased intracranial pressure above 20 mm H2O who presented with Glasgow Coma Score mean of 5.83. Surgical decompression was performed via wide uni- or bi-lateral frontotemporo-parietal hemicraniectomy and augmentation duraplasty.

Results: All patients showed decreased intracranial pressure postoperatively. This was not reflected as improved outcome except in those who sustained decreased ICP for one week. Eight patients showed good recovery (10%), 8 others were moderately disabled (10%), 5 patients were severely disabled (6%), while 16 remained vegetative (20%). Mortality was encountered in 43 cases (54%).

Conclusion: Decompressive craniectomy decreased high intracranial pressure in patients with severe traumatic brain injuries with high morbidity and mortality. Only patients who maintained a lowered intracranial pressure below 20 mm H2O showed clinical recovery. Patients who reached good functional outcome were those in whom lowered intracranial pressure was maintained after decompressive craniectomy for more than one week. Patients who showed a later secondary increased intracranial pressure are candidates for further studies & treatment alternatives and may be spared decompressive craniectomy.

Keywords: Craniectomy; Severe Traumatic Brain Injuries; Decompressive Craniectomy; Neurotrauma

Abbreviations

WHO: World Health Organization; DC: Decompressive Craniectomy; RTA: Road Traffic Accidents; STBI: Severe Traumatic Brain Injuries; ICP: Intracranial Pressure; ICU: Intensive Care Unit; CPP: Cerebral Perfusion Pressure; CSF: Cerebrospinal Fluid; PRx: Pressure Reactivity Index; mABP: mean Arterial Blood Pressure; SSS: Superior Sagittal Sinus; pO2: Partial Pressure of Oxygen

Introduction

The WHO report on Road Traffic Accidents (RTA) in March 2013 included 99% of world population. Egypt RTA rate is one of the highest where 12 fatal accidents occurred daily with 12300 death & 154000 injuries in 2009. Cyclists & pedestrians death accounts for 27% world wide and 45% in Eastern Mediterranean. Increased Intracranial Pressure (ICP) due to Severe Traumatic Brain Injuries (STBI) is the main etiologic factor for mortality. To date, there is no specific drug treatment for acute brain injury, and many pre-clinical animal drug trials have failed clinically. Evidence-based guidelines for TBI management in several countries have not made a major impact on recovery.

According to the Monroe Kellie Doctrine; in STBI, when the compensatory mechanisms start to fail, smaller increases in cerebral swelling/edema or minimal enlargement of a mass lesion will initiate incremental increases in decompensated ICP to a hazardous level that might be fatal. DC is performed to reverse ICP to compensated levels.

In order to alleviate the dire consequences of increased ICP Decompressive Craniectomy (DC) may be performed for indications such as STBI, extensive hemispherical infarctions, intracranial hemorrhages, or edema of infections [1-4]. Conflicting results of DC are published using different techniques and endpoints as well as study designs. Numerous complications may arise in a sequential fashion and at specific time points following DC [5]. However the procedure proved successful in decreasing ICP in most cases although it has failed to change prognosis. STBI management guidelines consider DC as the last -tier option. Given the favorable results of some prospective studies, DC procedure achieved popularity as a theoretical favorable remedy for patients with STBI and intractable ICP [6]. Selecting patients who may improve will increase the procedure acceptance and define criteria for success.

University of Alexandria, Egypt trial Objective was to evaluate the early role (first week) of DC in treatment of traumatic brain injury in terms of lowering increased ICP, 1-week outcome, rate of complications and ICP after one week of DC.

Patients and Methods

From Jan 2009-July 2014, the study recruited 80 patients with STBI (GCS < 9) & persistent increased ICP > 20 mm H2O for more than 12 hours who were admitted to the Neuro-ICU at the departments of neurosurgery, University of Alexandria, Egypt. They were screened with CT scans that were reported according to Marshall Scale [7]. ICP monitoring was implemented. Refractory cases of raised ICP who showed failure of best conservative measures to lower high ICP value were subjected to DC. Forty-three patients were randomized to primary DC, while another 37 patients crossed-over to DC from best medical treatment when their ICP persistently increased above 20 cm H2O for at least 12 hours in spite of occasional barbiturate administration. The two groups thus became a single cohort of 80 patients. DC was performed via wide uni- or bi-lateral frontotemporoparietal hemicraniectomy not less than 12 cm in longest dimension. An island of bone was left to cover the SSS. Supplementary subtemporal decompression was performed if impending or starting uncal herniation were suspected (Figure 1). Augmentation duraplasty was performed in all patients. Outcome of DC was evaluated as regards ICP value, procedure related complications and factors affecting outcome. Patient’s ICP was compared to their preoperative value in outcome analysis (patients were used as their own controls). Statistical analysis was performed (Student’s t-test for continuous variables and the Χ² test for categorical variables). A value of p < 0.05 was considered significant. SPSS software version 19.0 was used. The ethical committee of the University of Alexandria, Faculty of Medicine, approved the study. Informed consent was obtained from next of kin when available. Some patients were brought to hospital as unrecognized comatose patients.