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Object. In recent years, the role of decompressive craniectomy for the treatment of traumatic brain injury (TBI)
in patients with refractory intracranial hypertension has been the subject of several studies. The purpose of this review
was to evaluate the contribution of decompressive craniectomy in reducing intracranial pressure (ICP) and increasing
cerebral perfusion pressure (CPP) in these patients.
Methods. Comprehensive literature searches were performed for articles related to the effects of decompressive
craniectomy on ICP and CPP in patients with TBI. Inclusion criteria were as follows: 1) published manuscripts, 2)
original articles of any study design except case reports, 3) patients with refractory elevated ICP due to traumatic
brain swelling, 4) decompressive craniectomy as a type of intervention, and 5) availability of pre- and postoperative
ICP and/or CPP data. Primary outcomes were ICP decrease and/or CPP increase for assessing the efficacy of decompressive craniectomy. The secondary outcome was the persistence of reduced ICP 24 and 48 hours after the operation.
Results. Postoperative ICP values were significantly lower than preoperative values immediately after decompressive craniectomy (weighted mean difference [WMD] -17.59 mm Hg, 95% CI -23.45 to -11.73, p < 0.00001), 24
hours after (WMD -14.27 mm Hg, 95% CI -24.13 to -4.41, p < 0.00001), and 48 hours after (WMD -12.69 mm Hg,
95% CI -22.99 to -2.39, p < 0.0001). Postoperative CPP was significantly higher than preoperative values (WMD
7.37 mm Hg, 95% CI 2.32 to 12.42, p < 0.0001).
Conclusions. Decompressive craniectomy can effectively decrease ICP and increase CPP in patients with TBI
and refractory elevated ICP. Further studies are necessary to define the group of patients that can benefit most from
this procedure.
(http://thejns.org/doi/abs/10.3171/2012.6.JNS101400)
Abbreviations used in this paper: CPP = cerebral perfusion pressure; ICP = intracranial pressure; TBI = traumatic brain injury;
WMD = weighted mean difference.
Search Strategy
Methods
E. Bor-Seng-Shu et al.
tify human TBI studies concerning changes in ICP and
CPP associated with decompressive craniectomy. This
search included papers published between January 1995
and December 2010. Two independent observers (E.B.
and R.L.O.A.) performed a systematic PubMed database
search using the keywords decompressive craniectomy,
cerebral decompression, brain decompression, and
decompression craniotomy. These subject headings
were also combined with head injury, head trauma,
traumatic brain injury, intracranial pressure, and cerebral perfusion pressure. Reference lists of recovered
articles were examined for additional suitable papers. The
Related Articles feature in PubMed was also used for
all selected studies to maximize the probability of finding
additional relevant studies. A third independent investigator (E.G.F.) resolved potential disagreement between
the 2 independent observers as regarded study identification. The authors of selected articles were contacted by
electronic mail to provide additional data not available
in their publications. Unpublished data were provided by
authors of selected papers who responded positively to
our request.
Inclusion Criteria and Data Extraction
Statistical Analysis
Two authors who were not involved in data collection (J.S.V. and M.M.O.) performed all statistical analysis. Data synthesis and analysis were performed using
The Cochrane Collaboration review manager software
RevMan version 4.2.8. For continuous variables, where
continuous scales of measurement are used to assess the
effects of treatment, the WMD was used with 95% CIs.
Results
Number of Studies Retrieved
Twenty-three studies were identified. Corresponding authors of 4 studies were contacted; however, only
1 replied and provided the requested data. Three studies
590
Discussion
Main Findings
Our pooled results demonstrated 1) a statistically significant immediate decrease in ICP, and 2) a sustained
reduction in ICP associated with decompressive craniectomy. Intracranial pressure was the lowest soon after
brain decompression and increased gradually over the
first 2448 hours; however, it remained stable and significantly lower than preoperative values. A decrease in both
the number and duration of high ICP episodes was also
demonstrated in some articles.26,27 In contrast, decompressive craniectomy failed to decrease ICP to acceptable
values in 8%20% of the cases, which was associated
with an unfavorable outcome.1,13,26,31,32
The pooled results also demonstrated a statistically
significant increase in CPP after decompressive craniectomy. Although this concept is quite intuitive, some relevant papers failed to show postoperative CPP augmentation.16,27
Implications for Surgical Management
Severe head trauma can lead to brain swelling, increased ICP, reduced cerebral blood flow, inadequate
O2 delivery, ischemia, metabolic failure, further brain
J Neurosurg / Volume 117 / September 2012
Fig. 1. Intracranial pressure values immediately before and after decompressive craniectomy. N = number of patients.
There was considerable heterogeneity among the reviewed studies. First, the definition of refractory elevated
ICP varied; the ICP threshold was 20,1 25,28 30,16 or 40
mm Hg22 depending on the clinical series. Second, the
applied surgical technique varied as well: unilateral frontotemporoparietooccipital craniectomy, bifrontal crani-
Fig. 2. Intracranial pressure measured 24 hours after decompressive craniectomy as compared with preoperative values.
591
E. Bor-Seng-Shu et al.
Fig. 3. Intracranial pressure measured 48 hours after decompressive craniectomy as compared with preoperative values.
with more randomized controlled trials in this area because of the stricter controls on access to information
coming out of these trials.
Conclusions
592
40
Whitfield et al.,
2001
Stiefel et al.,
2004
Aarabi et al.,
2006
28
40
16
21
4
9
R
R
Howard et al.,
2008
Olivecrona et
al., 2007
Ho et al., 2008
Heppner et al.,
2006
Kan et al., 2006
Skoglund et al.,
2006
26
13
Taylor et al.,
2001
Mnch et al.,
2000
38.0 15.7
37.6 1.7
10 (514)
22.1 10.8
27 (1750)
25.3
28.8 (2043)
23 (459)
20 mm Hg
30 mm Hg plus
CPP <70 mm Hg
or ICP >35 mm
Hg
20 mm Hg w/ pla teau waves
20 mm Hg
9.6 6.9
28.2 9.6
68.5
45 (range 2157)
20 mm Hg
20 mm Hg for more
than 1 hr
20 mm Hg
20 mm Hg
11 6
115.2 (range
4.8384)
<48 (17 cases);
>48 (33 cases)
NR
surgery based on
CT scan & clini cal presentation
43.4 17.8
4.5 3.8 (63.3% 30 mm Hg for pe cases); 56.2 riod longer than
57 (36.7%
15 min
cases)
10 (1.1314.7) 17.3 (range
20 mm Hg
6.527.5)
27.6
37.9 15.9
35 13.5
25 6
36.4 3.4
47.5 9.5
29.2 3.5
35 8
24
26 4
37.5 10
26.4 7.9
22.1 11.1
31.7
Preop ICP
(mm Hg)
9.2 5.9
14.6 8.7
15.5 2
13.1 2.1
16.2 8.5
11.1 6
12 6
14.6
19 11
18.1 16
17.4 3.4
19.7 10.8
3.5
Postop ICP
(mm Hg)
IV
NR
IP
IV, IP
IV, IP
IV, IP
IP
IV, IP
IP
NR
IV, IP
NR
IV
ICP
Catheter
Outcome
mortality: 75%
good outcome: 68%; mortality:
11%
NR
(continued)
hemicraniectomy (39
patients); bifrontal
craniectomy (1 case)
hemicraniectomy; bi frontal craniectomy
hemicraniectomy
hemicraniectomy (unilat
or bilat); bifrontal
craniectomy
hemicraniectomy; bi frontal craniectomy
hemicraniectomy; bi frontal craniectomy
hemicraniectomy
hemicraniectomy
hemicraniectomy
bifrontal craniectomy
Surgical Technique
593
594
43
62
36
100
Daboussi et al.,
2009
Eberle et al.,
2010
Schneider et
al., 2002
Soustiel et al.,
2010
Ucar et al.,
2005
29 13.2
35.1 16.6
36.6
35.7 15.0
35.3 15
38 9.4
41 13.5
37 17
37 6.4
21.3 2.75
Preop ICP
(mm Hg)
20 mm Hg
30 mm Hg for more
than 15 min
25 mm Hg
23.9 4.9
4.1 10.9
9.8 1.3
16.3 12.6
20 13
11.2 7.1
12.73 5.15
Postop ICP
(mm Hg)
IV
IV, IP
IV, IP
IP
IV, IP
IP
ICP
Catheter
Outcome
bifrontal craniectomy
(78% cases); hemi craniectomy (22%
cases)
bilat hemicraniectomy
Surgical Technique
* Values are expressed as the means SD unless indicated otherwise. Abbreviations: GOS = Glasgow Outcome Scale; IP = intraparenchymal gauge device monitoring; IV = intraventricular catheter
monitoring; NR = not reported; P = prospective study; PVS = persistent vegetative state; R = retrospective study.
26
37
72 (range 0240)
35 (1655)
Timofeev et al.,
2008
27
E. Bor-Seng-Shu et al.
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