Decompressive craniectomy or medical management for refractory intracranial hypertension

An AAST-MIT propensity score analysis

Ram Nirula, D. Millar, Tom Greene, Molly McFadden, Lubdha Shah, Thomas M. Scalea, Deborah M. Stein, Louis J. Magnotti, Gregory Jurkovich, Gary Vercruysse, Demetrios Demetriades, Lynette A. Scherer, Andrew Peitzman, Jason Sperry, Kathryn Beauchamp, Scott Bell, Iman Feiz-Erfan, Patrick O'Neill, Raul Coimbra

Research output: Contribution to journalArticle

20 Citations (Scopus)

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. Conclusion: 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. LEVEL OF EVIDENCE: Therapeutic care/management, level III.

Original languageEnglish (US)
Pages (from-to)944-955
Number of pages12
JournalJournal of Trauma and Acute Care Surgery
Volume76
Issue number4
DOIs
StatePublished - 2014

Fingerprint

Decompressive Craniectomy
Propensity Score
Intracranial Hypertension
Glasgow Coma Scale
Therapeutics
Wounds and Injuries
Traumatic Subarachnoid Hemorrhage
Ventriculostomy
Survival
Trauma Centers
Diuresis
Brain Edema
Intracranial Pressure
Standard of Care
Coma

Keywords

  • brain injury
  • Decompressive craniectomy
  • mortality
  • propensity

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

Decompressive craniectomy or medical management for refractory intracranial hypertension : An AAST-MIT propensity score analysis. / Nirula, Ram; Millar, D.; Greene, Tom; McFadden, Molly; Shah, Lubdha; Scalea, Thomas M.; Stein, Deborah M.; Magnotti, Louis J.; Jurkovich, Gregory; Vercruysse, Gary; Demetriades, Demetrios; Scherer, Lynette A.; Peitzman, Andrew; Sperry, Jason; Beauchamp, Kathryn; Bell, Scott; Feiz-Erfan, Iman; O'Neill, Patrick; Coimbra, Raul.

In: Journal of Trauma and Acute Care Surgery, Vol. 76, No. 4, 2014, p. 944-955.

Research output: Contribution to journalArticle

Nirula, R, Millar, D, Greene, T, McFadden, M, Shah, L, Scalea, TM, Stein, DM, Magnotti, LJ, Jurkovich, G, Vercruysse, G, Demetriades, D, Scherer, LA, Peitzman, A, Sperry, J, Beauchamp, K, Bell, S, Feiz-Erfan, I, O'Neill, P & Coimbra, R 2014, 'Decompressive craniectomy or medical management for refractory intracranial hypertension: An AAST-MIT propensity score analysis', Journal of Trauma and Acute Care Surgery, vol. 76, no. 4, pp. 944-955. https://doi.org/10.1097/TA.0000000000000194
Nirula, Ram ; Millar, D. ; Greene, Tom ; McFadden, Molly ; Shah, Lubdha ; Scalea, Thomas M. ; Stein, Deborah M. ; Magnotti, Louis J. ; Jurkovich, Gregory ; Vercruysse, Gary ; Demetriades, Demetrios ; Scherer, Lynette A. ; Peitzman, Andrew ; Sperry, Jason ; Beauchamp, Kathryn ; Bell, Scott ; Feiz-Erfan, Iman ; O'Neill, Patrick ; Coimbra, Raul. / Decompressive craniectomy or medical management for refractory intracranial hypertension : An AAST-MIT propensity score analysis. In: Journal of Trauma and Acute Care Surgery. 2014 ; Vol. 76, No. 4. pp. 944-955.
@article{53179fa6de904c40aff81ad1abbeb816,
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. Conclusion: 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. LEVEL OF EVIDENCE: Therapeutic care/management, level III.",
keywords = "brain injury, Decompressive craniectomy, mortality, propensity",
author = "Ram Nirula and D. Millar and Tom Greene and Molly McFadden and Lubdha Shah and Scalea, {Thomas M.} and Stein, {Deborah M.} and Magnotti, {Louis J.} and Gregory Jurkovich and Gary Vercruysse and Demetrios Demetriades and Scherer, {Lynette A.} and Andrew Peitzman and Jason Sperry and Kathryn Beauchamp and Scott Bell and Iman Feiz-Erfan and Patrick O'Neill and Raul Coimbra",
year = "2014",
doi = "10.1097/TA.0000000000000194",
language = "English (US)",
volume = "76",
pages = "944--955",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",
number = "4",

}

TY - JOUR

T1 - Decompressive craniectomy or medical management for refractory intracranial hypertension

T2 - An AAST-MIT propensity score analysis

AU - Nirula, Ram

AU - Millar, D.

AU - Greene, Tom

AU - McFadden, Molly

AU - Shah, Lubdha

AU - Scalea, Thomas M.

AU - Stein, Deborah M.

AU - Magnotti, Louis J.

AU - Jurkovich, Gregory

AU - Vercruysse, Gary

AU - Demetriades, Demetrios

AU - Scherer, Lynette A.

AU - Peitzman, Andrew

AU - Sperry, Jason

AU - Beauchamp, Kathryn

AU - Bell, Scott

AU - Feiz-Erfan, Iman

AU - O'Neill, Patrick

AU - Coimbra, Raul

PY - 2014

Y1 - 2014

N2 - 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. Conclusion: 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. LEVEL OF EVIDENCE: Therapeutic care/management, level III.

AB - 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. Conclusion: 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. LEVEL OF EVIDENCE: Therapeutic care/management, level III.

KW - brain injury

KW - Decompressive craniectomy

KW - mortality

KW - propensity

UR - http://www.scopus.com/inward/record.url?scp=84897056519&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84897056519&partnerID=8YFLogxK

U2 - 10.1097/TA.0000000000000194

DO - 10.1097/TA.0000000000000194

M3 - Article

VL - 76

SP - 944

EP - 955

JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

IS - 4

ER -