Is it the end of decompressive Is it the end of decompressive craniectomy?craniectomy?

J. Marcoux, H. AlJ. Marcoux, H. Al--Jehani, R.W.R. Dudley, M. Jehani, R.W.R. Dudley, M. MalekiMaleki

Department of Neurosurgery, Montreal General Hospital &Department of Neurosurgery, Montreal General Hospital &Montreal Neurological Hospital, McGill UniversityMontreal Neurological Hospital, McGill University

Primary and secondary lesionsPrimary and secondary lesions

““Only part of the damage to the brain during Only part of the damage to the brain during head trauma occurs at the moment of head trauma occurs at the moment of impactimpact””

Brain Trauma FoundationBrain Trauma Foundation

Intracranial pressure (ICP)Intracranial pressure (ICP)Normal: 0Normal: 0--10 mmHg10 mmHg20 mmHg = limit chosen by most centers20 mmHg = limit chosen by most centers

BTF guidelines (level 2)BTF guidelines (level 2)* patients can * patients can herniateherniate with lower ICPwith lower ICP•• Therapy must also be guided by imaging and Therapy must also be guided by imaging and

clinical status of the patient. clinical status of the patient.

High ICP High ICP →→ secondary lesionsecondary lesionDecresaedDecresaed cerebral blood flow, globally and cerebral blood flow, globally and regionallyregionally

Escalating cycle of brain swelling. Escalating cycle of brain swelling resulting in increase in brain injury and poor outcome. Hutchinson et al., Curr Opin CritCare, Volume 10(2).April 2004.101-104

ICPICP

High ICP treatmentHigh ICP treatmentBasic measuresBasic measures

Sedation and analgesiaSedation and analgesiaPatient positionPatient positionMecanicalMecanical ventilationventilation

Extended measuresExtended measuresHyperosmolar therapyHyperosmolar therapyCSF drainageCSF drainage

other invasive measuresother invasive measuresDC DC BarbituricBarbituric ComaComaHypothermiaHypothermiaMarkedMarked Hyperventilation Hyperventilation ArterialArterial pressure pressure increaseincrease

Does treating Does treating hichhich ICP change the ICP change the outcome?outcome?

ClasseClasse IIIIIISaul and Ducker, 1982Saul and Ducker, 1982

•• ICP treated at 25mmHg = 46% mortalityICP treated at 25mmHg = 46% mortality•• ICP treated at 15mmHg = 28% mortalityICP treated at 15mmHg = 28% mortality

GhajarGhajar et al., 1993et al., 1993•• GCS < 8GCS < 8•• ICP 15mmHgICP 15mmHg•• Mortality 12% vs 53% if not monitoredMortality 12% vs 53% if not monitored

MetaMeta--analysisanalysis14 series14 series

•• 21% mortality if CSF drainage routinely done21% mortality if CSF drainage routinely done•• 35% mortality of done sometimes35% mortality of done sometimes•• 43% mortality if never done43% mortality if never done

If BTF guidelines are followedIf BTF guidelines are followed

Mortality rate (for survivors > 48h)Mortality rate (for survivors > 48h)Before Before protocoleprotocole: 17.8%: 17.8%Compliance 50%: 18.6%Compliance 50%: 18.6%Compliance 88%: 13.7%Compliance 88%: 13.7%

Length of stay Length of stay ICUICU

•• before: 9.8 daysbefore: 9.8 days•• after: 7.9 daysafter: 7.9 days

HospitalHospital•• before: 21.2 daysbefore: 21.2 days•• after: 15.8 daysafter: 15.8 days

Fakhry SM, Trask AL, Waller MA, Watts DD; IRTC Neurotrauma Task Force. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges.J Trauma. 2004 Mar;56(3):492-9

BTF guidelinesBTF guidelinesGOS at discharge 4 or 5GOS at discharge 4 or 5

before: 43.3%before: 43.3%Compliance 50%: 50.3%Compliance 50%: 50.3%Compliance 88%Compliance 88%**: 61.5%: 61.5%

RLAS at discharge of 8RLAS at discharge of 8before: 43.9%before: 43.9%Compliance 50%: 44%Compliance 50%: 44%Compliance 88%Compliance 88%**: 56.6%: 56.6%

* : GCS slightly lower in latest group* : GCS slightly lower in latest group

Fakhry SM, Trask AL, Waller MA, Watts DD; IRTC Neurotrauma Task Force. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges.J Trauma. 2004 Mar;56(3):492-9

And if ICP remains high?And if ICP remains high?

High ICP not responding to standard High ICP not responding to standard treatment may respond to barbituratestreatment may respond to barbiturates

High ICP not responding to barbiturate High ICP not responding to barbiturate coma = deathcoma = death

And ?And ?When routine measures fail to control TBI When routine measures fail to control TBI related brain edema, therapeutic options are related brain edema, therapeutic options are limited. limited. Polin et al, Neurosurg 1997, July(4)

J Marcoux

Case 1Case 1

17 17 yoyoMVCMVCGCS 3 at outside hospitalGCS 3 at outside hospital→→ intubatedintubatedGCS 7T in ICUGCS 7T in ICUDay # 2: high ICPDay # 2: high ICPDay # 3: ICP reaches 30mmHg Day # 3: ICP reaches 30mmHg →→ barbiturate barbiturate comacomaDay # 9: ICP reaches 40mmHgDay # 9: ICP reaches 40mmHg

A bit of A bit of historyhistory

11stst writtenwritten report by report by AnnandaleAnnandale in 1894 (1 in 1894 (1 patient)patient)Cushing in 1905 for Cushing in 1905 for highhigh ICP ICP fromfrominoperableinoperable tumortumorFor TBI in the 60s For TBI in the 60s

DoneDone in extremis and in extremis and resultsresults veryvery poorpoor……To tell To tell otherother people not to do the people not to do the samesame mistakemistake!!

Clark K, Nash TM, Hutchison GC. The failure of Clark K, Nash TM, Hutchison GC. The failure of circumferential craniotomy in acute traumatic cerebral circumferential craniotomy in acute traumatic cerebral swelling. swelling. Journal of Neurosurgery Journal of Neurosurgery 1968;1968;2929(4):367(4):367––7171

Types of DCTypes of DCPrimaryPrimary or or prophylacticprophylactic

Mass Mass lesionlesion requiringrequiring evacuationevacuationBasedBased on CT and/or intraon CT and/or intra--op op findingsfindings

SecondarySecondary or or therapeutictherapeuticTo To treattreat highhigh ICP ICP refractoryrefractory to to treatmenttreatment

SurgicalSurgical technictechnic

Craniectomy:Craniectomy:BifrontalBifrontal

•• In In factfact bibi--coronal coronal withwith or or withoutwithout SSS SSS ligationligation

FF--TT--P uni or P uni or bilateralbilateral•• MidlineMidline leftleft intactintact

circumferentialcircumferential

Surgical techniqueSurgical technique

DuraDuraIntactIntactSlitsSlitsOpen +/Open +/-- duraplastyduraplasty•• ClearlyClearly more efficient for more efficient for ↓↓ ICPICP

Yoo DS, Kim DS, Cho KS, Huh PW, Park CK, Kang JK. Ventricular pressure monitoring during bilateral decompression with duralexpansion. Journal of Neurosurgery 1999;91(6):953–9.

J Marcoux

Effect on ICPEffect on ICP24 patients with decompressive 

craniectomy  mean ICP pre‐op = 33 mmHgmean ICP post‐op = 9   mmHg

Al-Jishi A, Saluja RS, Al-Jehani H, Lamoureux J, Maleki M, Marcoux J.Primary or secondary decompressive craniectomy: different indication and outcome. Can J Neurol Sci. 2011 Jul;38(4):612-20.

Outcome?Outcome?GOSGOS Number (%)Number (%)

11 4 (15.4)4 (15.4)

22 2 (7.7)2 (7.7)

33 1 (3.8)1 (3.8)

44 10 (38.5)10 (38.5)

55 9 (34.6)9 (34.6)

OutcomeOutcome??

1 study class 11 study class 1PediatricPediatric27 patients randomized27 patients randomized↓↓ mortalitymortality↓↓ morbiditymorbidity

Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, et al.A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Child’s Nervous System 2001;17(3):154–162.

Case 2Case 2

19 19 yoyo malemalePedestrian hit by bikePedestrian hit by bikeGCS 3 on arrivalGCS 3 on arrival……reaches 6T within the reaches 6T within the 1st 24h1st 24h<< 48 h, ICP reaches 30mmHg despite 48 h, ICP reaches 30mmHg despite maximal medical management (no second maximal medical management (no second tiers)tiers)

Case 2Case 2

CT Post CT Post -- opop

Case 3Case 3

21 21 yoyoMVCMVCGCS 3GCS 3EVD insertedEVD inserted48h later, GCS reaches 8T off sedation48h later, GCS reaches 8T off sedationDay # 5, ICP increasingly difficult to control and Day # 5, ICP increasingly difficult to control and steadily steadily >> 20mmHg20mmHg

Case 3Case 3

ST segment changes on EKGST segment changes on EKGBy the time OR is ready, ICP reaches 40mmHgBy the time OR is ready, ICP reaches 40mmHgWhile draping, circulatory arrest (While draping, circulatory arrest (pulselesspulselesselectrical activity)electrical activity)

CardiomyopathicCardiomyopathic depressiondepression……neurogenicneurogenic origin? origin?

CPR < 3minCPR < 3minPostPost--resuscitation, pupils dilated + fixedresuscitation, pupils dilated + fixed

ComplicationsComplications

InfectionInfectionHemorrhageHemorrhageForeignForeign body (body (duraplastyduraplasty))CerebralCerebral damagedamage

ContusionContusionHerniationHerniationBonyBony protection protection lostlost

BoneBone resorptionresorptionHydrocephalusHydrocephalus????

DECRA trialDECRA trial

Cooper et al., March 2011Cooper et al., March 2011

DECRA trialDECRA trialRecruitment:Recruitment:

Dec 2002 to April 2010Dec 2002 to April 201015 tertiary centers in Australia, New15 tertiary centers in Australia, New--Zealand and Saudi ArabiaZealand and Saudi Arabia

Inclusion:Inclusion:age : 15age : 15--5959GCS 3GCS 3--8 or Marshall grade III8 or Marshall grade IIIBlunt traumaBlunt trauma

Exclusion:Exclusion:Deemed non suitable for active treatment (non salvageable Deemed non suitable for active treatment (non salvageable injury) injury) Pupils dilated + nonreactivePupils dilated + nonreactiveMass lesion requiring surgeryMass lesion requiring surgerySCISCICardiac arrest at the scene Cardiac arrest at the scene

DECRA trialDECRA trial

Treatment for ICP > 20mmHgTreatment for ICP > 20mmHgEarly refractory ICP:Early refractory ICP:

if > 20mmHgif > 20mmHgfor > 15minsfor > 15minsOver a 1 hour periodOver a 1 hour periodDespite optimization of firstDespite optimization of first--tiertier(sedation, normal CO(sedation, normal CO22, hypertonic saline, , hypertonic saline, MannitolMannitol, ,

CSF drainage, neuromuscular block)CSF drainage, neuromuscular block)

Monitor parenchymal or Monitor parenchymal or intraventricularintraventricular

DECRA trialDECRA trial

Randomized within 72 h (DC or standardRandomized within 72 h (DC or standard--care therapy care therapy DC from Polin`s technique (bifrontal)DC from Polin`s technique (bifrontal)In both groups:In both groups:

Mild hypothermiaMild hypothermiaBarbituratesBarbituratesDC for survival after 72h can be used in DC for survival after 72h can be used in standardstandard--care group!!!care group!!!

DECRA trialDECRA trialOutcome measures:Outcome measures:

Phone interviewPhone interviewPrimary outcome:Primary outcome:

•• GOSeGOSe at 6 months of 1 to 4at 6 months of 1 to 4•• And functional outcome And functional outcome

Secondary outcome:Secondary outcome:•• Time with elevated ICPTime with elevated ICP•• Index of high ICPIndex of high ICP•• GOSeGOSe 22--44•• Number of days in ICU and in hospitalNumber of days in ICU and in hospital•• Mortality in hospital and at 6 monthsMortality in hospital and at 6 months

***

DECRA trialDECRA trial

4 patients in standard4 patients in standard--care group and DC care group and DC withinwithin 72 h 72 h 15 patients more had DC after 72h15 patients more had DC after 72h

Therefore 19/82 (23.2%) had DC!!Therefore 19/82 (23.2%) had DC!!

70% 51%*

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DECRA trialDECRA trial

More surgical complicationsMore surgical complicationsSurvivors Survivors ‘‘shiftedshifted’’ from good outcome to from good outcome to poor outcomepoor outcome

Better ICP control with DCBetter ICP control with DCShorter ICU / hospital stayShorter ICU / hospital stay

DECRA trialDECRA trial

But:But:Pupils nonPupils non--reactive? reactive? ––bias??bias??Timing is very early? Timing is very early? ICP not necessarily uncontrolled?ICP not necessarily uncontrolled?Surgical technique used more prone to complications Surgical technique used more prone to complications (hydrocephalus)?(hydrocephalus)?Surgical technique not maximizing reduction in ICP?Surgical technique not maximizing reduction in ICP?Nearly Nearly ¼¼ in standardin standard--care group had DC! care group had DC! Restricted to a very precise population (155/3500)Restricted to a very precise population (155/3500)

Do not forgetDo not forget

PediatricPediatric studystudyRESCUE ICP TrialRESCUE ICP Trial……....

Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure