ICU SAQs · Raised ICP & TBI
Decompressive craniectomy in traumatic brain injury
The defining TBI controversy — decompressive craniectomy. Tests a critical appraisal of the two landmark trials (DECRA, RESCUEicp), their synthesis (craniectomy is a last-tier salvage, not a prophylactic measure, that trades death for survival-with-disability), and the goals-of-care conversation that follows.
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A 24-year-old man with severe diffuse traumatic brain injury has an intracranial pressure that remains at 28 mmHg despite maximal medical therapy (sedation, ventilation to normocapnia, hyperosmolar therapy and a barbiturate infusion). The neurosurgeons ask whether to perform a decompressive craniectomy. Discuss the evidence from the DECRA and RESCUEicp trials and how you would counsel the family and advise the team.
[1]References3ShowHide
- [1]Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury. New England Journal of Medicine, 2011.PMID 21434843
- [2]Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. New England Journal of Medicine, 2016.PMID 27602507
- [3]Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery, 2017.PMID 27654000