DECOMPRESSIVE CRANIECTOMY / DECRA TRIAL / RESCUE ICP TRIAL

1. DECOMPRESSIVE CRANIECTOMY
DR SHAMEEJ MUHAMED KV
SENIOR RESIDENT
DEPT OF NEUROSURGERY
GMC KOZHIKODE

2. HISTORY
• Ancient Egypt and Greece – TBI, epilepsy,
headache, mental illness- TREPHINATION
• First described by Annandale (1894)
• Surgical decompression to treat elevated ICP
– Kocher (1901) and Cushing (1905) –
subtemporal and suboccipital

4. • Erlich (1940) – For all head injuries with
persistent coma for more than 24-48 hrs
• Rowbotham (1942) – All traumatic comas
which improved at first and when medical
treatment was ineffective for 12 hrs
• Munro (1952) – If intra-op, the brain was
contused and swollen
• Guerra (1999) – personal results of 20 years
–2nd tier therapy in refractory ICP

5. ICP
• In a normal adult, the cranial vault
can accommodate an average volume
of approximately 1500 mL.
• V Intracranial space = V Brain + V Blood + V CSF
• The normal ICP is 10 to 15 mm Hg
• CPP = MAP – ICP
• Systemic hypertension is required to maintain
cerebral perfusion

9. Definition
• Decompressive hemicraniectomy and
durotomy is a surgical technique used to
relieve the increased ICP & brain tissue shifts
that occur in the setting of large cerebral
hemisphere mass, or space-occupying lesions.
• In general, the technique involves removal of
bone tissue (skull) and incision of the
restrictive dura mater covering the brain,
allowing swollen brain tissue to herniate
upwards through the surgical defect rather
than downwards to compress the brainstem.

10. CURRENT EVIDENCE
• Evidence supporting emergency DC in
Trauma remains controversial
• In animal studies, craniectomy has been a/w
decreased ICP
• Improved Oxygen tension
• Improved cerebral perfusion
• Increased cerebral edema,hemorrhagic infarcts and
cortical necrosis

11. “The role of decompressive craniectomy in
TBI and in the control of intracranial
hypertension remains a matter of debate.”

14. INDICATIONS
• Severe TBI
– Heterogeneous lesions in cerebral
parenchyma
– Focal (contusions/hematoma) and diffuse
• Malignant MCA infarction
• Aneurysmal SAH
• Others
– Central venous thrombosis
– Encephalitis
– Metabolic encephalopathies
– Intracerebral hematoma

15. Indications & Contraindications In
TBI• Indications:
– Coma or semicoma (GCS < 9)
– Pupillary abnormalities, but respond to
mannitol
– Supratentorial lesion with midline shift on CT
– Refractory ICP despite best conventional
therapy
– Age: initially < 80 years ,
now
70
years(Of patients who were > 70 years, 75% were
dead)
•Contraindications:
– Fatal brain stem damage
– GCS < 4 or fixed and dilated bilateral
pupils

16. When to perform?
• Bifrontal DC is indicated within 48 hours of injury
for patients with diffuse, post-traumatic cerebral
edema and medically refractory elevated ICP.
• Subtemporal decompression, temporal
lobectomy, and hemispheric DC can be
considered as treatment options for patients
who present with diffuse parenchymal injury and
refractory elevated ICP who also have clinical
and radiographic evidence for impending
transtentorial brain herniation.

17. GUIDELINES
• Up to date there are no specific guidelines or protocols
stating exactly when or in what circumstances DC is
appropriate, but there are some recommendations:
• The North American Brain Trauma Foundation suggests
DC may be the procedure of choice in the appropriate
clinical context and also considering the use of DC in the
first tier of TBI management. (Bullock et al, 2006)
• European Brain Injury Consortium recommend DC as an
option for refractory intracranial hypertension in all ages.
(Maas et al,1997)
• A Cochrane review (2006) recommended DC may be
justified in some children with medically intractable ICP
after head injury but concluded there was no evidence to
support its routine use in adults. (Sahuquillo & Arikan,
2006)

23. TYPES

24. EFFICACY BASED ON SIZE-BTF

26. Decompressive
hemicraniectomy• Foam / rubber donut
• No pins
• Cervical spine precautions
• Don’t compress the jugulars

27. DHC
• Supine
• Rolled towel beneath ipsilateral shoulder
• Head towards contralateral side
• Mark midline
• Incision – Reverse question mark
• Posterior extent – 15 cm behind key hole
• Deepened down to cranium
• Myocutaneous flap reflected
• Five burr holes are made in the following locations: (1)
temporal squamous bone superior to the zygomatic
process inferiorly, (2) keyhole area behind the
zygomatic arch anteriorly, (3) along the superior
temporal line posteroinferiorly, and in the (4) parietal
and (5) frontal parasagittal areas

28. • Smaller craniectomy  Damage to cortical veins and
parenchyma
• Dura dissected off from beneath the bone
• Bur-holes connected
• Bone flap removed
• Temporal decompression-upto middle cranial fossa
floor
• Wax bone edges
• Dural tack-up stitches
• Dural opening (controlled manner) with radial
incisions in stellate fashion
• Closure with dural substitute and after keeping
suction drain

35. BIFRONTAL CRANIECTOMY
• Bifrontal contusions / diffuse cerebral edema
• Mark midline and coronal suture
• Bicoronal incision (2-3 cm behind coronal)
• Myocutaneous flap brought over the orbital rim (Preserve
supra-orbital nerves)
• Bur-holes – b/l keys, b/l squamous temporal, straddling
the SSS just posterior to coronal suture
• Bone flap
• Temporal decompression
• Bone wax, dural tack-up stitches
• Divide the anterior portion of SSS and falx
• Dural opening wide

50. What is the percentage reduction
in
ICP attained by DC?
• Opening the dura has been shown to
improve the reduction in ICP from 30% (dura
left intact) to 85% (dura opened)

51. Complications
• 50-55 %
•Abnormalities in CSF absorption
•Expansion of hematomas after decompression
•Syndrome of the trephined
•Infection

52. CSF absorption disorders
• Subdural hygromas & hydrocephalus
• Causes:
– Ruptured arachnoid  One-way valve
– Pressure gradients between
hemispheres
– Alteration in brain’s shape
• Treatment
– Ventriculostomy & oversewing if CSF
leak
– VP shunt (programmable)
– Cranioplasty

53. Expanding hematomas
• New or existing mass lesions can develop
postoperatively,especially given the high
incidence of coagulopathy and platelet
dysfunction
• Evolution of both contusions and extra-axial
hematomas can occur after the tamponading
effects of cerebral edema, and elevated ICP
has been relieved by decompressive
craniectomy.
• Postoperative imaging is recommended
especially in the setting of no ICP monitoring

54. SYNDROME OF THE TREPHINED
• Variety of symptoms that can develop following
craniectomy, including fatigue, headache, mood
disturbances, and even motor weakness.
• Mechanisms:
– CSF flow abnormalities
– Direct atmospheric pressure on the brain
– Disturbances in cerebral blood flow.
• Often resolves with replacement of the bone flap
• There is no evidence that it is harmful or that delay
of cranioplasty can result in long-term consequences

55. Cranioplasty
• Usually carried out 6 to 8 weeks after the DC,
assuming that the patient has recovered from the
initial injury and hydrocephalus or brain swelling is
not present.
• In the interim - “hockey helmet”
• Autologous bone flap, (frozen after the initial
surgery / kept in abdominal subcutaneous tissue) is
used and provides good cosmetic results.
• The bone flap remains sterile in a −70°C freezer for
many months.
• Autoclaving of the bone (e.g., if contaminated by a
compound scalp wound before cranioplasty) 
reduce the viability of the graft.

56. CRANIOPLASTY
• Complication associated with abdominal
preservation of bone flap - bone resorption (5-
10%) due to hypovascular bone necrosis and
sepsis of the flap.
• Other materials - methyl methacrylate and
titanium mesh when the bone is heavily
comminuted or contaminated.
• For large, cosmetically important defects, the
use of casts, stereolithographicmodels, and CT-
based“computer-assisted design” reconstruction
technology

58. CONCLUSION
• IC-HTN results from many disease processes.
• Decompressive craniectomy can be life
preserving procedure.
• Selection criteria remains in involution.
• Best outcomes are achieved in young
patients
treated early in course of disease.

60. • The multicenter, randomized, controlled trial
to test the efficacy of bifrontotemporoparietal
decompressive craniectomy in adults under
the age of 60 years with traumatic brain injury
in whom first-tier intensive care and
neurosurgical therapies had not maintained
intracranial pressure below accepted targets
• Principal Investigator: D. J. Cooper (The Alfred
Hospital & National Trauma Research Institute)

61. Trial
design
• From December 2002 through April
2010,adults with severe traumatic brain injury
in the intensive care units (ICUs) of 15
tertiary care hospitals in Australia, New
Zealand, and Saudi Arabia were recruited
• The trial protocol was designed by the
study’s executive committee and approved
by the ethics committee at each study
center.

62. PATIENTS
• Inclusion criteria:
– Severe diffuse Traumatic Brain Injury defined as:
• GCS < 9 and CT scan with evidence of brain swelling (DII +
swelling, DIII or DIV)
• OR
• GCS >8 before intubation and DIII or DIV (basal cistern
compression ± midline shift)
– Age 15 – 60 years
– First 72 hours from time of injury
– ICP monitor in situ. EVD strongly recommended.
.

63. PATIENTS
Exclusion criteria:
•Intracranial haemorrhage > 3 cm diameter
•Intracranial mixed haemorrhagic contusion >5cm in long
axis
•Previous craniectomy
•EDH/SDH/ or large contusion requiring evacuation
•EDH/SDH >0.5 cm thickness
•Spinal cord injury
•Penetrating brain injury
•Arrest at scene
•Unreactive pupils >4mm, and GCS=3
•Neurosurgery contraindicated (eg: severe coagulopathy)
•No chance of survival after consideration of CT and
clinical findings following Neurosurgical consultant
assessment (eg hemispheric infarct after carotid

64. Study
Procedures
• Treated in ICUs with ICP monitors
• Patients received treatment for intracranial
hypertension whenever the intracranial pressure was
>20 mm Hg.
• An early refractory elevation in ICP was defined as a
spontaneous increase in intracranial pressure for
>15 minutes (continuously or intermittently) within a
1- hour period, despite optimized first-tier
interventions.

65. • Within the first 72 hours after injury,
patients were randomly assigned either to
undergo decompressive craniectomy plus
standard care or to receive standard care
alone, using an automated telephone
randomisation / allocation system.

66. Outcome Measures
• Outcome measures were evaluated by telephone by three
trained assessors who were unaware of study-group
assignments.
• The original primary outcome was the proportion of
patients with an unfavorable outcome, a composite of
death, a vegetative state, or severe disability, as assessed
with the use of a structured, validated telephone
questionnaire at 6 months after injury.
• After the interim analysis in January 2007, the primary
outcome was revised to be the functional outcome at 6
months after injury on the basis of proportional odds
analysis of the Extended GOS.
• Secondary outcomes were ICP measured hourly, the
intracranial hypertension index, the proportion of
survivors with a score of 2 to 4 on the Extended GOS, the
numbers of days in the ICU and in the hospital, and
mortality in the hospital and at 6 months.

67. • The median age was 23.7 years in the craniectomy
group and 24.6 in the standard-care group.
• The median ICP during the 12 hours before
randomization was 20 mm Hg.
• The median time from randomization to surgery in
the craniectomy group was 2.3 hours
• Fifteen patients (18%) in the standard-care group
underwent delayed decompressive craniectomy as a
lifesaving intervention, according to the protocol.
• In four patients (5%) in the standard-care
group, craniectomy was performed less than 72 hours
after admission, contrary to the protocol.

68. • Of patients, 70% in the craniectomy group
had an unfavourable outcome versus 51% in
the standard care group.

69. • Among adults with severe diffuse TBI and refractory
intracranial hypertension in the ICU, decompressive
craniectomy decreased ICP, the duration of mechanical
ventilation, and the time in the ICU, as compared with
standard care.
• In the craniectomy group, the duration of the hospital stay
was unchanged, and the rate of surgical complications was
low.
• However, patients in the craniectomy group had a lower
median score on the Extended Glasgow Outcome Scale
and a higher risk of an unfavorable outcome (as assessed
on that scale) than patients receiving standard care.

70. Criticisms
• The median ICP in the hours prior to randomization was 20 mm Hg, which raises
the important question of whether the patients in the study truly had intracranial
hypertension and whether the patients should have ever been considered for
surgery.
• 27% of the patients randomized to surgery had bilateral nonreactive pupils,
compared to only 12% of the patients in the medical group. This key
discrepancy was statistically significant, and when accounting for this between-
group difference, there was no difference in outcomes between patients in the
decompressive craniectomy and medical management groups.
• Performing their analysis via an “intention-to-treat” design, despite an 18%
crossover rate to surgery in the patient group initially randomized to medical
management.
• Managing ICPs for 15 minutes prior to randomization, changing the study design
at the midpoint analysis instead of stopping the trial for futility, and enrolling in
the study only 4% of screened patients over 7 years.
• The DECRA trial contains no data or valuable information to inform modern
management of TBI and thus should be ignored by practitioners evaluating
treatment options for severe TBI.

71. Conclusion
In patients with severe diffuse traumatic
brain injury and increased intracranial
pressure that was refractory to first-tier
therapies, the use of craniectomy, as
compared with standard care, decreased the
mean intracranial pressure and the duration
of both ventilatory support and the ICU stay
but was associated with a significantly worse
outcome at 6 months, as measured by the
score on the Extended GlasgowOutcome
Scale.

72. • R-andomised
• E-valuation of
• S-urgery with
• C-raniectomy for
• U-ncontrollable
• E-levation of
ICP
RESCUE ICP TRIAL

73. Randomised controlled trial comparing the
efficacy of decompressive craniectomy versus
optimal medical management for the
treatment of refractory intracranial
hypertension following brain trauma
- Collaboration between the
University of Cambridge Departments of
Neurosurgery/Neurointensive care and the
European Brain Injury Consortium (EBIC)

74. RESCUEicp differs from DECRA
•ICP threshold (25 vs. 20mmHg)
•Duration of refractory raised ICP (>1
hour vs. 15 minutes)
•Timing of surgery - any time after
injury vs. within 72 hours post-
injury)
•Acceptance of contusions
•Longer follow up (2 years).

75. UPDATEAs at September 2010
14th International Conference on Intracranial Pressure and Brain
Monitoring
Tubingen, Germany.
•Over 265 patients had been recruited so far (299 as at March 2011)
•Patients were from more than 40 centres in 17 countries
•The follow up rate at 6 months is 96%
•Evaluation of the first 120 patients showed equal distribution of
characteristics between the two arms
•Overall, 80% of the patients were male
•5% were hypoxic and 13% hypotensive at initial presentation
•73% were initially GCS 3-8, 16% GCS 9-12 and 12% 13 -15

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