An injury to the brain may cause it to swell. Pressure within the skull then increases as the brain has no room to expand; this excess pressure, known as intracranial pressure, can cause further brain injury. High intracranial pressure (ICP) is the most frequent cause of death and disability in brain-injured patients. If high ICP cannot be controlled using general or first-line therapeutic measures such as adjusting body temperature or carbon dioxide levels in the blood and sedation, second-line treatments are initiated. One of these is a procedure called decompressive craniectomy (DC). DC involves the removal of a section of skull so that the brain has room to expand and the pressure decrease. There is however clinical uncertainty regarding the use of DC and a lack of consensus on the optimal management of traumatic brain injury.
This review looked at all high quality trials investigating the effectiveness of DC, compared to conventional medical treatments, on survival and neurological outcomes for patients over the age of 12 months who had a raised ICP after traumatic brain injury (TBI). Only one trial was identified. This trial involved 27 pediatric patients (less than 18 years old). The results indicate that the risk of death and disability was moderately reduced when DC was used. No trials investigating the effectiveness in adults were found.
The authors of the review conclude that there is no evidence to support the routine use of DC to improve mortality and quality of life in brain-injured adults with high ICP. DC may improve survival and neurological outcomes in brain-injured pediatric patients with raised ICP for whom other medical treatments had failed. This one trial involved only a small number of patients and further studies are needed before applying DC as a routine treatment.
Two trials of DC are currently in progress, the results from which may allow further conclusions regarding the effectiveness of the procedure in adults. These will be incorporated into the review when they are completed.