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Peter J Hutchinson - One of the best experts on this subject based on the ideXlab platform.
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The Value of Decompressive Craniectomy in Traumatic Brain Injury
Evidence for Neurosurgery, 2019Co-Authors: Angelos G. Kolias, Athanasios Paschalis, Kostas N. Fountas, Peter J HutchinsonAbstract:Intracranial hypertension and brain swelling are well recognised secondary insults following traumatic brain injury (TBI), which are associated with increased mortality and worse outcomes. Decompressive Craniectomy refers to the practice of removing a large bone flap and opening the underlying dura. By “opening the box”, the intracranial pressure is lowered and the risk of herniation can be avoided, although not completely eliminated. This chapter aims to critically appraise the existing evidence base in order to define the role of Decompressive Craniectomy following TBI.
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The History of Decompressive Craniectomy in Traumatic Brain Injury.
Frontiers in Neurology, 2019Co-Authors: Zefferino Rossini, Peter J Hutchinson, Federico Nicolosi, Angelos G. Kolias, Paolo De Sanctis, Franco ServadeiAbstract:Decompressive Craniectomy consists of removal of piece of bone of the skull to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury. In the last century, many neurosurgeons have reported their experience, using different techniques of Decompressive Craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of Decompressive Craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that Decompressive Craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients’ preferences and quality of life expectations.
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trial of Decompressive Craniectomy for traumatic intracranial hypertension
The New England Journal of Medicine, 2016Co-Authors: Peter J Hutchinson, Marek Czosnyka, Angelos G. Kolias, Ivan Timofeev, Elizabeth A. Corteen, Diederik Bulters, Antonio Belli, Jake Timothy, Ian A Anderson, Andrew C EynonAbstract:BackgroundThe effect of Decompressive Craniectomy on clinical outcomes in patients with refractory traumatic intracranial hypertension remains unclear. MethodsFrom 2004 through 2014, we randomly assigned 408 patients, 10 to 65 years of age, with traumatic brain injury and refractory elevated intracranial pressure (>25 mm Hg) to undergo Decompressive Craniectomy or receive ongoing medical care. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOS-E) (an 8-point scale, ranging from death to “upper good recovery” [no injury-related problems]) at 6 months. The primary-outcome measure was analyzed with an ordinal method based on the proportional-odds model. If the model was rejected, that would indicate a significant difference in the GOS-E distribution, and results would be reported descriptively. ResultsThe GOS-E distribution differed between the two groups (P<0.001). The proportional-odds assumption was rejected, and therefore results are reported descriptively. At 6 months, the GOS...
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Decompressive Craniectomy operative technique and perioperative care
Advances and technical standards in neurosurgery, 2012Co-Authors: Ivan Timofeev, Angelos G. Kolias, Thomas Santarius, Peter J HutchinsonAbstract:With improvements in neurocritical care advanced measures of treating raised intracranial pressure (ICP) are more frequently utilised. Decompressive Craniectomy is an effective ICP-lowering procedure; however its benefits are maximised with optimal surgical technique and perioperative care, as well as by paying attention to possible complications. This article focuses on the current indications and rationale for Decompressive Craniectomy, and the surgical technique of bifrontal and unilateral decompression. The key surgical points include a large Craniectomy window and opening of the dura, leaving it unsutured or performing a wide non-constricting duroplasty. Perioperative care and possible complications are also discussed.
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The RESCUEicp Decompressive Craniectomy trial
Critical Care, 2009Co-Authors: Peter J Hutchinson, Ivan Timofeev, S Grainger, Elizabeth A. CorteenAbstract:The RESCUEicp study (Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure) aims to provide Class 1 randomised evidence as to whether Decompressive Craniectomy is effective for the management of patients with raised and refractory intracranial pressure (ICP) following traumatic brain injury.
Kwok M Ho - One of the best experts on this subject based on the ideXlab platform.
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the current role of Decompressive Craniectomy in the management of neurological emergencies
Brain Injury, 2013Co-Authors: Stephen Honeybul, Kwok M HoAbstract:AbstractDecompressive Craniectomy has been used as a lifesaving procedure for many neurological emergencies, including traumatic brain injury, ischaemic stroke, subarachnoid haemorrhage, cerebrovenous thrombosis, severe intracranial infection, inflammatory demyelination and encephalopathy. The evidence to support using Decompressive Craniectomy in these situations is, however, limited. Decompressive Craniectomy has only been evaluated by randomized controlled trials in traumatic brain injury and ischaemic stroke and, even so, its benefits and risks in these situations remain elusive. If one considers a modified Rankin Scale of 4 or 5 or dependency in daily activity as an unfavourable outcome, Decompressive Craniectomy is associated with an increased risk of survivors with unfavourable outcome (relative risk [RR] = 2.9, 95% confidence interval [CI] = 1.5–5.8, p = 0.002, I2 = 0%; number needed to operate to increase an unfavourable outcome = 3.5, 95% CI = 2.4–7.4), but not the number of survivors with a fav...
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delayed neurological recovery after Decompressive Craniectomy for severe nonpenetrating traumatic brain injury
Critical Care Medicine, 2011Co-Authors: Kwok M Ho, Stephen Honeybul, Edward LittonAbstract:Objective: This study aimed to assess the incidence and factors associated with delayed neurologic recovery after Decompressive Craniectomy for severe nonpenetrating traumatic brain injury. Design: Retrospective cohort study. Setting: Two major neurotrauma centers in Western Australia. Patients: One hundred and four adult neurotrauma patients who had had a Decompressive Craniectomy and remained moderately disabled or worse at 6-month follow-up. Measurements and Main Results: Glasgow Outcome Scale scores at 6, 12, and 18 months were used to assess the neurologic recovery of the patients, and logistic regression was used to identify the factors associated with delayed neurologic recovery between 6 and 18 months after surgery. Among a total of 176 patients who required Decompressive Craniectomy between 2004 and 2010, 104 (59%) had moderate to severe disability 6 months after surgery. Fifty of these patients (48%, 95% confidence interval: 39–58) had ≥1 grade of improvement in Glasgow Outcome Scale score between 6 and 18 months after surgery. Of the 59 patients who had an unfavorable outcome (severe disability or vegetative state) 6 months after surgery, 15 patients (25%, 95% confidence interval: 16–38) improved and had attained a favorable outcome (moderate disability or near normal neurologic function) by the 18-month follow-up. An absence of nonevacuated intracerebral hematoma (>1 cm in diameter) (odds ratio 6.67, 95% confidence interval: 1.12–33.3; p = .038) and a higher admission Glasgow Coma Scale (odds ratio per point increment 1.44, 95% confidence interval: 1.07–1.96; p = .018) were the only two factors significantly associated with a higher chance of delayed neurologic improvement from unfavorable to favorable neurologic outcome between 6 and 18 months after surgery. Conclusions: Delayed neurologic recovery after Decompressive Craniectomy for severe nonpenetrating traumatic brain injury was very common; absence of nonevacuated intracerebral hematoma and a high admission Glasgow Coma Scale were associated with a higher chance of delayed neurologic recovery after Decompressive Craniectomy.
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long term complications of Decompressive Craniectomy for head injury
Journal of Neurotrauma, 2011Co-Authors: Stephen Honeybul, Kwok M HoAbstract:Abstract There is currently much interest in the use of Decompressive Craniectomy for intracranial hypertension. Though technically straightforward, the procedure is not without significant complications. A retrospective analysis was undertaken of 164 patients who had had a Decompressive Craniectomy for severe head injury in the years 2004 to 2009 at the two major hospitals in Western Australia. Eighty-six patients had a bifrontal decompression and seventy-eight had a unilateral decompression. Two patients died due to post-operative care issues. Complications attributable to the Decompressive surgery were: herniation of the cortex through the bone defect (42 patients, 25.6%), subdural effusion (81 patients, 49.4%), seizures (36 patients, 22%), hydrocephalus (23 patients, 14%), and syndrome of the trephined (2 patients, 1.2%). Complications attributable to the subsequent cranioplasty included: sudden death due to massive cerebral swelling in 3 patients (2.2%), infection requiring removal of the bone flap i...
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observed versus predicted outcome for Decompressive Craniectomy a population based study
Journal of Neurotrauma, 2010Co-Authors: Stephen Honeybul, Kwok M Ho, Christopher Lind, Grant GillettAbstract:Abstract A number of studies have shown that Decompressive Craniectomy can reduce intracranial pressure and may improve outcome for patients with severe head injury. This cohort study assessed the long-term outcome of neurotrauma patients who had a Decompressive Craniectomy for severe head injury in Western Australia between 2004 and 2008. The web-based outcome prediction model developed by the CRASH trial collaborators was applied to the cohort. Predicted outcome and observed outcome were compared. Characteristics of outcome between those who had had a unilateral and those who had had a bilateral Decompressive procedure were compared. All complications were recorded. Among a total of 1,786 adult neurotrauma patients admitted during the study period, 147 patients (8.2%) had a Decompressive Craniectomy. A significant proportion of patients who required unilateral (37.3%) and bilateral (46.5%) Craniectomy were able to return to work or study at 18 months after the injury. The patients who required bilateral...
Stephen Honeybul - One of the best experts on this subject based on the ideXlab platform.
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Decompressive Craniectomy - A narrative review and discussion
Australian Critical Care, 2013Co-Authors: Stephen Honeybul, Kwok-ming HoAbstract:Abstract There continues to be considerable amount of interest in Decompressive Craniectomy however its use is controversial. It is technically straightforward however it is not without significant complications and although there is currently unequivocal evidence available that it can be a life saving intervention, evidence that outcome is improved over and above standard medical therapy is less forthcoming. This narrative review considers the current role of Decompressive Craniectomy in the management of neurological emergencies and focuses on four specific questions, namely; (i) Is the Decompressive Craniectomy a life saving procedure? (ii) Does Decompressive Craniectomy improve outcome? (iii) Are there any risks associated with Decompressive Craniectomy? (iv) How do patients feel about their eventual outcome? Finally the future directions for the use of Decompressive Craniectomy are explored.
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the current role of Decompressive Craniectomy in the management of neurological emergencies
Brain Injury, 2013Co-Authors: Stephen Honeybul, Kwok M HoAbstract:AbstractDecompressive Craniectomy has been used as a lifesaving procedure for many neurological emergencies, including traumatic brain injury, ischaemic stroke, subarachnoid haemorrhage, cerebrovenous thrombosis, severe intracranial infection, inflammatory demyelination and encephalopathy. The evidence to support using Decompressive Craniectomy in these situations is, however, limited. Decompressive Craniectomy has only been evaluated by randomized controlled trials in traumatic brain injury and ischaemic stroke and, even so, its benefits and risks in these situations remain elusive. If one considers a modified Rankin Scale of 4 or 5 or dependency in daily activity as an unfavourable outcome, Decompressive Craniectomy is associated with an increased risk of survivors with unfavourable outcome (relative risk [RR] = 2.9, 95% confidence interval [CI] = 1.5–5.8, p = 0.002, I2 = 0%; number needed to operate to increase an unfavourable outcome = 3.5, 95% CI = 2.4–7.4), but not the number of survivors with a fav...
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delayed neurological recovery after Decompressive Craniectomy for severe nonpenetrating traumatic brain injury
Critical Care Medicine, 2011Co-Authors: Kwok M Ho, Stephen Honeybul, Edward LittonAbstract:Objective: This study aimed to assess the incidence and factors associated with delayed neurologic recovery after Decompressive Craniectomy for severe nonpenetrating traumatic brain injury. Design: Retrospective cohort study. Setting: Two major neurotrauma centers in Western Australia. Patients: One hundred and four adult neurotrauma patients who had had a Decompressive Craniectomy and remained moderately disabled or worse at 6-month follow-up. Measurements and Main Results: Glasgow Outcome Scale scores at 6, 12, and 18 months were used to assess the neurologic recovery of the patients, and logistic regression was used to identify the factors associated with delayed neurologic recovery between 6 and 18 months after surgery. Among a total of 176 patients who required Decompressive Craniectomy between 2004 and 2010, 104 (59%) had moderate to severe disability 6 months after surgery. Fifty of these patients (48%, 95% confidence interval: 39–58) had ≥1 grade of improvement in Glasgow Outcome Scale score between 6 and 18 months after surgery. Of the 59 patients who had an unfavorable outcome (severe disability or vegetative state) 6 months after surgery, 15 patients (25%, 95% confidence interval: 16–38) improved and had attained a favorable outcome (moderate disability or near normal neurologic function) by the 18-month follow-up. An absence of nonevacuated intracerebral hematoma (>1 cm in diameter) (odds ratio 6.67, 95% confidence interval: 1.12–33.3; p = .038) and a higher admission Glasgow Coma Scale (odds ratio per point increment 1.44, 95% confidence interval: 1.07–1.96; p = .018) were the only two factors significantly associated with a higher chance of delayed neurologic improvement from unfavorable to favorable neurologic outcome between 6 and 18 months after surgery. Conclusions: Delayed neurologic recovery after Decompressive Craniectomy for severe nonpenetrating traumatic brain injury was very common; absence of nonevacuated intracerebral hematoma and a high admission Glasgow Coma Scale were associated with a higher chance of delayed neurologic recovery after Decompressive Craniectomy.
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long term complications of Decompressive Craniectomy for head injury
Journal of Neurotrauma, 2011Co-Authors: Stephen Honeybul, Kwok M HoAbstract:Abstract There is currently much interest in the use of Decompressive Craniectomy for intracranial hypertension. Though technically straightforward, the procedure is not without significant complications. A retrospective analysis was undertaken of 164 patients who had had a Decompressive Craniectomy for severe head injury in the years 2004 to 2009 at the two major hospitals in Western Australia. Eighty-six patients had a bifrontal decompression and seventy-eight had a unilateral decompression. Two patients died due to post-operative care issues. Complications attributable to the Decompressive surgery were: herniation of the cortex through the bone defect (42 patients, 25.6%), subdural effusion (81 patients, 49.4%), seizures (36 patients, 22%), hydrocephalus (23 patients, 14%), and syndrome of the trephined (2 patients, 1.2%). Complications attributable to the subsequent cranioplasty included: sudden death due to massive cerebral swelling in 3 patients (2.2%), infection requiring removal of the bone flap i...
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observed versus predicted outcome for Decompressive Craniectomy a population based study
Journal of Neurotrauma, 2010Co-Authors: Stephen Honeybul, Kwok M Ho, Christopher Lind, Grant GillettAbstract:Abstract A number of studies have shown that Decompressive Craniectomy can reduce intracranial pressure and may improve outcome for patients with severe head injury. This cohort study assessed the long-term outcome of neurotrauma patients who had a Decompressive Craniectomy for severe head injury in Western Australia between 2004 and 2008. The web-based outcome prediction model developed by the CRASH trial collaborators was applied to the cohort. Predicted outcome and observed outcome were compared. Characteristics of outcome between those who had had a unilateral and those who had had a bilateral Decompressive procedure were compared. All complications were recorded. Among a total of 1,786 adult neurotrauma patients admitted during the study period, 147 patients (8.2%) had a Decompressive Craniectomy. A significant proportion of patients who required unilateral (37.3%) and bilateral (46.5%) Craniectomy were able to return to work or study at 18 months after the injury. The patients who required bilateral...
Peter J Kirkpatrick - One of the best experts on this subject based on the ideXlab platform.
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effect of Decompressive Craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury
Journal of Neurosurgery, 2008Co-Authors: Ivan Timofeev, Peter J Kirkpatrick, Marek Czosnyka, Jurgens Nortje, Peter Smielewski, A K Gupta, Peter J HutchinsonAbstract:Object Decompressive Craniectomy is an advanced treatment option for intracranial pressure (ICP) control in patients with traumatic brain injury. The purpose of this study was to evaluate the effect of Decompressive Craniectomy on ICP and cerebrospinal compensation both within and beyond the first 24 hours of Craniectomy. Methods This study was a retrospective analysis of the physiological parameters from 27 moderately to severely head-injured patients who underwent Decompressive Craniectomy for progressive brain edema. Of these, 17 patients had undergone prospective digital recording of ICP with estimation of ICP waveform–derived indices. The pressure-volume compensatory reserve (RAP) index and the cerebrovascular pressure reactivity index (PRx) were used to assess those parameters. The values of parameters prior to and during the 72 hours after Decompressive Craniectomy were included in the analysis. Results Decompressive Craniectomy led to a sustained reduction in median (interquartile range) ICP value...
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Decompressive Craniectomy in traumatic brain injury outcome following protocol driven therapy
Acta Neurochirurgica, 2006Co-Authors: Ivan Timofeev, Peter J Kirkpatrick, Marek Czosnyka, David K Menon, Elizabeth A. Corteen, M Hiler, John D Pickard, Peter J HutchinsonAbstract:Although Decompressive Craniectomy following traumatic brain injury is an option in patients with raised intracranial pressure (ICP) refractory to medical measures, its effect on clinical outcome remains unclear. The aim of this study was to evaluate the outcome of patients undergoing this procedure as part of protocol-driven therapy between 2000–2003. This was an observational study combining case note analysis and follow-up. Outcome was assessed at an interval of at least 6 months following injury using the Glasgow Outcome Scale (GOS) score and the SF-36 quality of life questionnaire. Forty-nine patients underwent Decompressive Craniectomy for raised and refractory ICP (41 [83.7%] bilateral Craniectomy and 8 [16.3%] unilateral). Using the Glasgow Coma Scale (GCS), the presenting head injury grade was severe (GCS 3–8) in 40 (81.6%) patients, moderate (GCS 9–12) in 8 (16.3%) patients, and initially mild (GCS 13–15) in 1 (2.0%) patient. At follow-up, 30 (61.2%) patients had a favorable outcome (good recovery or moderate disability), 10 (20.4%) remained severely disabled, and 9 (18.4%) died. No patients were left in a vegetative state. Overall the results demonstrated that Decompressive Craniectomy, when applied as part of protocol-driven therapy, yields a satisfactory rate of favorable outcome. Formal prospective randomized studies of Decompressive Craniectomy are now indicated.
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Decompressive Craniectomy in head injury
Current Opinion in Critical Care, 2004Co-Authors: Peter J Hutchinson, Peter J KirkpatrickAbstract:PURPOSE OF REVIEW: To examine the evidence for the role of Decompressive Craniectomy in the management of traumatic brain injury. RECENT FINDINGS: This review highlights the importance of brain swelling and raised intra-cranial pressure (ICP) as of the one fundamental pathophysiological processes following traumatic brain injury. The role of protocol driven therapy in controlling raised intra-cranial pressure is discussed, with the staged application of medical interventions (including hypothermia and barbiturates). If these measures fail to control ICP, a surgical option - removal of the skull (Decompressive Craniectomy) can be considered. The evidence for this operation is reviewed in terms of data published in peer-reviewed journals since 1997. This evidence consists pre-dominantly of case series with no definitive Class I evidence and demonstrates a wide range of outcomes with no clear consensus regarding the indications for the operation. SUMMARY: Decompressive Craniectomy is currently being applied in the management of traumatic brain injury with a wide range of outcomes reported in the literature. Current opinion on the role of this operation is therefore divided and it is now appropriate to proceed to prospective randomised studies.
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bifrontal Decompressive Craniectomy in the management of posttraumatic intracranial hypertension
British Journal of Neurosurgery, 2001Co-Authors: Peter C Whitfield, Peter J Hutchinson, Hiren Patel, Marek Czosnyka, D Parry, David K Menon, J D Pickard, Peter J KirkpatrickAbstract:Bifrontal Decompressive Craniectomy has been used on an ad hoc basis for the treatment of post-traumatic intracranial hypertension for more than thirty years. In this observational study we report the clinical outcome and physiological effects of the procedure in a series of 26 patients with refractory intracranial hypertension treated on a protocol driven basis. Bifrontal Decompressive Craniectomy was associated with significant reductions in mean ICP from 37.5 to 18.1 mmHg ( p = 0.003). In addition, Craniectomy reduced the amplitude of ICP waves ( p < 0.02) and increased compensatory reserve ( p < 0.05). A favourable outcome was achieved in 69% of patients; 8% were severely disabled and 23% died. We conclude that this study provides pathophysiological evidence that bifrontal Decompressive Craniectomy significantly reduces posttraumatic intracranial hypertension and improves pressure dynamics. Our results support the continued use of bifrontal Decompressive Craniectomy in selected patients after head injury.
Juan Sahuquillo - One of the best experts on this subject based on the ideXlab platform.
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Decompressive Craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury
Cochrane Database of Systematic Reviews, 2006Co-Authors: Juan SahuquilloAbstract:Background High intracranial pressure (ICP) is the most frequent cause of death and disability after a severe traumatic brain injury (TBI). High ICP is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail to control high ICP, second-line therapies are initiated. Of these, barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (Decompressive Craniectomy) are used. Objectives To assess the effects of secondary Decompressive Craniectomy on outcomes and quality of life for patients with severe TBI in whom conventional medical therapeutic measures have failed to control a raised ICP. Search methods We searched the following electronic databases: Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, PubMed, EMBASE, ZETOC, CINAHL, and Controlled Trials metaRegister (www.controlled-trials.com/mrct/search). We searched the Internet using Google Scholar (http://scholar.google.com) and handsearched relevant conference proceedings. We also contacted experts in the field and authors of included studies. The searches were last conducted in May 2008. Selection criteria Randomized or quasi-randomized studies assessing patients over the age of 12 months with severe TBI who underwent Decompressive Craniectomy to control ICP refractory to conventional medical treatments. Data collection and analysis The electronic search and handsearching results were examined for reports of potentially relevant trials, which were then retrieved in full. The selection criteria were applied, data extraction performed, and studies assessed for methodological quality. Main results We found only one trial with 27 participants, conducted in a pediatric population. Decompressive Craniectomy was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72) and a RR of 0.54 (95% CI 0.29 to 1.01) for an unfavorable outcome (death, vegetative status, or severe disability 6 to 12 months after injury). To date, no results are available to confirm or refute the effectiveness of Decompressive Craniectomy in adults. Authors' conclusions There is no evidence from randomized controlled trials that supports the routine use of secondary Decompressive Craniectomy to reduce unfavorable outcomes in adults with severe TBI and refractory high ICP. In the study with a pediatric population, Decompressive Craniectomy reduced the risk of death and unfavorable outcomes. Despite the wide CI for death and the small sample size of this one identified study, the treatment may be justified in patients below the age of 18 years when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of Decompressive Craniectomy (RescueICP and DECRA) that will allow further conclusions on the efficacy of this procedure in adults.
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Decompressive Craniectomy in traumatic brain injury the randomized multicenter rescueicp study www rescueicp com
Acta Neurochirurgica, 2006Co-Authors: Peter J Hutchinson, Marek Czosnyka, David K Menon, J D Pickard, Elizabeth A. Corteen, A D Mendelow, Patrick Mitchell, Graham K Murray, E Rickels, Juan SahuquilloAbstract:The RESCUEicp (Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of intracranial pressure) study has been established to determine whether Decompressive Craniectomy has a role in the management of patients with traumatic brain injury and raised intracranial pressure that does not respond to initial treatment measures. We describe the concept of Decompressive Craniectomy in traumatic brain injury and the rationale and protocol of the RESCUEicp study.
