In order to more properly evaluate the benefits of DC, two multi-centre randomised controlled trials (RCTs) have recently been conducted. Although life-saving in severe cases, the long-term global outcome of these patients has been shown to be low. Decompressive craniectomy (DC) was first described in modern neurosurgery, by Kocher and Cushing in the beginning of the twentieth century and has ever since been a matter of much debate. There are various treatment protocols for elevated intracranial pressure (ICP), such as ICP-targeted or cerebral perfusion pressure (CPP)-targeted, that from different perspectives aim to reduce secondary brain injury. The annual incidence is estimated at 260 per 100,000 in Europe, with a fatality rate between 0.9 and 7.6%. Traumatic brain injury (TBI) continues to cause substantial morbidity and mortality. The place for DC in TBI management must be evaluated better, and we believe it is important that future RCTs should have clearer and less permissive ICP criteria regarding when thiopental should be followed by DC and DC followed by thiopental. Favourable outcome was 44% in patients treated with thiopental before DC, 56% in patients treated with DC without prior thiopental, 29% in patients treated primarily with DC and 52% in patients treated with thiopental with no DC. Eighty-eight percent of our DC patients would have qualified for the DECRA study and 38% for the Rescue-ICP trial. For 23 patients, no DC was needed after thiopental. Six patients received thiopental after DC. Of 35 DC patients, 9 were treated stepwise with thiopental before DC, 9 were treated stepwise with no thiopental before DC and 17 were treated primarily with DC. Background variables, intracranial pressure (ICP) measures and global outcome were analysed. Of 609 patients aged 16 years or older, 35 treated with DC and 23 treated with thiopental only were studied in particular. The study included all TBI patients treated at the neurointensive care unit, Akademiska sjukhuset, Uppsala, Sweden, between 20.

The aims of this study were to evaluate usage and outcome of DC and thiopental in a single centre. Two randomised controlled trials (RCTs) of decompressive craniectomy (DC) in traumatic brain injury (TBI) have shown poor outcome, but there are considerations of how these protocols relate to real practice.

Traumatized by Timothy J. Nilsson