A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension.
The object of our study was to determine, in children with traumatic brain injury and sustained intracranial hypertension, whether very early decompressive craniectomy improves control of intracranial hypertension and longterm function and quality of life.
                All children were managed from admission onward according to a standardized protocol for head injury management. Children with raised intracranial pressure (ICP) were randomized to standardized management alone or standardized management plus cerebral decompression. A decompressive bitemporal craniectomy was performed at a median of 19.2 h (range 7.3-29.3 h) from the time of injury. ICP was recorded hourly via an intraventricular catheter. Compared with the ICP before randomization, the mean ICP was 3.69 mmHg lower in the 48 h after randomization in the control group, and 8.98 mmHg lower in the 48 hours after craniectomy in the decompression group (P=0.057). Outcome was assessed 6 months after injury using a modification of the Glasgow Outcome Score (GOS) and the Health State Utility Index (Mark 1). Two (14%) of the 14 children in the control group were normal or had a mild disability after 6 months, compared with 7 (54%) of the 13 children in the decompression group. Our conclusion was that when children with traumatic brain injury and sustained intracranial hypertension are treated with a combination of very early decompressive craniectomy and conventional medical management, it is more likely that ICP will be reduced, fewer episodes of intracranial hypertension will occur, and functional outcome and quality of life may be better than in children treated with medical management alone (P=0.046; owing to multiple significance testing P <0.0221 is required for statistical significance). This pilot study suggests that very early decompressive craniectomy may be indicated in the treatment of traumatic brain injury.
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.