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CAMBRIDGE, UK – Decompressive craniectomy in patients with traumatic brain injury (TBI) and increased intracranial pressure definitely saves lives, according to a new study. But at what cost?
A report published recently in the New England Journal of Medicine points out that patients saved with the procedure also had high rates of vegetative state and severe disability.
The study team, which was led by researchers at the University of Cambridge and based at Addenbrooke's Hospital, recruited more than 400 TBI patients over a decade from the United Kingdom and 19 other countries. Participants were randomly assigned to one of two treatment groups: craniectomy or medical management.
Six months after the head injury, results indicate that just more than one in four patients (27%) who received a craniectomy had died compared to just less than half (49%) of patients who received medical management. Yet, patients who survived after a craniectomy were much more likely to be dependent on others for care — 30.4% compared to 16.5%, according to the results.
Patients who survived following a craniectomy continued improving from six to 12 months after injury, however, and study authors report that, by a year, nearly half of the patients whose skulls were opened were at least independent at home, 45.4%, as compared with one-third of patients in the medical group, 32.4%.
"Traumatic brain injury is an incredibly serious and life-threatening condition. From our study, we estimate that craniectomies can almost halve the risk of death for patients with a severe traumatic brain injury and significant swelling,” explained lead author Peter J. Hutchinson, PhD, FRCS. “Importantly, this is the first high-quality clinical trial in severe head injury to show a major difference in outcome. However, we need to be really conscious of the quality of life of patients following this operation, which ranged from vegetative state through varying states of disability to good recovery."
Background information in the article notes that decompressive craniectomy is a surgical procedure in which a large section of the skull is removed and the underlying dura mater is opened.
"Doctors and families will need to be aware of the wide range of possible long-term outcomes when faced with the difficult decision as to whether to subject someone to what is a major operation,” added co-author Angelos G. Kolias, PhD, MRCS. “Our next step is to look in more detail at factors that predict outcome and at ways to reduce any potential adverse effects following surgery. We are planning to hold a consensus meeting in Cambridge next year to discuss these issues."