This clinical study examined whether decompressive craniectomy (DC) reduces cumulative ischemic burden and therapeutic intensity levels in severe traumatic brain injury (TBI) patients with elevated intracranial pressure (ICP). The study found that performing DC on 10 severe TBI patients with elevated ICP reduced ICP immediately and lowered therapeutic intensity levels within 12 hours after surgery. DC also significantly reduced the duration and severity of cumulative ischemic burden in these patients. Overall mortality was lower than predicted, suggesting DC may help reduce secondary brain injury from elevated ICP in severe TBI.

1. CLINICAL STUDIES
Gregory M. Weiner, BA
Department of Neurosurgery,
University of Pennsylvania School of
Medicine,
Philadelphia, Pennsylvania
Decompressive Craniectomy for Elevated
Michelle R. Lacey, PhD
Department of Mathematics,
Tulane University,
Intracranial Pressure and Its Effect on the
New Orleans, Louisiana
Cumulative Ischemic Burden and Therapeutic
Larami Mackenzie, MD
Department of Neurology,
University of Pennsylvania School of
Intensity Levels After Severe Traumatic Brain Injury
Medicine,
Philadelphia, Pennsylvania
BACKGROUND: Increased intracranial pressure (ICP) can cause brain ischemia and com-
Darshak P. Shah, BA, BS promised brain oxygen (PbtO2 ≤ 20 mm Hg) after severe traumatic brain injury (TBI).
Department of Neurosurgery,
University of Pennsylvania School of OBJECTIVE: We examined whether decompressive craniectomy (DC) to treat elevated ICP
Medicine, reduces the cumulative ischemic burden (CIB) of the brain and therapeutic intensity level (TIL).
Philadelphia, Pennsylvania
METHODS: Ten severe TBI patients (mean age, 31.4 ± 14.2 years) who had continuous
Suzanne G. Frangos, RN, CNRN PbtO2 monitoring before and after delayed DC were retrospectively identified. Patients
Department of Neurosurgery,
University of Pennsylvania School of
were managed according to the guidelines for the management of severe TBI. The CIB was
Medicine, measured as the total time spent between a PbtO2 of 15 to 20, 10 to 15, and 0 to 10 mm Hg.
Philadelphia, Pennsylvania
The TIL was calculated every 12 hours. Mixed-effects models were used to estimate changes
M. Sean Grady, MD associated with DC.
Department of Neurosurgery,
University of Pennsylvania School of
RESULTS: DC was performed on average 2.8 days after admission. DC was found to imme-
Medicine, diately reduce ICP (mean [SEM] decrease was 7.86 mm Hg [2.4 mm Hg]; P = .005). TIL, which
Philadelphia, Pennsylvania was positively correlated with ICP (r = 0.46, P ≤ .001), was reduced within 12 hours after
Andrew Kofke, MD surgery and continued to improve within the postsurgical monitoring period (P ≤ .001).
Department of Anesthesiology and The duration and severity of CIB were significantly reduced as an effect of DC in this group.
Critical Care,
University of Pennsylvania School of The overall mortality rate in the group of 10 patients was lower than predicted at the time
Medicine, of admission (P = .015).
Philadelphia, Pennsylvania
CONCLUSION: These results suggest that a DC for increased ICP can reduce the CIB of the
Joshua Levine, MD brain after severe TBI. We suggest that DC be considered early in a patient’s clinical course,
Departments of Neurosurgery, Neurology,
and Anesthesiology and Critical Care,
particularly when the TIL and ICP are increased.
University of Pennsylvania School of KEY WORDS: Craniectomy, Ischemia, Trauma
Medicine,
Philadelphia, Pennsylvania
Neurosurgery 66:1111-1119, 2010 DOI: 10.1227/01.NEU.0000369607.71913.3E www.neurosurgery-online.com
James Schuster, MD, PhD
T
Department of Neurosurgery,
University of Pennsylvania School of raumatic brain injury (TBI) is a leading ment to maintain ICP ≤ 20 mm Hg, to optimize
Medicine, cause of death and disability among people cerebral perfusion pressure (CPP), and to pre-
Philadelphia, Pennsylvania
of all ages. Intracranial hypertension, par- vent secondary cerebral injury—is central to TBI
Peter D. Le Roux, MD ticularly when it does not respond to maximal management.8-10 Today, many neurointensive
Department of Neurosurgery, medical management, increases the risk of mor- care units (NICUs) also use multimodality mon-
University of Pennsylvania School of
Medicine,
tality and poor outcome. 1-7 Marmarou et al 4 itoring, eg, brain oxygen (PbtO2), continuous
Philadelphia, Pennsylvania observed a significant association between poor electroencephalogram, or microdialysis, to help
Reprint requests:
outcome and the number of hourly intracranial prevent secondary brain injury. In addition,
Peter D. LeRoux, MD, pressure (ICP) values that were > 20 mm Hg. advances in computer technology and the use of
Department of Neurosurgery, Consequently, ICP control—-specifically treat- derived ICP indexes suggest that ICP is a complex
Clinical Research Division,
University of Pennsylvania Medical Center, ABBREVIATIONS: APACHE II, Acute Physiology and parameter that, when carefully analyzed, con-
Philadelphia, PA 19104. Chronic Health Evaluation; CIB, cumulative ischemic tains information about cerebral compensatory
E-mail: Peter.LeRoux@uphs.upenn.edu mechanisms and mechanisms that contribute to
burden; CBF, cerebral blood flow; CPP, cerebral per-
Received, March 12, 2009. fusion pressure; DC, decompressive craniectomy; cerebral blood flow (CBF) regulation.11-14
Accepted, December 5, 2009. ICP, intracranial pressure; NICU, neurointensive care The concept of cerebral compensatory reserve
unit; TBI, traumatic brain injury; TIL, therapeutic is important. We have observed that cerebral
Copyright © 2010 by the intensity level
Congress of Neurological Surgeons infarction and poor outcome may occur even if
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2. WEINER ET AL
elevated ICP is successfully treated after severe TBI15 and that this Intracranial Monitoring
depends in part on the cerebral arteriovenous difference of oxygen. ICP (Camino®, Integra Neurosciences, Plainsboro, NJ), brain
Derived ICP indexes, eg, cerebrovascular reactivity and cere- temperature, PbtO2 (LICOX®, Integra Neuroscience), and blood
brospinal compensatory reserve, provide an insight into a patient’s pressure (arterial line) were monitored continuously. CPP was
reserve or how sick the brain is.11-14 A patient with an ICP of 20 calculated (CPP = MAP − ICP, where MAP is mean arterial pres-
mm Hg and impaired cerebrospinal compensatory reserve or cere- sure). Intraparenchymal probes (ICP, brain temperature, and
brovascular reactivity index is at much greater risk than a patient PbtO2) were inserted at the bedside in the NICU through a burr
with the same ICP but normal indexes and ICP waveform. These hole into the frontal lobe and secured with a triple-lumen bolt.
pathophysiological differences may be reflected in the therapeu- The monitors were placed into white matter that appeared normal
tic intensity level (TIL), a quantitative measure of the manage- on admission head computed tomography (CT) and on the side
ment required to control ICP.16 The greater the TIL is, the more of maximal pathology. When there was no asymmetry in brain
therapy is required and the more complex the therapy needs to pathology on CT, the probes were placed in the right frontal
be to control ICP (ie, the “sicker” the patient). This information region. Follow-up head CT scans were performed in all patients
is important because every aspect of ICP or CPP management within 24 hours of admission to confirm correct placement of the
has potential deleterious side effects.7,17-22 Thus, selecting a ther- various monitors, eg, not in a contusion or infarct. Probe func-
apy for elevated ICP or impaired CPP that does not cause extracra- tion and stability were confirmed by an appropriate PbtO2 increase
nial complications, eg, lung injury, is critical.19 after an oxygen challenge (FIO2 of 1.0 for 5 minutes; final PbtO2
When cerebral compensation is impaired, an escalating cycle value after 5–10 minutes > 20 mm Hg). To allow for probe equi-
of energy failure, edema, reduced substrate delivery, and further libration, data from the first 3 hours after PbtO2 monitor insertion
ICP increase may occur despite optimal medical management. In were discarded. ICP and PbtO2 monitors were removed once the
these patients, decompressive craniectomy (DC) is frequently used ICP was normal (≤ 20 mm Hg) without treatment (other than
to control elevated ICP.23-31 In recent years, there has been a resur- sedation for ventilator management) for > 24 hours or care was with-
gence in the use of DC after severe TBI, and currently, 2 random- drawn because of injury severity.
ized trials to examine its efficacy are underway (RescueICP32 and
DECRA33). It is well known that DC can reduce ICP,28,29,34-37 but General Clinical Management
the exact timing of when to perform DC is only beginning to be All patients were managed in the NICU according to a local
elucidated. In addition, it is hypothesized that DC interrupts the algorithm consistent with the Brain Trauma Foundation TBI guide-
cascade of ICP elevation, leading to cerebral ischemia and delayed lines.8,26,43 Each patient was fully resuscitated according to advanced
neuronal injury. However, the relationship between ICP and cere- trauma life support guidelines, intubated, and mechanically ven-
bral ischemia is not straightforward.15,38-42 In this study, we exam- tilated with the head of bed initially elevated approximately 20°
ined how DC influenced the TIL and PbtO2. We used PbtO2 to 30°. FIO2 and minute ventilation were adjusted to maintain
values to estimate a cumulative ischemic burden (CIB). We hypoth- SaO2 > 93%, PaO2 of 90 to 100 mm Hg, and PaCO2 of 34 to 38
esized that DC would decrease ICP and TIL while reducing the mm Hg. Volume resuscitation was achieved with 0.9% normal
CIB in a sustained manner. saline and albumin for a target central venous pressure of 6 to 10
cm H2O. Therapeutic targets were adjusted to avoid ICP > 20
MATERIAL AND METHODS mm Hg and CPP ≤ 60 mm Hg. After adequate fluid resuscitation,
phenylephrine (10–100 μg/min) was administered when CPP was
Patients ≤ 60 mm Hg and ICP was normal. A standard stairstep approach
Approval for the study was obtained from the Institutional was used to treat intracranial hypertension. Initial management
Review Board at the University of Pennsylvania. Patients with consisted of head of bed elevation, sedation (lorazepam), analge-
severe nonpenetrating TBI admitted to the Hospital of the University sia (fentanyl), neuromuscular blockade (vecuronium), and inter-
of Pennsylvania, a level I trauma center, who had ICP and PbtO2 mittent cerebrospinal fluid drainage with an external ventricular
monitoring for at least 12 hours in the NICU were studied as part drain. If ICP remained > 20 mm Hg for > 10 minutes despite the
of a prospective observational database. Patients were monitored initial management, osmotherapy (mannitol) was started, provided
if their admission Glasgow Coma Scale was ≤8 or they later dete- that serum osmolarity was ≤ 320 mosm/L and serum sodium was
riorated to that level. Patients in this study were retrospectively ≤ 155 mmol/L. Other second-tier therapies for refractory intracra-
identified from the database between January 2003 and December nial hypertension included optimized hyperventilation, barbitu-
2007 and met the following inclusion criteria: (1) required no rates, and DC. Induced hypothermia was not used.
immediate surgical intervention (ie, no space-occupying lesion),
(2) had medically intractable intracranial hypertension, (3) under- Decompressive Craniectomy
went a delayed DC for elevated ICP, and (4) had multimodality DC was performed at the discretion of the treating neurosur-
brain monitoring before and after DC. Patients who underwent geon and neurointensivist. In general, DC occurred when other
prophylactic DC at the time a space-occupying lesion was evac- methods to control ICP or CPP failed. Medically refractory ele-
uated were not included in this analysis. vated ICP was defined as an ICP of > 20 mm Hg for > 15 minutes
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3. DECOMPRESSIVE CRANIECTOMY AND BRAIN OXYGEN
in a 1-hour period. Patients had either a bifrontal or unilateral DC,
depending on the clinical indication and the injury distribution. TABLE 1. Classification Score
For a hemicraniectomy, a wide unilateral frontotemporoparietal Radiographic Conditions Score
craniectomy was performed and included a subtemporal craniec-
Marshall47 score
tomy to the middle cranial fossa floor. The medial margin was about
1 cm lateral to the midline, and the anterior-posterior diameter was Normal 1 (Diffuse injury I)
at least 12 cm in length. For a bifrontal DC, a coronal skin inci- Abnormal without 2 (Diffuse injury II)
sion was used, and a large bifrontal bone flap from the superior Midline shift >5 mm
orbital ridge to the coronal suture was made. Bilateral subtemporal Cistern compression
decompressions also were performed. The ICP and PbtO2 moni- Mass >25 cm3
tors were placed at the coronal suture on the same side that the Mass evacuation
monitor was before DC with either a bolt or tunnelable device. In
Cistern compression without 3 (Diffuse injury III)
all cases, the dura mater was opened as part of the operation, and
Midline shift >5 mm
the dural defect was covered with DuraGen (Integra Neurosciences).
A subgaleal drain was placed. The same intensive care management Mass >25 cm3
protocol was followed after DC, and therapy was tailored to achieve Mass evacuation
the same ICP and CPP targets. Midline shift >5 mm but without 4 (Diffuse injury IV)
Mass >25 cm3
Patient Evaluation
Mass evacuation
Clinical Surgically evacuated mass 5 (Evacuated mass lesion)
At admission, the patient’s postresuscitation Glasgow Coma of any size
Scale44 score and Acute Physiology and Chronic Health Evaluation Mass lesion >25 cm3, no 6 (Nonevacuated
(APACHE II45) score were recorded. An Internet-based APACHE surgical evacuation mass lesion)
II calculator46 was used to derive both the score and the predic- Rotterdam48 score
tor rate of death for each patient. Multiple variables are required No abnormalities 0
to calculate the APACHE score; for this study, the highest and
Basal cisterns Maximum 2
lowest values for each category (other than organ failure) during
Abnormal but not effaced 1
the first 24 hours of intensive care unit care was used for this cal-
culation. Effaced 2
Midline shift Maximum 1
Radiographic >5 mm 1
The Marshall47 and Rotterdam48 scores based on the initial Absence of epidural hematoma 1
head CT scan were calculated on all patients (Table 1). In addi- Traumatic subarachnoid and/or 1
tion, we calculated a basal cistern score (0 if normal, 1 if com- intraventricular hemorrhage
pressed but not effaced, and 2 if effaced) based on the CT scan
Bonusa +1
obtained before DC.
Maximum 6
Therapeutic Intensity Level a
For numerical consistency with Glasgow Coma Score grading and Marshall com-
The TIL modified from Maset et al16 was calculated every 12 puted tomography classification.47
hours for 2 days before and after DC. The number of calculated
TILs in some patients therefore depended on the interval between
admission and DC. There are 6 medical management categories as a Pbt O 2 between 15 and 20 mm Hg; moderate ischemia/
(hyperventilation, pressor administration, hyperosmolar therapy, hypoxia, between 10 and 15 mm Hg; and severe ischemia/hypoxia,
ventricular drainage, paralysis, and sedation) in the TIL. The max- PbtO2 ≤ 10 mm Hg.8,35,55-59 Individual episodes of PbtO2 ≤ 15 min-
imum score is 18 (Table 2). utes in duration in each category were not used in analysis. CIB was
estimated by the sum (in minutes) of PbtO2 recordings in each cat-
Cumulative Ischemic Burden egory during each 12-hour interval for 2 days before and after DC.
Several studies demonstrate that PbtO2 is influenced by a wide If a patient had severe ischemia/hypoxia, its duration was not used
range of parameters49-54 and may reflect the product of CBF and in calculating whether there was mild or moderate ischemia/hypoxia;
the arteriovenous difference in oxygen tension, ie, PbtO2 = CBF × ie, each patient was analyzed in 3 distinct potential PbtO2 categories.
AVTO2.52 Although a PbtO2 monitor is not simply an “ischemia”
or CBF monitor, we used PbtO2 values as a surrogate for cerebral Outcome
ischemia associated with elevated ICP. To do this, we calculated the Outcome was recorded as survival (dead or alive) at 30 days
CIB based on 3 PbtO2 ranges. Mild ischemia/hypoxia was classified after TBI.
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4. WEINER ET AL
admission (range, 0.55 to 10.5 days). Two patients had a bifrontal
TABLE 2. Modified Therapeutic Intensity Level Calculation16 and 8 patients a unilateral decompressive hemicraniectomy. The
Therapy Score effect of DC on ICP was immediate; the average decrease in ICP
from the 3 hours before surgery to the 3 hours after surgery was
Hyperventilation Maximum 4
7.86 with a standard error of 2.40 mm Hg (P = .005). Fitted mixed-
Intensive (PCO2 <30 mm Hg) 4 effects models for the entire time period not only showed a signif-
Moderate (PCO2 = 30-35 mm Hg) 2 icant decrease in ICP associated with surgery overall (P ≤ .001)
Pressor administration Maximum 4 but also demonstrated time-based trends, with ICP significantly
Intensive (cerebral perfusion pressure 3 increasing in the 96-hour window before surgery (P = .02) and
>80 mm Hg or mean arterial pressure >100 mm Hg) decreasing in the 96-hour window after surgery (P = .03; Table 4).
Moderate (cerebral perfusion pressure 2
≤80 mm Hg or mean arterial pressure ≤100 mm Hg)
TIL and DC
Hyperosmolar therapy Maximum 3 The TIL reflects the amount of medical therapy (eg, hyperven-
–1
Intensive mannitol (>1 g•h •kg )–1
3
tilation, osmotherapy, sedatives, muscle blockades, and pressers)
delivered to the patient to control ICP. Therapeutic values were cal-
Intensive mannitol (≤1 g•h–1•kg–1) 2
culated in 12-hour blocks up to 4 times before and after the DC.
Intensive hypertonic saline solution (≥2 L) 3
A reduction in TIL was observed after DC (Figure 1). A mixed-
Intensive hypertonic saline solution (<2 L) 2 effects model confirmed these findings statistically, with a signif-
Ventricular drainage Maximum 2 icant time-based increase in TIL before DC (P ≤ .001), an immediate
Intensive (≥4 cm3/h) 2 decrease associated with surgery (P ≤ .001), and a continued time-
Moderate (<4 cm3/h) 1 based decrease after DC (P ≤ .001). The mean estimated TIL
Paralysis induction 1 reduction associated with surgery was 3.56 (95% confidence inter-
Sedation 1
val, 1.63—5.5; Table 4). All 10 patients experienced a reduction
in TIL (on average > 33%) from 12 hours before surgery to 48
Maximum total score 18
hours after DC, with a median decrease of 5.5 (P = .003). TIL
and ICP were positively correlated (r = 0.46, P ≤ .001).
Statistical Analysis CIB and DC
Data were analyzed with the R software package.60 Data are The CIB was classified as mild, moderate, or severe, depending
recorded as the mean and standard deviation unless otherwise on whether PbtO2 was 15 to 20, 10 to 15, or ≤ 10 mm Hg, respec-
stated. A value of P ≤ .05 was considered statistically significant. tively. Nine of the 10 patients experienced PbtO2 ≤ 20 mm Hg at
Mixed-effects models51 were fit for PbtO2, ICP, and TIL to esti- some point during the observation period. Of these, 4 experienced
mate changes associated with DC while accounting for the random only mild hypoxia, 1 experienced mild to moderate hypoxia, and the
variation associated with individual patients and the varying lengths remaining 4 patients experienced at least 1 period of severe hypoxia.
of time for which they were monitored. Nonparametric Wilcoxon At 12 hours before surgery, 7 of the 10 patients had positive CIB val-
signed-rank tests61 were used to evaluate differences at specific ues (spent time with PbtO2 ≤ 20 mm Hg). For these 7 patients, we
time points and to analyze the CIB data, and an exact probabil- considered the total time spent with PbtO2 ≤ 20 mm Hg (denoted
ity calculation was used to analyze the outcome data with respect as the total CIB) during this period and observed a significant
to predicted mortality rates. decrease in this time in the 12 hours after surgery (P = .02). The 5
patients with moderate to severe ischemia in the 12 hours before
RESULTS DC experienced a significant post-DC reduction in the time spent
with PbtO2 ≤ 15 mm Hg (P = .03), and the number of patients
Patient Characteristics experiencing severe CIB (PbtO2 ≤ 10 mm Hg) decreased from 4
Ten patients, 8 male and 2 female patients (mean age, 31.4 ± before DC to 1 after DC. Overall, as shown in Figure 2, the mean
14.2 years), met the inclusion criteria for this study. Individual total CIB per patient was significantly reduced in the postsurgical
patient clinical and radiological characteristics, outcome, and expected period (P = .02), and the greatest severity level of CIB also was sig-
outcome are listed in Table 3. All patients had an admission Glasgow nificantly reduced (P = .05). Furthermore, a fitted mixed-effects
Coma Scale ≤ 7. The median (range) Rotterdam and Marshall scores model suggested that the average PbtO2 levels also increased by a
based on the initial head CT scan were 4 (3–6) and 3 (3–5), respec- small (9.83 mm Hg; 95% confidence interval, 3.6–16.1) but sig-
tively. The median (range) APACHE II score was 25 (16–33). nificant amount after surgery (P = .003; Table 4).
ICP and DC Outcome
Delayed DCs for persistently elevated ICP that was refractory to The predicted mortality for all patients based on the individ-
medical management were performed on average 2.8 days after ual APACHE II Scores ranged from 23.5 to 78.6, with a median
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5. DECOMPRESSIVE CRANIECTOMY AND BRAIN OXYGEN
TABLE 3. Patient Demographics and Admission Clinical and Radiographic Scoresa
Predictive 30-Day
Case/Age, Marshall Rotterdam
MOI Pathology GCS Apache II Mortality BCS DC Time, d Outcome
y/Sex Score Score
Rate, %b (Survival)
1/24/M ATV CHI 6 24 49.7 3 3 1 10.5 A
2/43/M MVC SDH 3 24 49.7 5 6 2 0.66 D
3/37/M Fall CHI 6 25 53.3 3 4 1 1 A
4/24/M Fall DAI 5 33 78.6 5 5 2 0.55 A
5/21/F Fall SDH 7 27 60.5 3 4 1 2 A
6/22/M Fall CHI 5 25 53.3 3 4 1 4 A
7/18/M A vs P CHI 3 26 56.9 3 4 1 3 A
8/47/M M vs P DAI 7 16 23.5 3 4 1 4 A
9/19/F MVC IPH 3 23 46 3 4 1 1.4 A
10/59/M A vs P CHI 3 25 53.5 5 5 2 1 A
a
MOI, mechanism of injury; GCS, Glasgow Coma Score44; APACHE II, Acute Physiology and Chronic Health Evaluation; BCS, basal cistern score; DC time, time from hospital
admission to decompressive craniectomy; ATV, all-terrain vehicle; CHI, closed-head injury/contusions; A, alive; MVC, motor vehicle collision; SDH, subdural hematoma; D, dead;
DAI, diffuse axonal injury; A, automobile; P, pedestrian; M, motorcycle; IPH, intraparenchymal hematoma.
b
The predictive mortality rate is based on the APACHE II score.45 The Marshall47 and Rotterdam48 scores are calculated from the admission head computed tomography scan,
and the BCS is calculated from the computed tomography obtained immediately before DC.
TABLE 4. Model Results for the Prediction of ICP, TIL, and
PbtO2 Associated With Decompressive Craniectomya
95% Confidence
Parameter Value P
Interval
Fixed effects: ICP
Intercept 17.83 <.0001 (14.88, 20.77)
Surgery –7.15 <.0001 (–9.78, –4.52)
Hour 0.06 .0224 (0.01, 0.11)
Surgery:hour –0.07 .0260 (–0.15, –0.01)
Fixed effects: TIL
Intercept 10.10 <.0001 (8.23, 11.93)
Surgery –3.56 .0008 (–5.48, –1.63)
Hour 0.14 <.0001 (–0.09, 0.20)
Surgery:hour –0.25 <.0001 (–0.32, –0.18)
Fixed effects: PbtO2 FIGURE 1. Line graphs illustrating individual patient therapeutic intensity
Intercept 29.94 <.0001 (21.50, 38.38) levels (TIL) before and after decompressive craniectomy (time, 0 hour). The
TIL was modified from Maset et al16 (see Table 2).
Surgery 9.83 .0029 (3.56, 16.09)
a
ICP, intracranial pressure; TIL, therapeutic intensity level.
nial hypertension, we examined how the procedure influenced
the TIL and the CIB as estimated by PbtO2. The results suggest
value of 53.3. At 30 days after TBI, only 1 patient was dead, result-
that DC can reduce TIL and the CIB of the brain. These find-
ing in a lower mortality rate than predicted (P = .015). Care was
ings imply that DC should be considered early in a patient’s course,
withdrawn in the patient who died (case 2).
particularly when the TIL is elevated.
DISCUSSION Study Limitations
In this study of 10 TBI patients who had PbtO2 monitoring Our study has several potential limitations. First, because the
before and after DC performed for medically intractable intracra- data set included only patients who underwent DC, we do not
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6. WEINER ET AL
limitations, our findings provide useful physiological data before
and after DC for elevated ICP. These data may be used to better
time when patients undergo DC and to better identify which
patients undergo DC.
Decompressive Craniectomy
DC is not new, but in recent years, there has been increased
interest in using this procedure to control elevated ICP after severe
TBI.22-24,26,28,30-32 Previous studies demonstrated an improve-
ment in a variety of physiological parameters, including ICP, com-
pliance, ICP indexes such as cerebrospinal compensatory reserve
and cerebrovascular reactivity, brain oxygen, and metabolic param-
eters measured by cerebral microdialysis.34,35,37,64 These physio-
logical improvements are often greater in those patients who
subsequently have a favorable outcome. Our findings are consis-
FIGURE 2. Histograms illustrating the number of minutes each patient had tent with and extend these observations. In particular, we show
evidence of mild (PbtO2, 15–20 mm Hg), moderate (PbtO2 10–15 mm Hg), that DC decreases the TIL and that the CIB as estimated by the
or severe (PbtO2 ≤ 10 mm Hg) brain hypoxia (or cumulative ischemic bur- cumulative time that PbtO2 is less than threshold. These findings
den) before and after decompressive craniectomy (DC). are important because the TIL represents in part a measure of how
“sick” the brain is and whether there is any compensatory reserve.
have a matched control group for comparison. Second, our sam- Knowing the TIL may allow better patient selection for DC and
ple size of 10 patients is small. Third, our selection criteria may have more targeted therapy for increased ICP. In addition, our data
introduced bias toward patients with edema (and elevated ICP) that imply, but do not prove, that early DC may reduce the likelihood
developed slowly or who were likely to survive. In addition, because of secondary ischemic or hypoxic injury in the brain.
the data were examined retrospectively, we cannot exclude the Despite these various physiological studies, the effect of DC
possibility that a surgical decision was made or influenced by on clinical outcome after TBI is not yet defined and is presently
PbtO2 even though our institutional policy for DC is based on being studied in 2 randomized trials (RescueICP and DECRA).
ICP. We also did not examine patients who had prophylactic DC Data from randomized stroke studies suggest that DC in TBI
after evacuation of mass lesions; thus, we do not know whether patients should improve outcome.65 However, even after the ran-
the findings apply to all patients who undergo DC. Fourth, the study domized trials, there are likely to be several unanswered questions.
was performed on patients treated at a single institution, so it may In particular, the optimal time to perform a DC for brain edema
lack external validity. However, our data reflect a patient popula- and elevated ICP is not precisely known. This is important because
tion managed according to an ICU protocol that is similar to pro- all medical therapies for elevated ICP, decreased CPP, and DC
tocols in use at many other institutions. Fifth, the PbtO2 monitor also have side effects, and although ICP may be reduced, outcome
we used measures local PbtO2 and may not always reflect global may not always be improved.7,17-22 Our data may help decide
brain oxygenation. However, studies have shown that PbtO2 indi- when to perform DC for cerebral edema after TBI, ie, when the
cates global brain oxygen when the monitor is located in the unin- TIL or the duration of compromised PbtO2 is increased. Whether
jured brain,62 as it was in our study. Sixth, direct comparison of these parameters are useful to select patients for DC, whether
preoperative and postoperative ICP and PbtO2 values may be sub- there is a specific threshold for TIL or PbtO2, and whether trends
ject to unavoidable errors because the monitors after DC are never should be used require further study.
in the exact same location as before surgery. Seventh, our method
to calculate a CIB reflects collection of data most commonly used Brain Oxygen and DC
in ICUs around the world, ie, a manual entry onto an ICU flow Today, the decision to perform a delayed DC after TBI is based
sheet every 15 minutes. It is conceivable that more subtle find- largely on elevated ICP (> 20 mm Hg) that is not controlled by
ings may have been apparent if area-under-the-curve analysis had medical means. However, ICP is more than a number, and under-
been used. However, this method frequently uses interpolation standing the regulatory processes for ICP and indexes that reflect
to account for missing data or times between records that exceed compensatory reserve may permit better selection of patients for
a certain threshold.63 Finally, because DC was performed at dif- surgery.12 The evolving concept of multimodality monitoring in
ferent time points after TBI, it is conceivable that further bias was neurointensive care and, in particular, the use of PbtO2 monitors
introduced because CBF and PbtO2 may change over time. However, to complement ICP data also may help select patients for DC in
we did use mixed-effects models51 that account for the random a timely and targeted manner. This requires further study. For
variation associated with individual patients and the varying lengths example, is the patient with controlled ICP but decreased PbtO2
of time for which they were monitored. For these various reasons, or decreasing PbtO2 a candidate for DC? Use of PbtO2 data to
our findings should be regarded as preliminary, but despite these complement ICP may be important because it is well know that
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7. DECOMPRESSIVE CRANIECTOMY AND BRAIN OXYGEN
brain hypoxia, specifically a longer duration of brain hypoxia, is 2. Clifton GL, Miller ER, Choi SC, Levin HS. Fluid thresholds and outcome from
associated with poor outcome after TBI.41,57,64,66-68 severe brain injury. Crit Care Med. 2002;30(4):739-745.
3. Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cere-
There has been less study of how DC affects PbtO2.35,64,69,70 We bral perfusion pressure: influence on neurological deterioration and outcome in
previously observed in 7 patients that DC immediately improves severe head injury: the Executive Committee of the International Selfotel Trial.
Pbt O 2 and that this effect is sustained. 64 In addition, Pbt O 2 J Neurosurg. 2000;92(1):1-6.
remained > 25 mm Hg as medical management for elevated ICP 4. Marmarou A, Anderson RL, Ward JD, Choi SC, Young HF, Eisenberg HM. Impact
of ICP instability and hypotension on outcome in patients with severe head trauma.
was weaned after DC. There also was a tendency for those patients J Neurosurg. 1991;75:S59—S66.
with normal PbtO2 before DC to have a better outcome. Recently, 5. Marshall LF, Smith RW, Shapiro HM. The outcome with aggressive treatment in
Ho et al35 studied 16 TBI patients who had DC and observed a severe head injuries, part I: the significance of intracranial pressure monitoring.
significant improvement in Pbt O 2 and an 85% reduction in J Neurosurg. 1979;50(1):20-25.
6. Narayan RK, Kishore PR, Becker DP, et al. Intracranial pressure: to monitor or
episodes of cerebral ischemia among patients who subsequently had not to monitor? A review of our experience with severe head injury. J Neurosurg.
a favorable outcome. This effect was not present in those who had 1982;56(5):650-659.
an unfavorable outcome. In addition, abnormal brain neurochem- 7. Saul TG, Ducker TB. Effect of intracranial pressure monitoring and aggressive
treatment on mortality in severe head injury. J Neurosurg. 1982;56(4):498-503.
istry, including glutamate, glycerol, and lactate measured with
8. Brain Trauma Foundation; American Association of Neurological Surgeons; Congress
microdialysis, also improved when a favorable outcome occurred. of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care,
Together, these data suggest that multimodality monitoring may AANS/CNS. Guidelines for the management of severe traumatic brain injury.
help guide treatment and DC selection or, at the very least, indi- J Neurotrauma. 2007;24(suppl 1):S65-S70.
9. Maas AI, Dearden M, Teasdale GM, et al. EBIC-guidelines for management of
cate when management, even after DC, is futile. Whether DC severe head injury in adults: European Brain Injury Consortium. Acta Neurochir (Wien).
should be regarded as only a “second-tier” therapy for elevated 1997;139(4):286-294.
ICP is not answered by this study, but rather than base manage- 10. Robertson C. Youmans Neurological Surgery. 5th ed. Philadelphia, PA: Saunders;
ment on only 1 parameter, we suggest that any monitored param- 2004.
11. Czosnyka M, Guazza E, Whitehouse M, et al. Significance of intracranial pressure
eter be interpreted with reference to others that are monitored at waveform analysis after head injury. Acta Neurochir (Wien). 1996;138(5):531-542.
the same time. Knowledge about the duration of compromised 12. Czosnyka M, Smielewski P, Timofeev I, et al. Intracranial pressure: more than a
PbtO2 may prompt earlier DC for increased ICP. number. Neurosurg Focus. 2007;22(5):E10.
13. Lang EW, Lagopoulos J, Griffith J, et al. Cerebral vasomotor reactivity testing in
head injury: the link between pressure and flow. J Neurol Neurosurg Psychiatry.
CONCLUSIONS 2003;74(8):1053-1059.
14. Steiner LA, Czosnyka M, Piechnik SK, et al. Continuous monitoring of cerebrovas-
The findings of the present study show that in TBI patients cular pressure reactivity allows determination of optimal cerebral perfusion pres-
sure in patients with traumatic brain injury. Crit Care Med. 2002;30(4):733-738.
DC improves ICP, reduces the TIL for elevated ICP after surgery,
15. Le Roux P, Newell DW, Lam AM, Grady MS, Winn HR. Cerebral arteriovenous
improves average PbtO2, and reduces the CIB estimated by PbtO2. difference of oxygen: a predictor of cerebral infarction and outcome in severe head
These data imply that ICP is “easier” to control after DC, that injury. J Neurosurg. 1997;87(1):1-8.
patients therefore are at reduced risk for the potential deleterious 16. Maset AL, Marmarou A, Ward JD, et al. Pressure-volume index in head injury.
J Neurosurg. 1987;67(6):832-840.
side effects that may occur with various ICP treatments, and that 17. Chestnut RM. Hyperventilation in traumatic brain injury: friend or foe? Crit Care
the likelihood of secondary neuronal injury associated with elevated Med. 1997;25(8):1275-1278.
ICP is reduced. Whether DC and subsequent improved ICP are 18. Coles JP, Minhas PS, Fryer TD, et al. Effect of hyperventilation on cerebral blood
associated with better outcome after TBI is not known and is the flow in traumatic head injury: clinical relevance and monitoring correlates. Crit
Care Med. 2002;30(9):1950-1959.
subject of current randomized trials. However, our data support 19. Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS. Adult respi-
a role for DC and, at the very least, provide useful physiological ratory distress syndrome: a complication of induced hypertension after severe head
data that may help decide whom to operate on or when to per- injury. J Neurosurg. 2001;95(4):560-568.
form DC. Ideally, a predictive paradigm that not only is based on 20. Eisenberg HM, Frankowski RF, Contant CF, Marshall LF, Walker MD. High-dose
barbiturate control of elevated intracranial pressure in patients with severe head
ICP, PbtO2, the TIL, and CIB but also includes other factors such injury. J Neurosurg. 1988;69(1):15-23.
as age, Glasgow Coma Scale, APACHE II, and the Rotterdam 21. Kaufmann AM, Cardoso ER. Aggravation of vasogenic cerebral edema by multi-
scores may best guide who undergoes DC and when it is opti- ple-dose mannitol. J Neurosurg. 1992;77(4):584-589.
mally performed. 22. Marshall LF, Smith RW, Rauscher LA, Shapiro HM. Mannitol dose requirements
in brain injured patients. J Neurosurg. 1978;48(2):169-172.
23. Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome
Disclosures following decompressive craniectomy for malignant swelling due to severe head
This work was supported by research grants from Integra Neurosciences (the man- injury. J Neurosurg. 2006;104(4):469-479.
ufacturer of the Licox PbtO2 monitor) (P.D.L.R.), the Integra Foundation (P.D.L.R.), 24. Albanèse J, Leone M, Alliez JR, et al. Decompressive craniectomy for severe trau-
and the Mary Elisabeth Groff Surgical and Medical Research Trust (P.D.L.R.). matic brain injury: evaluation of the effects at one year. Crit Care Med. 2003;31(10):
P.D.L.R. is a member of the Integra Speakers Bureau. 2535-2538.
25. Chibbaro S, Tacconi L. Role of decompressive craniectomy in the management of
severe head injury with refractory cerebral edema and intractable intracranial pres-
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matic brain injur y: the randomized multicenter RESCUEicp study 57. Maloney-Wilensky E, Gracias V, Itkin A, et al. Brain tissue oxygen and outcome after
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47. Marshall LF, Marshall SB, Klauber MR. A new classification of head injury based
on computerized tomography. J Neurosurg. 1991;75:S14—S20. Acknowledgments
48. Maas AI, Hukkelhoven CW, Marshall LF, Steyerberg EW. Prediction of outcome
in traumatic brain injury with computed tomographic characteristics: a compari- We acknowledge the hard and passionate work provided by the nurses in the Neuro
son between the computed tomographic classification and combinations of com- Intensive Care Unit at the Hospital of the University of Pennsylvania and are
puted tomographic predictors. Neurosurgery. 2005;57(6):1173-1182. grateful to the members of the Neurosurgical Clinical Research Division who have
49. Hemphill JC 3rd, Knudson MM, Derugin N, Morabito D, Manley GT. Carbon spent endless hours entering data.
dioxide reactivity and pressure autoregulation of brain tissue oxygen. Neurosurgery.
2001;48(2):377-384.
50. Johnston AJ, Steiner LA, Coles JP, et al. Effect of cerebral perfusion pressure aug- COMMENTS
A
mentation on regional oxygenation and metabolism after head injury. Crit Care
Med. 2005;33(1):189-195; 255-257. lthough several early publications about decompressive craniotomy
51. Pinheiro JC, Bates DM. Mixed-Effects Models in S and S-PLUS. New York, NY: did not show a therapeutic advantage, more recently, a growing num-
Springer; 2008. ber of reports support the idea. The importance of this article is that it not
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9. DECOMPRESSIVE CRANIECTOMY AND BRAIN OXYGEN
only adds to the idea that decompressive craniotomy is efficacious but Nevertheless, surrogate measures, for better or worse, remain unaccept-
also provides information regarding potential indications that could help able in proving clinical benefit. This can be accomplished only through
make the decision to do the operation. The article is not dissimilar to validated outcome measures in a prospective randomized clinical trial.
another recently published paper (their Reference 17). In that article, If indeed the ongoing clinical trials of decompressive craniectomy ref-
patients did not fare as well, and only patients with good outcomes showed erenced by the authors prove positive, then the information presented
brain metabolic improvement. Although we have to wait for the out- in this contribution may be used to refine appropriate candidates for
come of ongoing randomized trials to get the kind of evidence that would decompressive craniectomy. Until then, we continue to use unproven,
definitively define the role of decompressive craniotomy, a large num- but enticing, physiological explanations for our clinical interventions.
ber of patients who could have been helped may not have a procedure
with relatively low risk, considering the risk of dying and disability in Jack E. Wilberger
patients with uncontrolled intracranial pressure. Pittsburgh, Pennsylvania
Some of the limitations of the article, particularly the small sample
size, are considered in the Discussion. However, in addition, we can never
know in how many cases the surgeon was influenced by brain O2, which I n this article, the Penn Group has confirmed and extended previous
studies demonstrating that decompressive hemicraniectomy reduces
intracranial pressure and the Therapeutic Intensity Level in patients with
in a sense confounds the study. The authors should also tell us how they
formed 3 brain O2 groups. I understand that using brain 02 as a contin- traumatic brain injury. They also show that Pbto2 is improved after
uous function in this study is not really feasible, but I think a statement decompression. As the authors have acknowledged, the low Pbto2 in
about the formation of these groups, even if it is just the authors’ intu- patients before decompressive craniectomy likely represents lower cere-
ition and not based on statistics, is important. Lastly, what do the authors bral blood flow (Reference 1). Although this is not exactly “ischemic bur-
mean when they say decompressive craniotomy is being done in patients den,” they use this measure as a surrogate. Certainly, it would be informative
without medical management of intracranial pressure? This is a surprise to also measure other cerebral metabolic indexes such as CMRo2 or OEF,
and certainly not the case in our published series. Despite these criti- but this requires resources that are beyond most groups and will most
cisms, I am strongly in favor of the publication. likely not be widely available for routine use. Brain tissue oxygen mon-
itoring, on the other hand, is more widely available and is increasingly being
Howard M. Eisenberg used to monitor a variety of brain-injured patients. Although its patient
Baltimore, Maryland sample size is small, this study demonstrates the added value of moni-
toring end points beyond intracranial pressure. To improve the outcome
D ecompressive craniectomy remains a widely used yet controversial
and unproven therapy for posttraumatic “refractory” intracranial
pressure elevations. Even though not stated as such, it would appear that
of brain-injured patients, we need more surrogate measures to target and
refine our treatment. Despite the increasing use of decompressive hem-
icraniectomy in the treatment of traumatic brain injury, we still do not
Weiner et al are attempting to correlate the possibility of improved out- know exactly which patients will benefit from this procedure. The use
comes with surrogate measures such as intracranial pressure, therapeu- of additional neuromonitoring and surrogate measures may help answer
tic intensity levels and cumulative ischemic burden—based on Pbto2 this important question.
monitoring—before and after decompressive craniectomy.
It is certainly very important to have physiological evidence, such as that Geoffrey T. Manley
provided by this study, that a specific intervention works or is likely to work. San Francisco, California
SCIENCE TIMES
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