Brain Edema XV (Acta Neurochirurgica Supplement)
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However, the effects of secondary DC are still controversial and worth further exploring The present systematic review and meta-analysis aims to comprehensively summarize and quantify the effects of DC interventions on overall mortality rate and ICP as well as long-term prognosis in TBI patients. A total of studies were retrieved from the initial search, among which 20 were potentially related to our review and the full texts were reviewed. Of these 20 studies, 10 were excluded for various reasons, which were shown in Fig.
Therefore, a total of 10 eligible studies were included in our systematic review, with four RCTs in the meta-analysis. There were four RCTs 6 , 11 , 13 , 14 , five retrospective studies 9 , 15 , 16 , 17 , 18 and one prospective study 19 , totaling patients in the systematic review and in meta-analysis DCs, non-DCs.
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Risk of bias for each trial were assessed with the Cochrane risk of bias tool. Due to the nature of DC interventions, performing blinding methods to participants were usually impossible. So we assessed the performance bias according to the blinding of outcome assessors. In the domain of blinding of outcome assessment, three RCTs were at low risk of bias, while the other one was unclear due to the incomplete information on outcome assessment. For attrition bias, there were no dropouts or missing outcomes in three RCTs. But we found some missing outcome in one study.
We found no other suspect bias in four RCTs. DC, Decompressive Craniectomy.
Six more observational studies 9 , 15 , 16 , 17 , 18 , 19 explored the effect of DC on mortality rate in patients with traumatic ICH. Four of them 15 , 16 , 18 , 19 reported reduced mortality rate for patients undergoing DC compared with Non-DC treatment, whereas one study 9 detected similar mortality and another one 17 had incomplete data. According to the summary results, no significant difference was found between two groups RR, 0. When analyzed as continuous data, two studies 11 , 13 were availabale and mean GOS-E scores in Cooper et al.
In Cooper et al. In view of the discrepancies, more large scale RCTs were needed to unravel the effect of DC on functional outcomes. Improved outcome in DC group was detected in two studies 16 , 18 in comparison with medical care, with similar outcome in two studies 15 , 17 and worse outcome in one study Four studies were available in quantitatively assessing the effect of DC on ICP levels 6 , 11 , 13 , The results demonstrated that there was a significant reduction of ICP in patients receiving DC as compared with those receiving medical care.
ICP was reported as outcomes in three more observational studies 15 , 17 , 19 with all of them favoring effective control of ICP under DC. Two RCTs containing patients assessed the incidence of complications after intervention 11 , One more observational study 9 compared the incidence of complications after DC and medical care and reported increased incidence of complications after DC. In sensitivity analysis for mortality, similar results were detected when removing the study by Cooper et al. Whereas pooled results turned to be non-significant when removing Hutchinson et al.
For GOS at six months, no change was found until excluding the study by Cooper et al. For ICP level, there was no change when excluding studies one by one. ICH after TBI was related to the increased incidence of mortality and morbidity in most studies 1 , 20 , and DC was said to be effective in lowering ICP and improving outcomes in ischemic and traumatic injury 6 , The present systematic review and meta-analysis confirmed that DC could significantly lower ICP, reduce mortality rate, but was correlated to an increased incidence of complications.
Three studies 14 , 16 , 17 focused on children, with the remaining seven focusing on adults. Besides studies with incomplete data, DC could significantly reduce mortality and ICP in children 14 , 16 , while its benefit on functional outcomes can only be found in two studies 14 , 16 with another one 17 favoring similar effect of DC and conservative treatment. After TBI, mass effect caused by brain swelling and intracranial hematomas would lead to the elevation of ICP, which might decrease the cerebral perfusion pressure CPP and then bring about brain ischemia 2 , Theoretically, DC could lower ICP by allowing the expansion of swollen brain and then increase cerebral blood flow CBF , resulting in reduced damage size and improved outcome Therefore, despite lacking of level I evidence, DC was routinely used in the management of ICH in some trauma centers.
However, overall opinion on the effect of DC on patients with traumatic ICH was inconsistent and some authors found that DC might even lead to worse outcomes than traditional therapies 13 , Most early researches were retrospective and it was not until this decade that a few RCTs emerged to unravel the issue.
Despite of the small sample size, the trial detected that children treated with standardized management plus DC had lower ICP In another RCT, 74 patients with brain swelling were randomly divided into unilateral DC group and unilateral routine temporoparietal craniectomy group 6. The findings revealed that DC contributed to lower ICP and mortality rate, higher incidence of vegetative state, lower severe disability, and upper severe disability as compared with medical care at six months.
Several systematic review and meta-analysis are available exploring the effect of DC on patients with traumatic ICH. A Cochrane review published in only included one RCT and found little evidence to support the routine use of secondary DC 4. A recent meta-analysis based on three RCTs which had different results to our study reported that DC, when compared with conventional treatment, could reduce ICP and decrease hospital stay, but was associated with similar mortality rate Results for functional outcomes were not discussed in the article. Our study has advantages in including the latest RCT with the largest sample size and acceptable recruitment criterion, which account for the maximum weight in all analysis in the current study.
Moreover, we conducted quantitative synthesis for the functional outcomes and complications rate after interventions for the first time. There are several limitations in our study. Firstly, different biases exist due to the defects of meta-analysis itself, such as selection bias and publication bias. Patients receiving DC might have a higher preoperative ICP than those receiving traditional therapies and tend to have a worse outcome The language was limited to English, which might lead to the overlook of non-English studies. Therefore, caution was needed in interpretating these results.
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Thirdly, the number of pertinent high-quality trials was limited. Only one large scale RCT with acceptable inclusion criterion was available Fourthly, although we did quantitative synthesis for the overall incidence rate of complications, pooled analysis for each detailed complications of DC were not conducted in our study owing to the lack of complete data. This may result in some misconception. For example, DC could decrease the incidence of cenencephalocele, despite an elevation was found in the incidence of other complications like subdural effusion, intracranial hematoma and hydrocephalus 6.
Finally, although ICP was routinely monitored in the management of TBI patients, its prognostic relevance is limited compared with CBF and oxygenation, which has proved to be intimately related to neurological outcomes after TBI 19 , 25 , 26 , However, CBF and metabolism are seldomly evaluated in common practice due to the inconvenience, expensiveness and exposure to radiation. Moreover, despite of the significant effects on controlling ICP levels and maintaining CBF, DC might lead to significantly lower cerebral metabolic rate of oxygen compared with medical management, which may account for the non-significant improvement of functional outcomes after DC Previous studies suggested DC failed to respond to the mitochondrial damage, resulting in cellular energy crisis and edema and eventually the poor prognosis 19 , 25 , Despite the limitations, our findings presented certain clinical implications that DC seemed to effectively lower ICP, reduce mortality rate but increase incidence of complications, meanwhile its benefit on functional outcomes was not statistically significant.
Caution was required when interpreting these results due to the limited number of large scale RCTs and significant heterogeneities among included studies. The reference lists of the original studies were also examined. We restricted the language of publications to English. Two authors D. We excluded studies if they: 1 recruited patients with spinal cord injury or mass lesions; 2 did not report quantitative outcome data. Disagreements were consulted by joint review. All data were extracted by two authors J. Primary outcome was mortality at six months after randomization. GOS scores of one to five represent death, vegetative state, severe disability, moderate disability, good recovery, respectively GOS-E scores of one to eight represent death, vegetative state, lower severe disability, upper severe disability, lower moderate disability, upper moderate disability, lower good recovery, and upper good recovery, respectively A systematic descriptive review was conducted on all included studies.
For RCTs, we calculated the I 2 statistic and Chi-square test to assess the homogeneity among studies. Otherwise, we used fixed effects model. GOS score was analyzed as both dichotomous and continuous variable as well, and only studies with sample sizes of more than 60 in each group were included when it was analyzed as continuous measures due to its trend of skew distribution.
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According to the Cochrane handbook, median was estimated to be mean and SD was calculated as width of IQR divided by 1. We performed a subgroup analysis according to the timing of DC. Sensitivity analyses were performed by excluding one study at a time to test the stabilization of our results. Publication bias were not assessed because of the limited studies in the review. Statistical analyses were conducted with Review Manager RevMan , version 5.
The quality assessment was performed independently by two review authors Y. We assessed the quality of RCTs based on the quality domains in the Cochrane risk of bias tool: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting and any other potential bias.
Each domain was rated as high, low or unclear. Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Badri, S. Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive care medicine 38 , —, doi: Hutchinson, P.
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Intracranial pressure monitoring in severe traumatic brain injury. BMJ Clinical research ed. Mahmoodpoor, A. Traumatic intracranial hypertension. The New England journal of medicine , —, doi: Sahuquillo, J. Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury.
The Cochrane database of systematic reviews, Cd Bratton, S. Guidelines for the management of severe traumatic brain injury. Journal of neurotrauma 24 Suppl 1 , S91—95, doi: Qiu, W. Effects of unilateral decompressive craniectomy on patients with unilateral acute post-traumatic brain swelling after severe traumatic brain injury. Critical care London, England 13 , R, doi: Grindlinger, G.
Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis. SpringerPlus 5 , , doi: Timofeev, I. Decompressive craniectomy - operative technique and perioperative care. Advances and technical standards in neurosurgery 38 , —, doi: Nirula, R.
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The journal of trauma and acute care surgery 76 , —; discussion —, doi: Kolias, A. Decompressive craniectomy following traumatic brain injury: developing the evidence base. British journal of neurosurgery 30 , —, doi: Wang, R. Medicine 94 , e, doi: Cooper, D. Decompressive craniectomy in diffuse traumatic brain injury. Taylor, A. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension.
He has won provincial and ministerial level scientific and technological progress awards three times and holds three national invention patents. He hopes to create more precise neuroprotective drugs for SAH. Hua Feng is a neurosurgical professor, doctoral supervisor and chief physician who, since , has been Director of the Department of Neurosurgery, Southwest Hospital of the Third Military Medical University, Chongqing, China. He is also a visiting professor at the University of Toronto, Canada. His major research interests include cure and restoration of neurological function after CNS injury, minimally invasive surgery for CNS malignancies, personalized minimally invasive surgery and prevention of complications of cerebrovascular diseases.
Feng has been the principal investigator in more than 40 studies funded by national research grants and has published more than 80 research articles. He has been editor or translator in chief of five books and was invited Guest Editor of Acta Neurochir Suppl , volume He has been the recipient of various awards. John H. Zhang is the author of almost original articles and has edited 14 stroke- and CNS disorder-related books and guest edited 11 special journal issues on stroke research. In addition he has delivered more than invited speeches at meetings. Large Animal Stroke Models vs.