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Cambridge study shapes advice on brain surgery

A body dedicated improving outcomes for victims of traumatic brain injury has updated guidelines for clinicians following latest findings from a Cambridge-led trial.

The US-based Brain Trauma Foundation says craniectomy – the process of removing part of the skull to relieve pressure on the brain – is recommended to improve survival and better outcomes for certain patients.

It has been producing internationally accepted guidelines since 1995 and the latest follows findings from the RESCUEicp Randomised Clinical Trial led by the University of Cambridge’s Department of Clinical Neurosciences, based at Addenbrooke’s Hospital.

The trial recruited over 400 traumatic brain injury patients from 19 countries, including the UK, over ten years and randomly assigned them to one of two for treatment – craniectomy or “medical management” with drugs.

Analysis of patients at six and 12 months after treatment and published in 2016 highlighted better survival results with decompressive craniectomy, but also an increase in the number of patients left disabled.

However, the latest results show that not only is the improved survival sustained at 24 months, but surgical patients are more likely to improve over time compared to patients in the medically managed group.

It’s estimated that for every 100 individuals treated surgically, 21 additional patients survived to 24 months, of which six were dependent, seven were independent and back home, and eight were independent outside their home and possibly able to return to work.

Now the study group have had their findings published in the peer-reviewed journal JAMA Neurology . The results have also informed the international Brain Trauma Foundation guidelines, which now state that “decompressive craniectomy performed for late refractory intracranial pressure elevation is recommended to improve mortality and favourable outcomes”.

Signs and symptoms for the onset of late refractory intracranial pressure include deterioration of consciousness until the patient becomes comatose, decreased respiratory and pulse rates, and increased blood pressure. However, all patients in the study had their intracranial pressure measured continuously with a fine brain probe, which is part of standard care.

Angelos Kolias head and shoulders
Lead author Angelos Kolias

Lead author Angelos Kolias, an Addenbrooke’s honorary consultant neurosurgeon and university clinical senior lecturer, said:

The trial findings support the use of decompressive craniectomy in the management of patients with refractory post-traumatic intracranial hypertension, instead of barbiturate infusion.

Lead author, Angelos Kolias

“However, survivors have a range of possible outcomes, including dependence. Therefore, an open discussion with families is crucial, as dependence may be unacceptable to some patients. It is also important to acknowledge that a dismal neurological prognosis – such as substantial brainstem injury or poor pre-morbid performance status - won’t be improved by a craniectomy.”

Professor Peter Hutchinson head and sholulders
Study chief investigator, Professor Peter Hutchinson

Study chief investigator Peter Hutchinson, an honorary consultant neurosurgeon and university professor, said

The results show that decompressive craniectomy has a clear role to play in managing refractory traumatic intracranial hypertension, but it should not be considered a panacea.

Study chief investigator, Professor Peter Hutchinson

He said more research is needed to understand why surgical patients are more likely to improve over time and whether cranioplasty – the process of repairing defects in the skill left behind after a previous operation or injury – should be done sooner.

Latest research was funded by the Medical Research Council (MRC) and managed by the National Institute for Health and Care Research (NIHR) on behalf of the MRC–NIHR partnership, with further support from the NIHR Cambridge Biomedical Research Centre, the Academy of Medical Sciences, the Health Foundation, the Royal College of Surgeons of England and the Evelyn Trust.

For more information about the Brain Trauma Foundation, visit http://www.braintrauma.org/

Story listing picture by: Gerd Altman from Pixabay