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Comparison of Decompressive Craniectomy and Maximal Medical Management with Barbiturates in Severe Traumatic Brain Injury Patients with Refractory ICP: A Randomized Controlled Study

Manohar S., Assistant Professor, Department of Neurosurgery, Sri Devraj Urs Medical College, Kolar, karnataka 563101, India , Somil Jaiswal1 , Manohar S.2 , Manish Jaiswal3 , Anil Chandra4 , Chhitij Srivastava5 , Bal Krishna Ojha6 , Sunil K. Singh

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International Journal of Neurology and Neurosurgery 10(3):p 214-221, Jul-Sep 2018. | DOI: DOI: http://dx.doi.org/10.21088/ijnns.0975.0223.10318.12

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Abstract

  Context: Traumatic brain injury is the major cause of death and disability worldwide. Management of severe traumatic brain injury still remains elusive, some prefer surgical intervention while others advocate medical treatment. Objective: To compare the effect of decompressive craniectomy (DC) and maximal medical management with barbiturates in management of severe Traumatic Brain Injury (sTBI) patients with refractory Intracranial pressure (ICP). Settings and Design: 57 patients of severe traumatic brain injury admitted from September 2013 to august 2015 were evaluated based on inclusion and exclusion criteria and subjected to ICP monitoring. Materials and Methods: Patients with ICP refractory to conventional medical management (n=37) were randomized to decompressive craniectomy (n=23) or maximal medical management with addition of barbiturates (n=14). The primary outcome was functional status on Extended Glasgow Outcome Scale (GOS­E) at 7 days and 3 months. Secondary outcome measures were assessment of ICP control and days of hospitalization. Statistical Analysis used: Chi­square test and Student’s t­test were used for data analysis. Logistic regression analysis was employed to assess the effect of multiple variables in the outcome. Results: In decompressive craniectomy group (23), the mean ICP was reduced from 27.81 to 14.06 mmHg after surgery. Eight patientsin this group were alive at 3 months, among which 7 (30.43%) patients achieved good GOS­E of  4. Among 14 patients who underwent medical management with barbiturates the mean ICP reduced from 27.82 to 20.41 mmHg after therapy. In this group, one patient was alive (GOS­E 3) at 3 months. None of the patients in barbiturate group achieved good GOS­E (score 4) at 3 months. Conclusion: ICP monitoring of sTBI patients helps in early identification of patients whose ICP becomes refractory to conventional treatment methods. Decompressive craniectomy provides better outcome in terms of survival and achievement of good outcome as compared to maximal medical management with barbiturates

Keywords: Intracranial Pressure; Severe Traumatic Brain Injury; Decompressive Craniectomy; Barbiturate

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DOI: DOI: http://dx.doi.org/10.21088/ijnns.0975.0223.10318.12

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