The Effect of Controlled Decompression for Severe Traumatic Brain Injury: A Randomized, Controlled Trial

Abstract

Background: Experimental evidence has indicated the benefits of intraoperative controlled decompression for the treatment of severe traumatic brain injury (sTBI). Intraoperative rapid decompression (conventional decompression) for the treatment of sTBI may result in intra- and post-operative complications. Controlled decompression may reduce these complications. Previous clinical trials in China have not yielded conclusive results regarding controlled decompression for sTBI. Therefore, we explored whether controlled decompression treatment decreases the rates of complications and improves the outcomes of patients with sTBI. Methods: We performed this randomized, controlled trial at our hospital. Patients with sTBI aged 18-75 years old were randomly (1:1) divided into controlled decompression surgery (n = 124) or rapid decompression surgery groups (n = 124). The primary outcome measures were the Extended Glasgow Outcome Scale (GOS-E) score at 6 months and 30-days all-cause mortality. The secondary outcomes were the incidences of intraoperative brain swelling, post-traumatic cerebral infarction, and delayed hematoma. Results: Compared with the rapid decompression group, the controlled decompression group had reduced 30-days all-cause mortality (18.6 vs. 30.8%, P = 0.035) and improved the 6-months GOS-E scores, and the difference was significant. In addition, the patients in the controlled decompression group had a lower intraoperative brain swelling rate (13.3 vs. 24.3%, P = 0.036), a lower delayed hematoma rate (17.7 vs. 29.0%, P = 0.048) and a relatively lower post-traumatic cerebral infarction rate (15.0 vs. 22.4%, P = 0.127) than those in the rapid decompression group. Conclusions: Our data suggest that controlled decompression surgery significantly improves sTBI outcomes and decreases the rates of sTBI-related complications. However, this was a single-hospital study, and well-designed multicenter randomized controlled trials are needed to evaluate the effects of controlled decompression surgery for the management of patients with sTBI. Clinical Trial Registration: Chinese Clinical Trial Registry; Date: 14/Dec/2013; Number: ChiCTR-TCC-13004002.

Keywords: ICP; RCT; controlled decompression; delayed hematoma; intraoperative brain swelling; traumatic brain injury.

Figure 1

CONSORT diagram of the study.

Figure 2

Procedure for controlled decompression and ICP monitoring. First step: ICP probe implantation. If the ICP was higher than 40 mmHg, then CSF was released under ventricular ICP monitoring until the ICP was 40 mmHg. Second step: Skull removal. Craniotomy was performed with a bone window 12 × 15 cm in size, and the ICP was maintained at 40 mmHg. Third Step: Dural incision and hematoma removal. The dura was opened with an incision that was generally no larger than 5 mm, and the hematoma and brain contusion tissue were slowly aspirated, gradually reducing the ICP.