Lifting the lid on decompressive craniectomy by Associate Professor Lindy Jeffree
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Associate Professor Lindy Jeffree: Lifting the lid on decompressive craniectomy. From CICM ASM PROGRAM 2019.
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Lifting the lid on decompressive craniectomy by Associate Professor Lindy Jeffree
- 1. Lifting the Lid on Decompressive Craniectomy Associate Professor Lindy Jeffree Royal Brisbane Hospital University of Queensland
- 2. Decompressive craniectomy Huh J 2018 J Korean Neurosurgical Society Ragel BT 2010 JNS Hieu PD 1996 Childs Nerv. Syst. Unilateral Bifrontal …sinus strip• Stroke • Trauma • RBWH practice • Cranioplasty • Decisions
- 3. Craniectomy for MCA stroke DECIMAL DESTINY HAMLET Stroke size >50% MCA >2/3 MCA territory >145cms DWI basal ganglia mass effect Age 18-55 yrs 18-60 yrs NIHSS ≥16 ≥18, ≥ 20 ≥16, ≥21, GCS <14 Timing <30 hrs <42 hrs <99 hrs Craniectomy ‘large’ > 12 cms Outcome MRS 0-3 vs 4-6 Vahedi K 2007 Stroke Juttler E 2007 Stroke Hofmeijer J 2006 BMC
- 4. Decompression for MCA stroke MRS >4 12 months MRS >3 12 months Death at 12 months DECIMAL DESTINY HAMLET Total Vahedi K et al 2007 Lancet Neurol 2007; 6: 215–22 Modified Rankin Scale 0 No symptoms 1 No significant disability 2 Slight disability, 3 Moderate disability 4 Moderately severe disability 5 Severe disability 6 Death Favours conservative Favours surgery
- 5. Decompression for MCA stroke: Pooled results Vahedi K et al 2007 Lancet Neurol 2007; 6: 215–22 NNT 2 to prevent death, 8.3 to achieve slight disability NNH 3.6 => mod-severe disability, 55% aphasia Good Death Conservative treatment Surgery Bedridden Help with ADLs & walking
- 6. DECRA trauma trial: Methods • 15 hospitals: Australia, NZ, Saudi Arabia • 15-59 years, • GCS 3-8 or Marshall class III • EVD • ICP > 25mmHg for >5 mins x2 in 30 mins • Randomised in first 48 hours • Bifrontotemporal craniectomy Cooper DJ et al (2011) NEJM 364:1493-1502
- 7. Protocol modifications Randomization < 3 days ICP >20 for 15 mins EVD not required (~70%) DECRA trial: Recruitment Cooper DJ et al (2011) NEJM 364:1493-1502 Dec 2002 – April 2010 Follow up 100% Follow up 100% 5%
- 8. Cooper DJ et al (2011) NEJM 364:1493-1502 Death Good recovery DECRA trial: Outcomes
- 9. RESCUEicp: Methods • Aimed for 400 patients over 4 years • 10-65 years old • ICP >25 for 1 hour • Unilateral or bifrontal craniectomy • Crossover permitted if Stage 3 failed Hutchinson N Engl J Med 2016; 375:1119-1130
- 10. RESCUEicp: Results • 408 patients • 15 hospitals • UK, Europe • 2004-2014 • NNT GOS >3 =12 Hutchinson N Engl J Med 2016; 375:1119-1130 Death Good recovery
- 11. What is a ‘good outcome’. https://lifeinthefastlane.com/rescueicp-and-the-eye-of-the-beholder/ Dr Alistair Nichol
- 12. Audit of RBWH practice • Ethics exemption • Bone Flap Register • 2012-2018 • Diagnosis • Reason for surgery • Outcome • Cranioplasty timing & complications
- 13. RBWH Craniectomies: Reasons for surgery Pure decompressionCraniectomy en passant
- 14. RBWH outcomes: Craniectomy for MCA stroke RBWH n=25 Pooled trials n=93 HomeRehabN/HDeath
- 15. RBWH outcomes: Craniectomy for MCA stroke Time to surgery (hours) From presentation From RBWH admission Mean (hours) 51 32 Range 2-117 22-118 Length of stay post op (days) RBWH all RBWH survivors Total QHealth Mean 45 62 122 Range 8-421 22-421 Hours Glasgowoutcomescale Low disability Death
- 16. RBWH outcomes: Decompression in Trauma Time to surgery 68 hours (5-230) QHealth admission 111 days (39-243) RBWH n=10 RESCUEicp n=408
- 17. RBWH Craniectomies: Diagnosis Pure decompressionCraniectomy en passant
- 18. Fraioli, M 2016 Open Access Library Journal International Business Times Hempenstall J 2012 JICS neurowhoa.blogspot.comhttps://www.bbc.com/....-23195940
- 19. Cranioplasty at RBWH • Time to cranioplasty 117 days (14 – 799) • 41 during index admission • Length of stay 6 days Complications Return to theatre for haemorrhage 15 Symptomatic haemorrhage 1 Imaging haemorrhage 6 Infected & removed 1 CSF circulation problem 7 Infection 3 Post op neuro deficit 4 Bone resorbed 1 Bone loose 1 39 = 33% Cranioplasty material (n=119) Pre-formed Ti AcrylicOwn bone
- 20. PRECIS Prospective Randomized Evaluation of therapeutic decompressive Craniectomy In Severe traumatic brain injury with mass lesions • Mass lesion • Replace if possible vs leave out anyway • +- Salvage decompression • 15 x 12 cms craniotomy • ICP <25, CPP >60 • Salvage if ICP >30 or ICP >25 for 1hr & midline shift etc on scan. • Acute SDH • 990 patients >16 yo • >11cm craniotomy • Randomised intra-op • Outcomes include Return to OT • May 2019: Enrolment “officially over” - 463 patients randomised Zhao H-X (2016) BMC Neurology 16:1http://www.rescueasdh.org/home
- 21. When to consider decompressive craniectomy • Large volume MCA stroke & patient who is drowsy: => doubles survival, patient disabled. • Severe closed head injury and ICP >25 mmHg for 1 hour: => reduced mortality, survivors severely disabled. Whether to do one depends on what the patient would consider an acceptable outcome.
- 22. Talking to the family 1. Listen about the – Event - Person 2. Explain - Extent of injury - Range of outcomes - Best outcome 3. Offer Care options: Shared decision https://www.news-mail.com.au/news/the-life-of-a-trauma-patient/3231785/.
Notas del editor
- When Michael invited me to speak here I was both delighted, because on the whole I like intensivists, and troubled because I find craniectomy the most mucky, confusing and heart breaking operation in all of neurosurgery.
- I will talk about the Evidence Base in Stroke & Trauma, what actual happens at the Royal Brisbane Hospital and the outcomes, about cranioplasty (death or cranioplasty), & how to make decisions with families in heat of the crisis. Definition: removal of bone to lower the intracranial pressure. Emphasis on getting down to base of middle cranial fossa to prevent uncal herniation and brain stem compression.
- Similar with subtle variations. Timing is to theatre = time to randomisation (24, 36, 96) plus time to theatre (6, 6, 3). The Pooled analysis only includes HAMLET patients within 48 hours. The MRS was dichotomised differently in the publications.
- The Y axis is the equivalence point. Individual trials equivocal about quality of life but combined it is clear. Controversy about where to dichotomise.
- If we were dealing with slaves, no doubt operation is beneficial, but we’re dealing with patients. Cf NNT carotid endarterectomy 22 to stop 1 stroke in 10 years. Hamlet included pts <48 hours. Final results no sig benefit ?b/c too late. 3 Moderate disability (red) 4 Moderately severe disability (blue) 5 Severe disability (light green)
- Excluded if dilated unreactive pupils, mass lesion requiring surgery, cardiac arrest or SCI. Marshall class III is moderate diffuse injury. ICP increase spontaneous, not stimulated, could be intermittent but cumulative, optimized first tier interventions including sedation, CO2, hypertonic etc.
- 200-240 patients over 4 years. Only got 155 patients over 8 years. This feels like a more common problem than it is. Surgeons don’t do equipoise.
- Post randomization control group significantly more: hypertonic saline, mannitol, paralysis, thiopentone & CSF drainage. Controlled ICP does not lead to improved outcomes. Why ? Axonal stretch, ? Complications. More bilateral fixed pupils in surgical group.
- Differences: stages, threshold, timing, barbituates, conceptually medical vs surgical.
- Upper severe disability are largely independent around their homes but need assistance with traveling or shopping, whereas patients who are in the category of lower severe disability live in a supervised facility (care facility) ie yellow = independent at home, orange = NH. 10% of decompression patients got barbituates. 37% medical patients got decompression. NNT ~12 (10 – 14 depending on time of assessment). (From here on Death is on the Left).
- Not posterior fossa. This is the acrylic mould you get given when you purchase a 3D printed acrylic bone plate. The plate gets put in the patient and these get left lying around.
- 179 operations on 177 patients. Vast majority bone left out after another procedure. The small numbers are striking: ~800 strokes a year in our Area Health Service = 5000 in the period of the audit. Presuming only half are MCA even if only 10% are big MCA strokes there should be 250 eligible patients. Similarly, several hundred closed head injuries admitted to our ICU. In the patients we did operate on, how did they go?
- More of our patients die – maybe, and no more are in the ‘good’ category. Reading the stories the quality of life sounds OK “family happy he can now use mobile phone as he is home alone all day”, OT assessments: “preparing meals would be easier if he had a trolley in the kitchen”. “Moderate disability” = could work with adaptations.
- Time to surgery is longer than recommended. But no correlation with outcome. Length of stay is on average 1 ½ -2 months acute hospital stay & 4 months total. Huge burden not only on health cost but on family. Part of my decision making discussion is “if they are going to pull through, it will mean a month here then a couple of months in rehab.”
- Results similar to trials. Again a large group of severely disabled patients. Different population group, multiple missed appointment with orthopaedics and rehab then representation with overdose, alcohol withdrawal seizures, etc. Only half home – severely disabled head injury patients end up in care c.f. MCA stroke, maybe due to the diffuse injury. Evidence based decompressions: Too slow, too few and not as good as published.
- What about the patients who had the bone left out for another reason? Do they matter? 66 of the 144 the op notes say “brain swollen”, 17 clearly prophylactic. The American Armed forces protocol is that if you get a craniotomy, the bone gets left out.
- A patient of mine and some off the internet showing what they look like while they wait for their cranioplasty. The brain sag and shift can cause neurological deficits known as syndrome of the trephined – borderline or fluctuating patient you must put the bone back & treat the hydrocephalus before deciding for certain.
- 119 cranioplasties – patients died. 39 complications in 34 patients = 33% = same at literature. So we shouldn’t be doing this without good reason.
- Listen – so the family trusts you understand. Explain in terms that make sense to them. Brain doesn’t recover. Emphasis that we don’t know exactly what will happen. Try not to say “die”. Graphic personal description of likely outcome: no cricket, drink coffee without tube but not make a cuppa, turn pages of magazine and look at pictures but not understand words. No right answer. Outcome not certain either way, we are just changing the possibility –intervention or conservative care. What would the patient say if they were here? I also support the decision what ever they make. Three things happen: 1 If he can’t .. he would not want to live! 2 As long as he can.. That’s OK. 3. There will be a miracle. Do everything or I’ll sue you. More time you spend on 1. (not 2.) the less likely this is.