A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension

Object: The object of our study was to determine, in children with traumati c brain injury and sustained intracranial hypertension, whether very early decompressive craniectomy improves control of intracranial hypertension and long-term function and quality of life. Methods: All children were managed from admission onward according to a standardized protocol for head injury management. Children with raised intracranial pressure (ICP) were randomiz ed to standardized management alone or standardized management plus cerebra l decompression. A decompressive bitemporal craniectomy was performed at a median of 19.2 h (range 7.3-29.3 h) from the time of injury. ICP was record ed hourly via an intraventricular catheter. Compared with the ICP before ra ndomization, the mean ICP was 3.69 mmHg lower in the 48 h after randomizati on in the control group, and 8.98 mmHg lower in the 48 hours after craniect omy in the decompression group (P = 0.057), Outcome was assessed 6 months a fter injury using a modification of the Glasgow Outcome Score (GOS) and the Health State Utility Index (Mark 1). Two (14%) of the 14 children in the c ontrol group were normal or had a mild disability after 6 months, compared with 7 (54%) of the 13 children in the decompression group. Our conclusion was that when children with traumatic brain injury and sustained intracrani al hypertension are treated with a combination of very early decompressive craniectomy and conventional medical management, it is more likely that ICP will be reduced, fewer episodes of intracranial hypertension will occur, a nd functional outcome and quality of life may be better than in children tr eated with medical management alone (P=0.046; owing to multiple significanc e testing P <0.0221 is required for statistical significance). This pilot s tudy suggests that very early decompressive craniectomy may be indicated in the treatment of traumatic brain injury.