Sahuquillo J, Arikan F
Vall d'Hebron University Hospital, Neurosurgery, Paseo Vall d'Hebron 119 - 129, Barcelona, Spain, 08035.
Cochrane Database Syst Rev. 2006 Jan 25(1):CD003983. doi: 10.1002/14651858.CD003983.pub2.
High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). High ICP is treated by general maneuvers (normothermia, sedation etc) and a set of first line therapeutic measures (moderate hypocapnia, mannitol etc). When these measures fail to control high ICP, second line therapies are started. Among these, second line therapies such as barbiturates, hyperventilation, moderate hypothermia or removal of a variable amount of skull bone (known as decompressive craniectomy) are used.
To assess the effects of secondary decompressive craniectomy (DC) on outcome and quality of life in patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP.
We searched the Cochrane Injuries Group's Trial Register, CENTRAL, MEDLINE, EMBASE, Best Evidence, Clinical Practice Guidelines, PubMed, CINAHL, the National Research Register and Google Scholar. We also handsearched relevant conference proceedings and contacted experts in the field and the authors of included studies.
Randomized or quasi-randomized studies assessing patients over the age of 12 months with a severe TBI who underwent DC to control ICP refractory to conventional medical treatments.
Two authors independently examined the electronic search results for reports of possibly relevant trials and for retrieval in full. One author applied the selection criteria, performed the data extraction and assessed methodological quality. Study authors were contacted for additional information.
We found one trial with 27 participants conducted in the pediatric population (>18 years). DC was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72), and RR of 0.54 for death, vegetative status or severe disability 6 to 12 months after injury (95% CI 0.29 to 1.07).
AUTHORS' CONCLUSIONS: There is no evidence to support the routine use of secondary DC to reduce unfavourable outcome in adults with severe TBI and refractory high ICP. In the pediatric population DC reduces the risk of death and unfavourable outcome. Despite the wide confidence intervals for death and the small sample size of the only study identified, this treatment maybe justified in patients below the age of 18 when maximal medical treatment has failed to control ICP. To date, there are no results from randomised trials to confirm or refute the effectiveness of DC in adults. However, the results of non-randomized trials and controlled trials with historical controls involving adults, suggest that DC may be a useful option when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of DC (Rescue ICP and DECRAN) that may allow further conclusions on the efficacy of this procedure in adults.
颅内压升高（ICP）是重度创伤性脑损伤（TBI）后最常见的死亡和致残原因。高ICP通过一般措施（正常体温、镇静等）和一系列一线治疗措施（适度低碳酸血症、甘露醇等）进行治疗。当这些措施无法控制高ICP时，便开始采用二线治疗。其中，会使用巴比妥类药物、过度通气、适度低温或去除一定量颅骨（即减压性颅骨切除术）等二线治疗方法。
评估在常规医学治疗措施未能控制ICP升高的重度TBI患者中，二次减压性颅骨切除术（DC）对预后和生活质量的影响。
我们检索了Cochrane损伤组试验注册库、Cochrane系统评价数据库、医学期刊数据库、荷兰医学文摘数据库、最佳证据、临床实践指南、医学期刊数据库、护理学与健康领域数据库、国家研究注册库和谷歌学术。我们还手工检索了相关会议论文集，并联系了该领域的专家以及纳入研究的作者。
评估年龄超过12个月、患有重度TBI且接受DC以控制对常规医学治疗无效的ICP的患者的随机或半随机研究。
两位作者独立检查电子检索结果，查找可能相关试验的报告并进行全文检索。一位作者应用入选标准、进行数据提取并评估方法学质量。我们联系了研究作者以获取更多信息。
我们发现一项针对儿科人群（>18岁）的试验，有27名参与者。DC与死亡风险比（RR）为0.54（95%CI 0.17至1.72）相关，且与受伤后6至12个月死亡、植物状态或严重残疾的RR为0.54（95%CI 0.29至1.07）相关。
没有证据支持常规使用二次DC来降低重度TBI和难治性高ICP成人的不良预后。在儿科人群中，DC可降低死亡风险和不良预后。尽管死亡的置信区间较宽且唯一确定的研究样本量较小，但当最大程度的医学治疗未能控制ICP时，这种治疗方法对于18岁以下的患者可能是合理的。迄今为止，尚无随机试验结果来证实或反驳DC在成人中的有效性。然而，涉及成人的非随机试验和有历史对照的对照试验结果表明，当最大程度的医学治疗未能控制ICP时，DC可能是一种有用的选择。目前有两项正在进行的DC随机对照试验（Rescue ICP和DECRAN），这可能会让我们对该手术在成人中的疗效得出进一步结论。
