Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. In this randomized clinical trial, patients with intractable intracranial hypertension after traumatic brain injury who received a decompressive craniectomy had a sustained reduction in mortality at 24 months compared with those who received standard medical care.

2. Although rates of good recovery were similar in both groups, surgical patients were more likely to improve over time and had a wide spectrum of outcomes compared with patients in the medical group.

Evidence Rating Level: 1 (Excellent)

Study Rundown:

Although outcomes of traumatic brain injury in the acute and subacute period have been well-characterized, there is a lack of long-term data on outcomes for patients receiving surgical vs medical treatment for traumatic intracranial hypertension. The RESCUEicp trial investigated outcomes over 24-month for patients with traumatic intracranial hypertension treated with decompressive craniectomy (surgical group) or ongoing medical treatment (medical group). The primary endpoint was measured using the Extended Glasgow Outcome Scale (1=death; 8=upper good recovery) up to 24-month. Among 408 patients with traumatic intracranial hypertension randomized 1:1 to receive either decompressive craniectomy or standard care, surgical patients had sustained reduced mortality but higher rates of vegetative state, severe disability, and moderate disability at 24 months. Although rates of good recovery were similar in both groups, surgical patients were more likely to improve over time and had a wide spectrum of outcomes compared with patients in the medical group. A limitation of this study was that a subset of patients in the medical group received decompressive craniectomy after failing medical treatment, potentially mitigating the observed treatment effect.

In-Depth [randomized clinical trial]:

The RESCUEicp trial enrolled 408 patients with traumatic intracranial hypertension (>25mmHg) randomly assigned 1:1 to receive decompressive craniectomy (N = 206; mean [SD] age, 32.3 [13.2] years; 165 [81.7%] male) or standard medical care (N = 202; 34.8 [13.7] years; 156 [80.0%] male). Eligible patients were enrolled from 52 centers in 20 countries between 2004-2014 with traumatic brain injury (confirmed via computed tomography), intracranial pressure monitoring, and sustained and refractory elevated intracranial pressure despite pressure-controlling measures. At 24 months, surgical patients had sustained reduced mortality (61 [33.5%] vs 94 [54.0%]; absolute difference, −20.5 [95%CI, −30.8 to −10.2]) but higher rates of vegetative state (absolute difference, 4.3 [95%CI, 0.0 to 8.6]), lower or upper moderate disability (4.7 [−0.9 to 10.3] vs 2.8 [−4.2 to 9.8]), and lower or upper severe disability (2.2 [−5.4 to 9.8] vs 6.5 [1.8 to 11.2]; P = .001). Significant differences in net improvement (≥1 grade) were observed between the surgical vs medical group at 6 and 24 months (55 [30.0%] vs 25 [14.0%]; P = .001).

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