Long-term outcome following decompressive craniectomy: an inconvenient truth?

Purpose Of Review: There is little doubt that decompressive craniectomy can reduce mortality following malignant middle cerebral infarction or severe traumatic brain injury. However, the concern has always been that the reduction in mortality comes at the cost of an increase in the number of survivors with severe neurological disability.

Recent Findings: There has been a number of large multicentre randomized trials investigating surgical efficacy of the procedure.

Uncertainty, conflict and consent: revisiting the futility debate in neurotrauma.

The concept of futility has been debated for many years, and a precise definition remains elusive. This is not entirely unsurprising given the increasingly complex and evolving nature of modern medicine. Progressively more complex decisions are required when considering increasingly sophisticated diagnostic and therapeutic interventions.

Long-term survival with unfavourable outcome: a qualitative and ethical analysis.

Objective: To assess the issue of 'retrospective consent' among a cohort of patients who had survived with unfavourable outcome and to assess attitudes among next of kin regarding their role as surrogate decision makers.

Methods: Twenty patients who had survived for at least 3 years with an unfavourable outcome following a decompressive craniectomy for severe traumatic brain injury were assessed with their next of kin. During the course of a semistructured interview, participants were asked whether they would have provided consent if they had known their eventual outcome.

Validation of the CRASH model in the prediction of 18-month mortality and unfavorable outcome in severe traumatic brain injury requiring decompressive craniectomy.

Object: The goal in this study was to assess the validity of the corticosteroid randomization after significant head injury (CRASH) collaborators prediction model in predicting mortality and unfavorable outcome at 18 months in patients with severe traumatic brain injury (TBI) requiring decompressive craniectomy. In addition, the authors aimed to assess whether this model was well calibrated in predicting outcome across a wide spectrum of severity of TBI requiring decompressive craniectomy.

Methods: This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia between 2004 and 2012 and for whom 18-month follow-up data were available.

Futility in neurosurgery: a patient-centered approach.

The concept of futility has been a source of discussion for many years. Even though it is tempting to propose that an action or clinical intervention should be deemed futile if it does not achieve the goals of that action, further clarification is needed in terms of the nature of the likely outcomes of an intervention and the probabilities of various outcomes being achieved. The outcome, in an age of balance between autonomy and necessity, should, at a minimum, be acceptable to the person on whom the intervention is to be performed.

Cost-effectiveness of decompressive craniectomy as a lifesaving rescue procedure for patients with severe traumatic brain injury.

Background: Decompressive craniectomy has been traditionally used as a lifesaving rescue procedure for patients with refractory intracranial hypertension after severe traumatic brain injury (TBI), but its cost-effectiveness remains uncertain.

Methods: Using data on length of stay in hospital, rehabilitation facility, procedural costs, and Glasgow Outcome Scale (GOS) up to 18 months after surgery, the average total hospital costs per life-year and quality-adjusted life-year (QALY) were calculated for patients who had decompressive craniectomy for TBI between 2004 and 2010 in Western Australia. The Corticosteroid Randomisation After Significant Head Injury prediction model was used to quantify the severity of TBI.

Decompressive craniectomy for diffuse cerebral swelling after trauma: long-term outcome and ethical considerations.

Background: There is currently much interest in the use of decompressive for the management of diffuse cerebral swelling after trauma. Although the use of the procedure may improve survival, some of those survivors may be left severely disabled. The aim of this study was to see whether severe disability can be predicted and discuss the difficult ethical issue that this raises.

Surgical intervention for severe head injury: ethical considerations when performing life-saving but non-restorative surgery.

Background: The aim of this study was to compare the predicted outcome with observed outcome in those patients who have had a unilateral decompressive craniectomy following evacuation of an intracranial mass lesion and to consider some of the ethical issues that need to be addressed when performing life-saving but non-restorative surgery.

Methods: By using the web-based outcome prediction model developed by the CRASH trial collaborators predicted and observed outcomes were compared for those patients who had had a unilateral decompression after evacuation of a mass lesion in the two major neurotrauma hospitals in Western Australia between 2004 and 2008. Three cases were selected with differing outcome predictions.

Observed versus predicted outcome for decompressive craniectomy: a population-based study.

A number of studies have shown that decompressive craniectomy can reduce intracranial pressure and may improve outcome for patients with severe head injury. This cohort study assessed the long-term outcome of neurotrauma patients who had a decompressive craniectomy for severe head injury in Western Australia between 2004 and 2008. The web-based outcome prediction model developed by the CRASH trial collaborators was applied to the cohort.

Decompressive craniectomy for neurotrauma: the limitations of applying an outcome prediction model.

Background: There is currently much interest in the use of decompressive craniectomy for patients with severe head injury. A number of studies have demonstrated that not only can the technique lower intracranial pressure but can also improve outcome. Whilst many patients who would otherwise have died or had a poor outcome now go on to make a good recovery, there is little doubt that complications can have a very significant impact on long term outcome.

The subjective brain, identity, and neuroethics.

The human brain is subjective and reflects the life of a being-in-the-world-with-others whose identity reflects that complex engaged reality. Human subjectivity is shaped and in-formed (formed by inner processes) that are adapted to the human life-world and embody meaning and the relatedness of a human being. Questions of identity relate to this complex and dynamic reality to reflect the fact that biology, human ecology, culture, and one's historic-political situation are inscribed in one's neural network and have configured its architecture so that it is a unique and irreplaceable phenomenon.

The retrospective application of a prediction model to patients who have had a decompressive craniectomy for trauma.

There is currently a resurgence of interest in the use of decompressive craniectomy. As the procedure is used more frequently, there may be an increasing number of patients surviving a severe traumatic brain injury with severe neurological impairment. The aim of this study was to determine if we could predict those cases that fall into this category.

Ethics, stem cells and spinal cord repair.

Attempted repair of human spinal cord injury by transplantation of stem cells depends on complex biological interactions between the host and graft. Extrapolating results from experimental therapy in animals to humans with spinal cord injury requires great caution. There is great pressure on surgeons to transplant stem cells into humans with spinal cord injury.