Article
Is decompressive craniectomy better than standard care alone for increased intracranial pressure – a systematic review and meta-analysis
Ist dekompressive Kraniektomie besser als Standardversorgung für Patienten mit gesteigertem intrakraniellem Druck: Eine Literaturübersichtsarbeit und Meta-Analyse
Search Medline for
Authors
Published: | May 25, 2022 |
---|
Outline
Text
Objective: Increased intracranial pressure (ICP) is a common but potentially life-threatening pathology in Neurology and Neurosurgery. Decompressive craniectomy (DC) is a surgical procedure, which significantly reduces ICP and mortality, but its role in improving neurological outcomes is still controversial. This meta-analysis explores the efficacy of DC in improving neurological outcomes and reducing mortality compared to standard care alone in patients with conditions causing increased ICP.
Methods: Seven databases were searched from their inception until 14th February 2021. Studies were included if they compared neurological outcomes between patients who underwent DC in addition to standard care versus standard care alone in acute conditions involving increased ICP. Two reviewers independently screened full-text publications for eligibility and extracted the relevant information. The primary outcome was the standardised mean difference (SMD) for the neurological outcome at short-term (1-6 months) and long-term (> 6 months), and the secondary outcome was the risk ratio (RR) for mortality. The pooled effects were calculated using random-effects models. Subgroup analysis and meta-regression were conducted. Publication bias was investigated through Egger's test. The quality of evidence was assessed using GRADE approach.
Results: A total of 77 studies (5,970 patients) were included. In the short term, DC improved neurological outcomes more than the standard care alone (SMD= 0.46, 95% CI 0.3-0.61), but in the long-term, the pooled effect was not significant (SMD= 0.19, 95% CI -0.08-1.24). Mortality was lower after DC, both at short-term (RR= 0.62, 95% CI 0.54-0.72) and at long-term (0.73, 95% CI 0.60-0.88). In the subgroup, DC was most effective in patients with malignant middle cerebral artery infarction at short-term (SMD= 0.83, 95% CI 0.62- 1.04) (Figure 1 [Fig. 1]) and long-term (SMD= 0.59, 95% CI 0.22- 0.97) (Figure 2 [Fig. 2]). Three variables have significantly associated with the effect size in the univariable meta-regression: Glasgow Coma Scale, midline shift, and age; however, in the multivariable, all B-coefficients were non-significant. Egger's test was at short-term significant (p-value= 0.004), and non-significant at long-term (p-value= 0.319). Overall, the quality of the evidence was low.
Conclusion: This meta-analysis demonstrated that DC improves mortality in patients with increased ICP, but the positive effect on neurological outcomes can be only demonstrated in the first six months.