gms | German Medical Science

73. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC)
Joint Meeting mit der Griechischen Gesellschaft für Neurochirurgie

Deutsche Gesellschaft für Neurochirurgie (DGNC) e. V.

29.05. - 01.06.2022, Köln

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

Meeting Abstract

  • presenting/speaker Ali Mulhem - University of Oxford, Department for Continuing Education, Oxford, Vereinigtes Königreich; Vivantes Klinikum im Friedrichshain, Neurochirurgie, Berlin, Deutschland
  • Amrita Jaiswal - University of Oxford, Department for Continuing Education, Oxford, Vereinigtes Königreich
  • Abdul Almasih Alsuliman - Vivantes Klinikum im Friedrichshain, Neurochirurgie, Berlin, Deutschland
  • Kaspar Lewis Yaxley - University of Oxford, Department for Continuing Education, Oxford, Vereinigtes Königreich
  • Karolina Wartolowska - University of Oxford, Department for Continuing Education, Oxford, Vereinigtes Königreich

Deutsche Gesellschaft für Neurochirurgie. 73. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), Joint Meeting mit der Griechischen Gesellschaft für Neurochirurgie. Köln, 29.05.-01.06.2022. Düsseldorf: German Medical Science GMS Publishing House; 2022. DocV258

doi: 10.3205/22dgnc250, urn:nbn:de:0183-22dgnc2506

Published: May 25, 2022

© 2022 Mulhem et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


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.