John Myburgh on the misunderstood craniectomy. The management of raised ICP and what we do when our options run out.

1. Raised intracranial pressure:
keeping a lid on it
UNSW
John Myburgh
MBBCh PhD FCICM
The George Institute for Global Health
St George Clinical School, University of New South Wales

2. P(mmHg)
V (ml)
1783, 1824
Monro-Kelly doctrine
Intracranial volume
remains constant at any
given time

3. Bryan Jennett
Douglas Miller
Larry Marshall
1978
1979
1980
Fearnside: Br J Neurosurg 1992

4. Inflammatory modulation
Bayir: Crit Care Med 2003

5. Neuroprotective trials
Maas: Neurosurgery 1999
HIT I (n=351)
HIT II (n=852)
HIT III (n=123)
PEGSOD (n=463)
Tirilizad (n=1128)
Triamcinolone (n=396)
HIT II tSAH
Tirilizad tSAH
Triamcinolone GCS 8
+focal lesion
Neuroprotective agents
All steroids
mean = 435

6. Rat / human model 20th century
Take a young male rat.
Infuse alcohol or speed until intoxicated.
Throw rat at high speed into brick wall
Break its femur and pelvis.
Leave it lying in the corner for 1 hour.
Get resident to resuscitate it using albumin
Include an oesophageal intubation and hypoxia for 20m.
Get orthopod to fix femur and lose 20% blood volume.
Do a CT head, but don’t tell the researcher the results.
Get a resident to put in ICP monitor 6-36 hours after injury.
Do the intervention.
Random use of mannitol, hyperventilation, hypothermia, barbs
Count how many rats are dead after 1 week.

7. Randy Chesnut
Nino Stocchetti
Andrew Maas
www.braintrauma.org
2001, 2003, 2007

8. Critical pathway
BTF Guidelines 1st, 2nd editions

9. Tier 1
Critical pathway: proposed
Tier 2
Tier 3
Low dose mannitol
Normothermia
Decompressive craniectomy
Induced hypothermia
Neuromuscular blockade
High dose mannitol
Hypertonic saline
Mild hypothermia (35-37)
BTF Guidelines Working Group: 2009

10. Rat / human model 21th century
Take a rat of any age.
If young, infuse alcohol or speed until intoxicated.
If old, give warfarin and aspirin
Early intubation and resuscitation
Pan-scan and damage control surgery
Standardise ICP monitoring
Do the intervention.
Flog CPP with noradrenaline
Use hypothermia, barbiturates to keep ICP<20
Decompressive craniectomy if these don’t work
Keep going until the rat’s family tells you when to stop
Count how many rats are dead after 6 months.

11. Comparative data
ATBIS
GCS<9
SAFE TBI
GCS<9
(Albumin)
SAFE TBI
GCS<9
(Saline)
n 363 160 158
Inception period 2000-2001 2001-2003 2001-2003
12-month mortality: n/N (%) 105/299 (35.1) 61/153 (39.9) 32/149 (21.5)
Myburgh J Trauma: 2008

14. Decompressive craniectomy
Indication
Age
Diffuse vs mass lesion
Traumatic vs non-traumatic
Timing
Pre-emptive
Rescue
Trigger
CT / clinical
ICP
Technique
Bifrontal vs unilateral
Dura open vs closed
Outcome
Physiological
Death / functional outcome

15. Honeybul: Brian inj 2013

16. Jiang:J Neurotrauma: 2005
Multicentred RCT, blinded outcome adjudication
1998 – 2001
n=486
Age < 70
Clinical / CT triggers for decompression
Primary outcome: 6m GOS
Standard Limited

17. Jiang:J Neurotrauma: 2005
GR / MD SD / PVS Dead
0
10
20
30
40
50
Standard DC (n=241))
Limited DC (n=245)
6m GOS
%
0
10
20
30
40
50
Day
ICP(mmHg)
Pre DC 1 day 3 days 7 days
Standard DC (n=36)
Limited DC (n=47)
p=0.03

18. Cooper: New Eng J Med 2011
Multicentred RCT, blinded outcome adjudication
2002-2011
N=155 (age <60)
Age < 60; < 72h post injury
CT trigger: Diffuse injury
ICP trigger: >20 mmHg
Primary outcome: 6m GOS
vs Medical therapy

19. Cooper: New Eng J Med 2011
Unfavourable Favourable
70% 51%
OR: 2.21 95%CI 1.14 to 4.26; P=0.02

21. www.rescueicp.com
Multi-centre RCT, blinded outcome adjudication
366/400 patients recruited
Age 18-65
ICP>25 mmHg
Refractory to medical therapy (2nd tier)
Included evacuated mass lesions
Clinically directed decompression
Primary outcome: Discharge + 6m GOSE

22. Honeybul: Brian inj 2013
Decompression for TBI
Survivors with unfavourable outcomes
Survivors with favourable outcomes
Survivors with favourable outcomes

23. Honeybul: Brian inj 2013

24. Middle cerebral artery infarction
Age limited: <60y
Time limited: < 48 hours
Co-morbidity / non-dominant hemisphere
DECIMAL: n=38 (Germany)
DESTINY: n=32 (France)
HAMLET: n=39 (Netherlands)
Hofmeijer: Lancet 2009

25. Middle cerebral artery infarction
Age limited: >60y
Time limited: < 48 hours
Low co-morbidity / non-dominant hemisphere
Juttler: NEJM 2014

26. Honeybul: Brian inj 2013
Decompression for non-TBI
Survivors with unfavourable outcomes
Survivors with favourable outcomes

27. Does Intensive Care improve outcome
from TBI?

28. Chesnut: NEJM 2012
Multi-centred RCT, blinded outcome adjudication
2008-2011
N=324
Age >13 <60
GCS<9 , < 48h post injury
Pressure/monitoring: ICP >20 mmHg + 3-tiered protocol
Imaging/clinical exam: 3-tiered protocol
Primary outcome: composite functional outcome 6m

29. Chesnut: NEJM 2012
ICP monitoring group
Imaging/exam group
P=0.60
ICP
(n=157)
ICE
(n=167)
OR (95%CI) p
CFOS 56 (22-37) 53 (21-76) 1.09 (0.74 to 1.58) 0.49
Death 56/144 (39%) 67 (41%) 1.10 (0.77 to 1.57) 0.60

30. T H Huxley
1825 - 1895
m
“That the great tragedy of
Science is the slaying of a
beautiful hypothesis with an
ugly fact”

31. Some concluding thoughts
Outcome from ABI is primarily determined by geography…
… and genetics
ICP is primarily an indicator of severity of injury
Treating ICP comes at a cost …
… saving the head, but killing the body…
… and those who care for the patient

32. Some concluding thoughts
Beware the therapeutic imperative to do what we can…
… and not what we should