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The DECRA Trial: Early Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury

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ClinicalTrials.gov Identifier: NCT00155987
Recruitment Status : Completed
First Posted : September 12, 2005
Last Update Posted : September 10, 2020
Sponsor:
Collaborators:
National Health and Medical Research Council, Australia
Victorian Trauma Foundation
ANZICS Foundation
Western Australian Institute for Medical Research
Information provided by (Responsible Party):
Prof Jamie Cooper, National Trauma Research Institute

Study Description
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Brief Summary:

This is a multi-centre randomised trial to evaluate the effect of early decompressive craniectomy on neurological function in patients with severe traumatic brain injury.

The primary outcome is neurological function measured at 6 months post injury using the Glasgow Outcome Score. Neurological function is qualified as proportion of favourable outcomes (Glasgow Outcome Score Extended [GOSE] grades 5-8).


Condition or disease Intervention/treatment Phase
Brain Injuries Procedure: Early decompressive craniectomy Phase 3

Detailed Description:

Comparison After meeting the entry criteria, and the patient will be randomised to either early DC surgery (see below) or best current conventional management. Those randomised to surgery will have the operation done within 6 hours of randomisation. They will then return to the ICU and be managed thereafter in the same way as the conventional arm. Patients in the conventional arm will have all the usual therapies for increasing ICP optimised again. They then may have cooling to 35.0C or thiopentone bolus or thiopentone coma. These options are at the clinicians discretion. Late DC surgery in the control patients is discouraged however it may be done at the neurosurgeons discretion. These patients will be included in the intention to treat analysis.

Surgical Technique The technique described by Polin will be used. The operation will comprise bi-frontal decompressive craniectomies with a single fronto-temporal bone flap extending across the midline. The temporalis muscles will be reflected inferiorly. Burr holes are located either side of the sagittal sinus at the posterior extent and bilaterally at the keyhole and at the root of the zygoma. This will create a large bifrontal craniectomy defect extending posteriorly to the coronal sutures. Bilateral large sub-temporal decompressions will be performed down to the skull base. The final bone cut is made along the supra-orbital ridges with an attempt to preserve the frontal sinus. Burr holes will be placed either side of the sagittal sinus inferiorly and the bone will be lifted out.

The dura will be opened in one of two alternative ways:

  1. The dura is opened with a cruciate incision bilaterally. OR
  2. A large L shaped incision with the lower corner of the L facing laterally. The advantage to this method is that the cerebral veins are not disturbed medially by this incision.

The dural opening should be covered with a dural or facial patch, so that the brain does not adhere to the scalp. Water tight dural closure is not necessarily aimed for. For patients receiving EVD monitoring, an ICP monitor with ventricular catheter (± optional PO2 and temperature monitor) may be placed prior to closure. Some patients will have been randomised to parenchymal catheter only. These patients will not have an EVD inserted.

The bone flap is replaced once bone swelling has resolved and the patient has improved and left the intensive care unit (6-12 weeks). The bone flap is stored at minus 20o-70oC until reinsertion or it may be implanted in the subcutaneous tissue of the abdominal wall as an alternative.

Study Design
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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 155 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Multi-centre Prospective Randomised Trial of Early Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury
Study Start Date : August 2003
Actual Primary Completion Date : November 2010
Actual Study Completion Date : December 2010

Resource links provided by the National Library of Medicine


Arms and Interventions
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Intervention Details:
  • Procedure: Early decompressive craniectomy
    Large bifrontotemporal decompressive craniectomy

Outcome Measures
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Primary Outcome Measures :
  1. Proportion (%) of favourable outcomes (GOSE 5-8) [ Time Frame: 6 month post injury ]

Secondary Outcome Measures :
  1. Mean and maximum hourly intracranial pressure (ICP) [ Time Frame: 36hrs post randomisation ]
  2. Favourable outcomes (GOSE) [ Time Frame: 12 months post injury ]
  3. Mean GOSE using ordinal logistic regression [ Time Frame: 6 months and 12 months ]
  4. Mortality [ Time Frame: hospital, 6 months, 12 months ]
  5. length of stay [ Time Frame: ICU admisssion ]
  6. Brain metabolites using microdialysis (The Alfred Hospital only) [ Time Frame: During monitoring phase ]

Eligibility Criteria
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Ages Eligible for Study:   15 Years to 60 Years   (Child, Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Age 15 - 60 years and within the first 72 hrs from time of injury
  • Severe diffuse Traumatic Brain Injury defined as:
  • GCS < 9 and CT scan* with any evidence of brain swelling CT brain scan (DII + some evidence of swelling or DIII or DIV) OR
  • GCS >8 before intubation and DIII or DIV CT brain scan (basal cistern compression ± midline shift)
  • ICP monitor in situ. EVD recommended.
  • "Refractory ICP" despite best conventional management. Refractory ICP in this study will be defined as the spontaneous persistent increase in ICP despite optimal conventional ICU therapies (including intermittent EVD venting) of >20mm Hg for more than 15 mins (continuously or cumulative over one hour).

Exclusion criteria:

  • Intracranial haemorrhage > 3 cm diameter
  • Intracranial mixed haemorrhagic contusion >5cm in long axis
  • Previous craniectomy
  • EDH/SDH/ or large contusion requiring evacuation
  • EDH/SDH >0.5 cm thickness
  • Spinal cord injury
  • Penetrating brain injury
  • Arrest at scene
  • Unreactive pupils >4mm, and GCS=3
  • Neurosurgery contraindicated (eg: severe coagulopathy)
  • No chance of survival after consideration of CT and clinical findings following Neurosurgical consultant assessment (eg hemispheric infarct after carotid dissection).
Contacts and Locations
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Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT00155987


Locations
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Australia, Victoria
The Alfred Hospital
Melbourne, Victoria, Australia, 3004
Sponsors and Collaborators
National Trauma Research Institute
National Health and Medical Research Council, Australia
Victorian Trauma Foundation
ANZICS Foundation
Western Australian Institute for Medical Research
Investigators
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Principal Investigator: D. J. Cooper The Alfred Hospital & National Trauma Research Institute
More Information
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Responsible Party: Prof Jamie Cooper, Chief Investigator, National Trauma Research Institute
ClinicalTrials.gov Identifier: NCT00155987    
Other Study ID Numbers: 68/02
First Posted: September 12, 2005    Key Record Dates
Last Update Posted: September 10, 2020
Last Verified: September 2020
Keywords provided by Prof Jamie Cooper, National Trauma Research Institute:
Severe diffuse TBI refractory intracranial hypertension.
Additional relevant MeSH terms:
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Brain Injuries
Brain Injuries, Traumatic
Wounds and Injuries
Brain Diseases
 Central Nervous System Diseases
Nervous System Diseases
Craniocerebral Trauma
Trauma, Nervous System