Expansive Craniotomy versus Standard Decompressive Craniectomy in Refractory Intracranial Hypertension: A Systematic Review and Meta-Analysis.

Abstract

Raised intracranial pressure can have devastating consequences on mortality and outcome after acute brain injury. Decompressive craniectomy (DC) is an established surgical procedure for controlling refractory intracranial hypertension; however, this requires subsequent cranioplasty. Expansive craniotomy (EC) techniques, where the bone flap is returned but only partially fixed in place, have been developed to avoid the need for cranioplasty. However, comparative safety and efficacy is not well defined. A systematic review to identify studies comparing EC with DC was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, including all study types except systematic/scoping reviews. Meta-analysis was performed for three outcomes (mortality, acute reoperation rate, and Glasgow Outcome Scale). A total of 29 studies met the inclusion criteria, and are summarized in narrative review. Eight studies were included in meta-analysis: two randomized controlled trials and six case-control studies. Meta-analysis found no significant difference in mortality. EC was associated with improved Glasgow Outcome Scale score (mean difference, 0.44; P < 0.05); however, this may be attributable to selection bias. There was a marginal increase in early additional surgery rates associated with EC (risk difference, 0.08; P = 0.05). Risk of bias was moderate to high across included studies. Current evidence cannot robustly inform clinical decision-making on the use of EC. Based on reports of success of EC, EC appears to be a valid alternative to DC in selected cases; however, greater acute reoperation rates because of inadequate decompression is a risk. Overall, there is strong support for an appropriately powered randomized controlled trial to robustly evaluate EC.