icu

Questions and Answers

　　After the session, Dr. Antonios Liolios, of Brussels, Belgium, asked Dr. Thomas Bleck several questions about the topic of craniectomy. The following are Dr. Bleck?s answers.
　　Dr. Liolios: Do you believe craniectomy is underutilized in the treatment of intractable intracranial hypertension? If so why?
　　Dr. Bleck: Yes, I believe that it is underutilized in the sense that most patients currently subjected to extreme medical therapy (eg, barbiturate anesthesia) or hypothermia might be better served by craniectomy. Even if the outcome were no better than with medical therapy, the physiologic strain on the patient and the psychologic strain on the family are much less with craniectomy. The expenses appear to be much less (based on shorter ICU length of stay as well as the costs of the therapies). Having said that, we really need a randomized trial to look at the quality of life among the survivors from each approach.
　　Dr. Liolios: Which are the most worrisome complications of craniectomy? Are there any good data on outcome post-craniectomy?
　　Dr. Bleck: The complications are quite minimal if the craniectomy is sufficiently large to allow the brain to swell without herniating at an acute angle at the edge of the incision. The best outcome data we have come from single center series reports like the reports by Polin and colleagues[4] and Schwab and coworkers.[6] Preliminary data from a randomized trial of craniectomy for stroke, headed by Dr. Jeffrey Frank, will be presented at the American Academy of Neurology meeting later on.
　　Dr. Liolios: For which conditions do you consider craniectomy to be appropriate?
　　Dr. Bleck: Almost any situation in which (1) one is confronted by refractory elevation of ICP in (2) a patient whose neurologic lesion would permit a reasonable quality of life if he or she survived it and (3) who does not have uncorrectable coagulopathy, sepsis, or some other condition that might render the risk of the craniectomy greater than that of medical management. Refractory ICP elevation means that the patient does not respond to mannitol or hypertonic saline, attention to head positioning, sedation, NMJ blockade, and other therapies short of barbiturate anesthesia or hypothermia. The issue of age is also important. In the trauma population, it appears that younger patients benefit while older patients may not. Stroke, of course, is another issue.