This review describes the evidence base that has helped define the role of decompressive craniectomy (DC) in the management of patients with traumatic brain injury (TBI).
The publication of two randomized trials (DECRA and RESCUEicp) has strengthened the evidence base. The DECRA trial showed that neuroprotective bifrontal DC for moderate intracranial hypertension is not helpful, whereas the RESCUEicp trial found that last-tier DC for severe and refractory intracranial hypertension can significantly reduce the mortality rate but is associated with a higher rate of disability. These findings have reopened the debate about 1) the indications for DC in various TBI subtypes, 2) alternative techniques (e.g. hinge craniotomy), 3) optimal time and material for cranial reconstruction, and 4) the role of shared decision-making in TBI care. Additionally, the role of primary DC when evacuating an acute subdural hematoma is currently undergoing evaluation in the context of the RESCUE-ASDH randomized trial.
This review provides an overview of the current evidence base, discusses its limitations and presents a global perspective on the role of DC, as there is growing recognition that attention should also focus on low- and middle-income countries due to their much greater TBI burden.