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Updated: Oct 16, 2025
Controlled Cortical Impact Model for Traumatic Brain Injury
Published on: August 5, 2014
Decompressive Craniectomy After Traumatic Brain Injury: Incorporating Patient Preferences into Decision-Making
Christos Lazaridis1, Ali Mansour1, Manasvini Singh2
1Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, Chicago, Illinois, USA.
Insights
Decompressive craniectomy (DC) decision-making needs patient preferences. A new decision aid, based on Expected Utility Theory, helps incorporate patient values for better outcomes in severe traumatic brain injury.
Area of Science:
- Neurosurgery
- Decision Science
- Medical Ethics
Background:
- Decompressive craniectomy (DC) effectively reduces intracranial hypertension but lacks clear guidelines on patient selection, optimal timing, and functional outcomes.
- Recent updates to Brain Trauma Foundation guidelines, informed by DECRA and RESCUEicp trials, still do not address incorporating patient or surrogate preferences into decision-making.
Purpose of the Study:
- To address the gap in incorporating patient preferences into decisions regarding DC for refractory post-traumatic intracranial hypertension.
- To propose a novel decision aid grounded in Decision Theory, specifically Expected Utility Theory, to aid clinical decision-making.
Main Methods:
- Utilized principles of Expected Utility Theory to develop a decision aid framework.
- Analyzed 1-year outcome data from the DECRA and RESCUEicp clinical trials.
Main Results:
- Early secondary DC, as per DECRA trial data, demonstrated decreased expected utility across all preference rankings.
- Recommending late secondary DC versus intensive medical therapy, based on RESCUEicp findings, necessitates consideration of individualized patient outcome preferences.
Conclusions:
- While DECRA and RESCUEicp trial outcomes inform current guidelines, unaided interpretation may be insufficient for personalized patient care.
- Decision aids, such as the one proposed using expected utility theory, can significantly enhance individualized decision-making for decompressive craniectomy.
Background:
Decompressive craniectomy (DC) is highly effective in relieving intracranial hypertension; however, patient selection, intracranial pressure threshold, timing, and long-term functional outcomes are all subject to controversy. Recently, recommendations were made to update the Brain Trauma Foundation guidelines in regards to the use of DC based on the DECRA (Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury) and RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) clinical trials. Neither the updated recommendations, nor the aforementioned trials, provide a method in incorporating individualized patient or surrogate decision-maker preferences into decision making.
Methods:
In this manuscript, we aimed to redress the gap of not incorporating patient preferences in such value-laden decision making as in the case of DC for refractory post-traumatic intracranial hypertension. We proposed a decision aid based on principles of Decision Theory, and specifically of Expected Utility Theory.
Results:
We showed that 1) early secondary DC as studied in DECRA, and based on the 1-year outcome data, is associated with decreased expected utility for all possible preference rankings of outcomes; and 2) recommending a late secondary DC versus tier-3 medical therapy, as studied in RESCUEicp, should be informed by individualized patient preference rankings of outcomes as elicited via shared decision-making.
Conclusions:
The 1-year outcomes from DECRA and RESCUEicp have served as the basis for updated guidelines. However, unaided interpretation of trial data may not be adequate for individualized decision-making; we suggest that the latter can be significantly supported by decision aids such as the one described here and based on expected utility theory.
