Primary and Secondary Decompressive Craniectomy in Traumatic Brain Injury: Indications and Timing

Primary evacuation of traumatic intracranial hematomas is well-supported by literature. Secondary decompressive craniectomy for refractory intracranial pressure at or beyond 72 hours postinjury yields significantly improved mortality and functional outcomes compared to nonoperative management, with benefits increasing over time postinjury. Benefits of secondary decompression within 24 to 72 hours postinjury on outcomes is less clear, highlighting how the use of static intracranial pressure thresholds alone are unsuitable for neurosurgical decision-making. Contemporary research to address these knowledge gaps requires integration of sociodemographic and clinical predictors, blood-based biomarkers, and quantitative neuroimaging features to optimize clinical decision-making and outcome trajectories in neurotrauma.