The Role of Decompressive Craniectomy for Severe Refractory Head Injury

Decompressive craniectomy is a potential therapeutic option for patients with severe traumatic brain injury and refractory intracranial hypertension, although its indications and clinical benefits remain controversial. A total of 4060 articles were identified, with 94.6% published after 2010. Several major randomized clinical trials have shaped current understanding of decompressive craniectomy, including the RESCUE-ASDH for primary intracranial hypertension, and the DECRA and RESCUEicp for secondary intracranial hypertension. RESCUE-ASDH and DECRA showed no overall benefit and suggested potential harm associated with decompressive craniectomy. RESCUEicp trial showed reduced mortality and sustained long-term improvement in a subset of patients, although many survivors remained in a dependent state. Critical appraisal of the inclusion and exclusion criteria of these trials, together with supporting evidence from animal studies, suggest that decompressive craniectomy should not be treated as primary intervention for traumatic brain injury. Instead, it may be more appropriately used as an adjunct procedure to prevent worsening cerebral edema following other neurosurgical interventions - such as evaluation of contusions or hematomas - when the operative hemisphere is tight and swollen. Decompressive craniectomy performed solely to control refractory intracranial hypertension in traumatic brain injury is unlikely to provide meaningful patient-centered benefit. Its role as an adjunct procedure after evacuation of contusions or hematomas remains uncertain, particularly in patients with a low predicted risk of unfavorable outcome. Decision regarding decompressive craniectomy should incorporate shared decision making and reflect careful consideration of the functional outcomes acceptable to patients and their families.