Following traumatic brain injury (TBI), 60% of patients survive with severe disability or die.1–3 This results in a yearly cost within the United States of greater than $60 billion.4 Although there are proposed guidelines for the treatment of patients with TBI,5–11 the benefits of surgical therapy remain unclear. When common medical therapies fail to control intracranial hypertension, decompressive craniectomy is often carried out in TBI patients. There have been limited prospective, randomized clinical trials to assess decompressive craniectomy in TBI patients and surgery remains controversial.12–14
The Decompressive Craniectomy (DECRA) in Diffuse Traumatic Brain Injury study published in 2011 randomized TBI patients to craniectomy vs maximal medical therapy.14 Patients in the surgical arm received decompression if intracranial pressures (ICP) were increased for more than 15 min (continuously or intermittently) within a 1-hour period, despite optimized first-tier interventions (optimized sedation, the normalization of arterial carbon dioxide pressure, and the use of mannitol, hypertonic saline, neuromuscular blockade, and external ventricular drainage). Despite decreased time with ICP above the treatment threshold, fewer interventions for increased ICP, fewer days in the intensive care unit, and fewer days in the hospital, patients receiving craniectomy did not have better outcomes.14 A number of questions about the external validity of the trial were noted including limited entry which might be a reflection of selection bias, the definition of refractory intracranial hypertension, and differences between the 2 cohorts including a significantly higher number of patients with bilateral nonreactive pupils in the surgically treated arm.15,16
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