Decompressive craniectomy for traumatic brain injury: a review of recent landmark trials

Traumatic brain injury (TBI) is a leading cause of trauma-related morbidity and mortality worldwide, with decompressive craniectomy (DC) serving as a critical surgical intervention. This article reviews the recent studies evaluating the role of DC in the management of elevated intracranial pressures (ICPs) associated with TBI and its impact on functional outcomes. Decompressive Craniectomy in Diffuse Traumatic Brain Injury (DECRA), Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of intracranial pressure (RESCUEicp), and Randomized Evaluation of Surgery with Craniectomy for patients Undergoing Evacuation of Acute Subdural Hematoma (RESCUE-ASDH) are three landmark trials that used varying thresholds for surgical intervention after TBI and examined how functional outcomes improved with time. The DECRA trial evaluated early DC in patients with moderate ICP elevations, demonstrating reduced intensive care unit and hospital stays but poorer functional outcomes at 6 months. Conversely, the RESCUEicp trial emphasized the benefits of delayed DC as a rescue strategy for refractory ICP, showing reduced mortality and improved Glasgow Outcome Scale-Extended scores at 24 months. The RESCUE-ASDH trial compared DC and craniotomy for acute subdural hematoma, finding no significant differences in functional outcomes but distinct profiles of surgical complications. Key recommendations emphasize individualized decision-making based on patient-specific factors, including preinjury functional status and family involvement. This comprehensive review underscores the importance of tailoring DC timing and techniques to optimize functional recovery and align with patient-centered goals, advancing the multidisciplinary management of severe TBI.