Abstract
BackgroundTwo randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach.MethodsThe International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries.ResultsThe invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval.ConclusionsIn this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
Highlights
Traumatic brain injury (TBI) is a major public health and socioeconomic problem around the world
Between December 2002 and April 2010, the trial collaborators randomly assigned 155 adults with severe diffuse traumatic brain injury (TBI) to either bifrontotemporoparietal decompressive craniectomy (DC) or standard treatment if they developed intracranial hypertension defined as intracranial pressure (ICP) of more than 20 mmHg for more than 15 min in a 1-h period refractory to first-tier therapies [24]
Mortality was similar in the two treatment groups (19% in DC group and 18% in control group), but unfavourable outcome was higher in the DC group compared to the control group (70% vs 51%; odds ratio, 2.21; p = 0.02)
Summary
Traumatic brain injury (TBI) is a major public health and socioeconomic problem around the world. World Health Organisation (WHO), more than 5 million people die every year as a result of trauma, accounting for 9% of the world’s deaths. Trauma results in millions of non-fatal injuries leading to life-long disability [90]. Of all the types of traumatic injuries, those to the brain are the most likely to result in death or permanent disability [102]. It is estimated that 69 million (95% CI 64–74 million) individuals worldwide suffer a TBI each year. Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach
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