Decompressive craniectomy is indispensible in the management of severe traumatic brain injury

Abstract

Dear editor, The role of decompressive craniectomy (DC) in the management of severe traumatic brain injury (TBI) is a subject of debate in the present era. It is a widely accepted procedure across the globe for intracranial pressure (ICP) reduction. The Cochrane review in 2009 [8] identified only one high-powered randomised controlled trial (RCT). It was done amongst the paediatric population to compare surgery with medical treatment [9]. The results showed moderate but definite reduction in death and disability in the surgical arm. The recent Decompressive Craniectomy in Diffuse Traumatic Brain Injury (DECRA) Trial [2] that studied 155 patients has cast doubts on the effectiveness of the procedure. The study evaluated the effect of early DC on mortality and neurological outcomes at 6 months using the Extended Glasgow Outcome Scale (GOSE) in patients with severe TBI aged 15–60. Patients admitted within 72 hw ere randomised in an intention-to-treat analysis to medical arm versus surgical decompression followed by medical treatment. Although the DC arm showed earlier reduction in ICP and length of stay in the ICU, it was associated with unfavorable functional outcome. The question is how much DECRA could potentially affect current neurosurgical practice. As the first randomised controlled trial on DC on adults, it has significant academic and clinical implications. However, the impact on neurosurgical practice can be misleading if the results were generalised. The patients recruited had diffuse brain injury without a large haematoma that needed surgery. This represented only a minority group among patients treated by DC in real practice. DECRA recruited only less than 10 percent of the patients enrolled, suggesting a tight selection of patients that does not represent the general patient population.