Decompressive Craniectomy for Severe Traumatic Brain Injury: A Review of its Current Status

Over the past two decades there has been a resurgence of interest in the use of decompressive craniectomy in the management of severe traumatic brain injury. A number of retrospective studies have demonstrated that in the context of intractable intracranial hypertension surgical decompression can lower the intracranial pressure and a significant number of patients make a good long term recovery. It has been generally assumed that by lowering the intracranial pressure not only are patients more likely to survive but outcome is also improved. However a recent trial has demonstrated that this is not necessarily the case. The DECRA study compared early decompressive craniectomy with standard medical therapy and the results were that there were more unfavourable outcomes in the patients in the surgical arm of the trial. Whilst there were some problems with randomisation and crossover of patients from the standard therapy to the medical arm, overall the trial has provided the first class I evidence in adult neurotrauma and should have been heralded as a landmark study. Unfortunately this has not been the case and commentary on the trial has in most cases been somewhat critical. This review examines the trial in detail and outlines the current role and future direction of decompressive craniectomy in the management of severe traumatic brain injury.