Decompressive Craniectomy in Management of Severe Traumatic Brain Injury

problem, with an estimated 27 million cases per year leading to subsequent hospitalization and possible mortality. Decompressive craniectomy (DC), the surgical removal of a portion of the skull with exposure of the dura mater, has long been used for the treatment of severe TBI as an established means of decreasing mortality. In a comparison of the 2 largest randomized clinical trials (RCTs) evaluating the efficacy of DC versus medical management for refractory intracranial pressures (rICPs) (DECRA 2011 vs RESCUEicp 2016 trials), one revealed no significant impact on surgically treated patient mortality, whereas the other demonstrated a clear reduction of patient fatality in the surgically treated arm, but at the expense of creating a larger cohort of survivors with severe incapacitation, at least in the short term. Although DC has remained a standard treatment of acute subdural hematoma (ASDH), it is only now being compared in a large RCT (RESCUE-ASDH) to emergent craniotomy, another widely accepted procedure. Such results demonstrate the persistence of clinical equipoise when determining the utility of DC versus medical management or craniotomy for patients with severe TBI resulting in rICPs. In this article, we review the indications, pathophysiology, surgical technique, complications, controversy, and ethical considerations involving DC.