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Decompressive Craniectomy and a Stepwise Approach to Elevated ICP in Patients with Severe TBI

Updated: Oct 7, 2022

Decompressive Craniectomy and a Stepwise Approach to Elevated ICP in Patients with Severe TBI

Elevated intracranial pressure (ICP) is associated with increased mortality and worse outcome in patients with traumatic brain injury (TBI). Specific interventions regarding ICP management in the setting of severe TBI are listed in different tiers from 0 to 3 in the above graph..

Decompressive craniectomy is effective in controlling ICP and might be lifesaving in patients with severe TBI. However, those patients may be left with severe disability. Results of clinical trials are limited due to short follow-up time. The DECRA and the RESCUEicp trials that are the main studies that will be listed here:

  • The DECRA (Decompressive Craniectomy in Diffuse Traumatic Brain Injury) study is a randomized trial that included 155 adults with severe diffuse TBI and ICP >20 mmHg for 15 minutes that did not improve with standard interventions within a one-hour period. The study compared bifrontal craniectomy with continued medical care and demonstrated a better control of ICP and shorter stay in the intensive care unit. However, there was a worse outcome of extended Glasgow Outcome Scale (E-GOS) at six month, The study has several limitations as it excluded patients with intracranial hematoma, had a lower threshold for ICP, and used extensive bilateral craniectomy not reflecting clinical practice [1].

  • The RESCUEicp trial is a larger study of 408 patients with refractory ICP >25 mmHg for 1-12 despite maximal medical therapy. Patients were randomized to continued medical therapy or craniectomy. Mortality rate at six months was lower in the surgical group compared to the medical group (27 versus 49%). However, there was a higher rate of vegetative state (8.5 versus 2.1%), higher rate of severe disability. Rates of moderate disability and good recovery were similar between the two groups. One caveat is that 37% crossover rate from medical to surgical treatment would have likely diluted the apparent treatment effect. A prespecified analysis of outcomes at one year revealed that the surgical group had a higher rate of favorable outcomes [2].



  1. Servadei F. Clinical value of decompressive craniectomy. N Engl J Med. 2011 Apr 21;364(16):1558-9. doi: 10.1056/NEJMe1102998. Epub 2011 Mar 25. PMID: 21434844.

  2. Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ; RESCUEicp Trial Collaborators. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med. 2016 Sep 22;375(12):1119-30. doi: 10.1056/NEJMoa1605215. Epub 2016 Sep 7. PMID: 27602507.

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