Decompressive Craniectomy for Severe Traumatic Brain Injury: A Systematic Review

OBJECTIVE: Systematic review of the literature to evaluate the role of decompressive craniectomy (DC) after severe traumatic brain injury (TBI), comparing the first major randomized clinical trial on this topic (DECRA) with subsequent literature. METHODS: A systematic literature search was performed from 2011 to 2015. Citations were selected using the following inclusion criteria: closed severe TBI and DC. Exclusion criteria included most patients <= 18 years old, <= 20 participants, review articles, DC for reasons other than TBI, or surgical procedures other than DC. Primary outcomes included mortality and Glasgow Outcome Scale (GOS) at discharge, 6 months, and 1 year after injury. Assessment of risk of bias of the randomized controlled trials was also performed. RESULTS: Only 12 of 5528 articles satisfied the eligibility criteria; of these studies, 3 were randomized controlled trials. DC in specific populations does not offer GOS or mortality advantages compared with medical treatment; on the other hand, when DC with open dural flap was compared with an alternative means of decompression, e.g., DC with multiple dural stabs, the latter showed significant advantage in mortality and GOS. Nonrandomized studies showed decreased mortality and increased GOS in patients aged <= 50 years when DC was performed <5 hours after TBI and with Glasgow Coma Scale score >5. CONCLUSIONS: Our study underscores the importance of continued international prospective data collection for assessing types of surgical interventions in addition to DC and their timing in patients who have severe TBI. In addition, in geographic areas with limited access to advanced medical treatment for severe TBI, DC is of benefit when performed <5 hours after injury in younger patients with Glasgow Coma Scale >5.