• Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations

    • This is an updated guideline by the Brain Trauma Foundation on decompressive craniectomy (DC). This guideline specifically included the RESCUE ICP trial as well as the DECRA trial 12-month data
    • There are 3 new Level IIA recommendations while one Level IIA recommendation from previous guideline remains the same. These include:

    Level IIA–to improve mortality and overall outcomes

    1. NEW–Secondary DC performed for laterefractory ICP elevation is recommended to improve mortality and favorable outcomes.
    2. NEW–Secondary DC performed for earlyrefractory ICP elevation is not recommended to improve mortality and favorable outcomes
    3. A large frontotemporoparietal DC (not less than 12 × 15 cm or 15 cm in diameter) is recommended over a small frontotemporoparietal DC for reduced mortality and improved neurological outcomes in patients with severe TBI

    Level IIA–for ICP control

    1. NEW–Secondary DC, performed as a treatment for either early or late refractory ICP elevation, is suggested to reduce ICP and duration of intensive care, though the relationship between these effects and favorable outcome is uncertain.

     

    • The recommendations are primarily based on data from the DECRA trial and RESCUE ICP trial, mainly addressing secondary DC. While the guidelines separated the indications for early versus late refractory ICP elevation, there was no clear distinction between early and late given in the guideline.  Presumably, this is based on the DECRA (early) and RESCUE ICP (late) trial population, but there is likely significant overlap of the two populations.  Therefore, there is not a clear cutoff that defines which patient is considered as having early versus late refractory ICP.

    Source

    Neurosurgery

    Neurosurgery 87(3): 427-434

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