Hutchinson et al. recently reported on the Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) trial, comparing unilateral or bilateral decompressive craniectomy with aggressive medical management for refractory ICP elevation after severe traumatic brain injury (TBI). The DECRA trial published 5 years ago showed craniectomy was worse for Extended Glasgow outcome scale (GOS-E) scores at 6 months than medical care (P = 0.03), with similar death rates at 6 months (19% and 18%, respectively). In the RESCUEicp trial, surgery was associated with better ICP control, reduced mortality, and higher rates of worse functional outcomes, although this improved at 12 months. RESCUEicp included more commonly encountered TBI patients with traumatic lesions and by defining refractory ICP elevation as greater than 25 mm Hg for 1 to 12 hours. These results suggest that lifesaving procedures may not restore normal functions, and that maximal medical therapy may not be adequate in ICP control. Decompressive craniectomy is a last-tier treatment for severe refractory ICP, reducing mortality while increasing incidence of unfavorable outcome at six months. The decision for surgery must include discussions with TBI patients’ surrogates about potential outcomes, prolonged recovery times, and poor quality of life.
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