title: Decompressive craniectomy in traumatic brain injury after the DECRA trial. Where do we stand?
abstract: OBJECTIVE
  The results of the multicentre, randomized, controlled trial to test the effectiveness of decompressive craniectomy in adults with traumatic brain injury and high intracranial pressure (Decompressive Craniectomy, DECRA) were published in 2011. DECRA concluded that decompressive craniectomy decreased intracranial pressure (ICP) but was associated with more unfavourable outcomes. Our review aims to put the DECRA trial into context, comment on its findings and discuss whether we should include decompressive craniectomy in our clinical armamentarium.
  
  
  RESULTS
  The key message that DECRA conveys is that decompressive craniectomy significantly lowers ICP and shortens the length of the stay in the ICU. However, neither mortality nor unfavourable outcome was reduced when adjusting the significant baseline covariates.
  
  
  CONCLUSIONS
  The claim that decompressive craniectomy increases unfavourable outcome is overstated and not supported by the data presented in DECRA. We believe it premature to change clinical practice. Given the dismal outcome in these patients, it is reasonable to include this technique as a last resort in any type of protocol-driven management when conventional therapeutic measures have failed to control ICP, the presence of operable masses has been ruled out and the patient may still have a chance of a functional outcome. The main lesson to be learned from this study is that an upper threshold for ICP must be used as a cut-off for selecting decompressive craniectomy candidates.
authors: Department of Neurosurgery and Neurosurgery and Neurotraumatology Research Unit (UNINN), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain. sahuquillo@neurotrauma.net
authors: Juan
authors: J
authors: Sahuquillo
authors: Francisco
authors: F
authors: Martínez-Ricarte
authors: Maria-Antonia
authors: MA
authors: Poca
mesh_terms: D001930:Brain Injuries / Q000150:complications / Q000401:mortality / Q000601:surgery*; D003422:Critical Care / Q000379:methods*; D056424:Decompressive Craniectomy / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D007427:Intracranial Pressure; D008297:Male; D015337:Multicenter Studies as Topic; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome