Background and Goal of Study: Decompressive craniectomy (DC) to control refractory intracranial hypertension in patients with traumatic brain injury (TBI) has been listed as possible but controversial therapeutic approach in the latest version of TBI management guidelines. This study aims to perform a systematic review and meta-analysis on efficacy and safety of DC compared to standard care in TBI patients.

Materials and Methods: A database search (PubMed, EMBASE, CENTRAL and International Web of Science) from 2011 to 2017 was conducted to identify randomized clinical trials (RCTs) and observational studies pertinent to DC compared to standard care after severe TBI. The primary outcomes were mortality and functional outcome upon hospital discharge and at 6 and 12 months after intervention, whereas intracranial pressure (ICP) control, hospitalization data and occurrence of DC-related adverse events or systemic side-effects served as secondary outcomes.

Results and Discussion: Three RCTs and two observational studies, enrolling 1269 patients, were selected for qualitative analysis, among which one deemed unsuitable to be included in meta-analysis. Most of the retrieved studies were of high risk of bias and rather low quality. Mortality and functional outcome constituted the combined end-points in 4 studies, whilst in one trial the main point of interest was mortality. DC-treated patients showed a significant reduction in their overall mortality (RR, 0.57; 95%CI, 0.5–0.66; P<0.001; I2=17%) with no profound beneficial effect on their functional outcome (RR, 0.89; 95%CI, 0.78–1.02; P=0.09; I2=58%) compared to those receiving standard care. However, a notable improvement on functional outcome was recorded only at 12 months after intervention (RR, 0.80; 95%CI, 0.70–0.92; P=0.001; I2=0%). Although, DC yielded a positive impact on ICP control and duration of ICU stay, its effect in reducing the length of hospitalization was less clear. In terms of safety, DC was associated with an augmented risk of adverse effects.

Conclusion(s): Based on current evidence, DC emerges as a superior practice to standard care for intracranial hypertension control, with a subsequent short- to long-term survival benefit in TBI patients. Available evidence also suggests a trend towards to late functional outcome improvement; yet no definite conclusion can be drawn due to limited quantity and considerable heterogeneity of available data.

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02 / Decompressive craniectomy in patients with refractory intracranial hypertension after traumatic brain injury: a systematic review and meta-analysis of current evidence.