To Do or Not to Do: Decompressive Craniectomy for Severe Traumatic Brain Injury

Abstract Globally, severe traumatic brain injury (TBI) is a significant cause of death and disability, particularly among young adults in their productive years. The management of elevated intracranial pressure (ICP) following TBI remains one of the greatest challenges in neurotrauma care, with decompressive craniectomy (DC) being a prominent, albeit contentious, treatment option. DC, a surgical procedure that involves removing a portion of the skull to accommodate brain swelling, has emerged as a potential life-saving intervention in such scenarios. The rationale is that by reducing ICP and enhancing cerebral perfusion, DC may mitigate further neurological damage. However, while DC effectively reduces mortality, its association with a high prevalence of severe disability and poor long-term functional outcomes has led to ongoing debate regarding its clinical utility, ethical justification, and cost-effectiveness. From a health care economics standpoint, DC has been shown to be more cost-effective than alternatives like barbiturate coma, particularly in younger patients with less severe injuries. Yet, this advantage diminishes in older populations or those with profound neurological impairment, where survival often comes at the cost of substantial long-term care needs and significantly impaired quality of life. Additionally, the decision to perform DC often occurs under critical circumstances where inherent prognostic uncertainty of early outcome prediction and emotional stress further complicate the shared decision-making process. To aid in navigating these complex choices and to guide ethical resource allocation, prognostic models such as Corticosteroid Randomization After Significant Head injury (CRASH) and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) have been developed, offering evidence-based predictions of functional outcomes based on preoperative clinical and radiographic variables. Nevertheless, these models have limitations. This review synthesizes current evidence on the clinical effectiveness, cost utility, and ethical dimensions of DC in severe TBI. It also explores the role of predictive tools in facilitating evidence-informed and ethically responsible decisions. A literature review was conducted using major biomedical databases to identify and synthesize clinical, ethical, and economic evidence related to DC in severe TBI. We also sought the opinion of various experts and tried to provide a comprehensive, multidimensional understanding of DC in neurotrauma care to support clinicians in navigating the complexities of managing severe TBI patients.