DECRA

Clinical question

Does early bifrontotemporoparietal decompressive craniectomy for diffuse TBI with early intracranial hypertension improve functional outcome?

What the trial found

Early decompressive craniectomy for diffuse TBI with intracranial hypertension controlled ICP more effectively than medical management alone but resulted in worse functional outcomes at 6 months.

Clinical interpretation

DECRA demonstrated that successfully lowering ICP does not guarantee a better functional outcome — an important general lesson, not just a craniectomy-specific one. Interpretation is complicated by a baseline imbalance in pupillary reactivity (a strong outcome predictor) between the two groups, and by the relatively low ICP threshold (20 mmHg) and short duration used to trigger the intervention, which is lower/shorter than the refractory threshold used in RESCUEicp.

Limitations

• Baseline imbalance in pupillary reactivity between groups, a major outcome predictor, complicates interpretation.
• Relatively low ICP threshold and short duration for enrollment compared with how 'refractory' intracranial hypertension is defined in later trials/guidelines.