LandmarkRCT

RESCUEicp

Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension

New England Journal of Medicine, 2016 · International, multicenter, randomized controlled trial (2004-2014).

Clinical question

In TBI with intracranial hypertension refractory to medical therapy, does decompressive craniectomy improve outcome compared with continued medical management?

Population: 408 patients aged 10-65 with TBI and intracranial pressure sustained above 25 mmHg despite tiered medical therapy.
Intervention: Decompressive craniectomy.
Comparator: Continued medical management (which could include barbiturates as a further tier).
Primary outcome: Extended Glasgow Outcome Scale (GOS-E) at 6 months.
Result: Craniectomy reduced mortality but increased the proportion of survivors in a vegetative state or with severe disability; rates of moderate disability and good recovery were similar between groups.

What the trial found

In refractory intracranial hypertension after TBI, decompressive craniectomy reduced 6-month mortality compared with continued medical management, but this came with an increased rate of vegetative state and severe disability among survivors — the rate of a good functional outcome was not clearly improved.

Current guideline position

Incorporated into the Brain Trauma Foundation 4th edition guideline's 2020 update on decompressive craniectomy, which recommends a large frontotemporoparietal craniectomy over a smaller one when the procedure is performed, without resolving the fundamental mortality-versus-disability trade-off this trial identified.

Clinical interpretation

RESCUEicp shows that decompressive craniectomy trades death for survival with a substantial chance of severe disability in many patients, rather than clearly improving overall outcome — this trade-off should be discussed explicitly in shared decision-making with family, rather than framed simply as 'craniectomy saves lives.'

Limitations

Long enrollment period (2004-2014) during which other aspects of TBI care evolved.
The mortality-benefit/disability-cost trade-off makes 'benefit' highly dependent on how outcomes are weighted, which is a value judgment as much as a clinical one.

High certainty

Clinical Context & Relevant Topics (1)

Disease Reference

Intracranial Hypertension & Cerebral Edema

Monro-Kellie doctrine, ICP waveforms (P2>P1, Lundberg A-waves), CPP targets (60–70 mmHg), herniation syndromes, and the 4-tier BTF management protocol.

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