Decompressive craniectomy in neurocritical care

• Decompressive craniectomy (DC) significantly reduces the risk of death in malignant middle cerebral artery infarction (MCAI).
• DC does not reduce the risk of death in severe traumatic brain injury (TBI).
• The composite risk of death or dependence is not reduced in either MACI or TBI.
• Randomized controlled trials on TBI are uncommon and further trials are needed.

Recently, several randomized controlled trials (RCT) investigating the effectiveness of decompressive craniectomy in the context of neurocritical illnesses have been completed. Thus, a meta-analysis to update the current evidence regarding the effects of decompressive craniectomy is necessary. We searched PUBMED, EMBASE and the Cochrane Central Register of Controlled Trials. Other sources, including internet-based clinical trial registries and grey literature, were also searched. After searching the literature, two investigators independently performed literature screening, assessing the quality of the included trials and extracting the data. The outcome measures included the composite outcome of death or dependence and the risk of death. Ten RCT were included: seven RCT were on malignant middle cerebral artery infarction (MCAI) and three were on severe traumatic brain injury (TBI). Decompressive craniectomy significantly reduced the risk of death for patients suffering malignant MCAI (risk ratio [RR] 0.46, 95% confidence interval [CI]: 0.36–0.59, P < 0.00001) in comparison with no reduction in the risk of death for patients with severe TBI (RR: 0.83, 95% CI: 0.48–1.42, P = 0.49). However, there was no significant difference in the composite risk of death or dependence at the final follow-up between the decompressive craniectomy group and the conservative treatment group for either malignant MCAI or severe TBI. The present meta-analysis indicates that decompressive craniectomy can significantly reduce the risk of death for patients with malignant MCAI, although no evidence demonstrates that decompressive craniectomy is associated with a reduced risk of death or dependence for TBI patients.