Decompressive Craniectomy Following Traumatic Brain Injury; Does International Practice Align with Evidence? Harmonised, Multi-Centre Cohort Studies in Europe, the United Kingdom and Australia

Background: Clinical practice guidelines recommend both for and against use of decompressive craniectomy (DC) for treatment of intracranial hypertension following traumatic brain injury (TBI). The contemporary use of DC internationally, and the alignment of practice, evidence, and clinical practice guidelines, are unknown. Methods: We analysed the harmonised CENTER-TBI and OzENTER-TBI Core study datasets, which include patients of any age with TBI of any severity admitted to participating ICUs in Europe, the UK and Australia between 2015 and 2017. Patients were compared between different regions and by injury characteristics. Outcomes of interest were treatment with DC, and alignment with evidence and the Brain Trauma Foundation guidelines. Findings: Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13·7%): in 64/1422 (4·5%) patients with diffuse TBI, and 195/640 (30·5%) patients with traumatic mass lesions. Secondary DC (used for treatment of measured intracranial hypertension) was used infrequently in patients whose characteristics matched the enrolment criteria of the two randomised clinical trials informing the guidelines: in 11/124 (8·9%) of those matching DECRA eligibility, and in 30/224 (13·4%) of those matching RESCUEicp eligibility. Of the patients who underwent DC 258/320 (80·6%) were ineligible for either trial: 149/320 (46·6%) underwent primary DC, 62/320 (19·4%) were outside the trials’ age criteria, and 126/320 (39·4%) did not develop intracranial hypertension refractory to medical therapies prior to DC. Interpretation: Decompressive craniectomy remains in widespread use following TBI. Secondary DC was used infrequently in patients in whom it has been shown to be potentially harmful, indicating satisfactory alignment between evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefitted from DC remains unknown.  Funding: European Commission 7th Framework programme, Australian National Health and Medical Research Council, and Victorian Transport Accident Commission. Declaration of Interest: AIRM declares consulting fees from PresSura Neuro, Integra Life Sciences, and NeuroTrauma Sciences. DJC is an Australian NHMRC Practitioner Fellow and reports grants from the NHMRC and consulting fees to Monash University from PresSura Neuro; additionally, he is the Chief Investigator for the DECRA trial. All other authors declare no competing interests. Ethical Approval: Human research ethics approvals were granted with waivers of consent by the ethics committees of all individual participating hospitals, and additionally of Monash University for OzENTER.