Decompressive craniectomy versus conservative treatment in refractory post-traumatic intracranial hypertension: systematic review and meta-analysis

Abstract

Introduction: Optimal management of severe traumatic brain injury remains controversial, particularly concerning the use of intracranial pressure monitoring and decompressive craniectomy.

Objective: To evaluate the effect of intracranial pressure monitoring and decompressive craniectomy on mortality and functional outcomes in patients with severe traumatic brain injury through a systematic review and meta-analysis of observational studies.

Methods: A systematic search was conducted in MEDLINE, Embase, Web of Science, CENTRAL, and Scopus from 2008 to 2024. Studies were eligible if they included ≥20 adult patients with severe traumatic brain injury and reported comparative outcomes for intracranial pressure monitoring vs. no monitoring or decompressive craniectomy vs. alternative management. Adjusted odds ratios (OR) or hazard ratios (HR) were extracted and converted to the log scale. Random-effects models were applied, and heterogeneity was assessed using I² statistics.

Results: Fourteen studies (n ≈ 53,000) met inclusion criteria. Intracranial pressure monitoring was associated with a nonsignificant reduction in in-hospital mortality (pooled OR 0.83; 95% CI 0.68–1.01; I² = 85%). No significant differences were observed for decompressive craniectomy in terms of 6-month mortality (OR 1.39; 95% CI 0.29–6.65) or functional independence (OR 0.88; 95% CI 0.71–1.09). Heterogeneity was high across comparisons.

Conclusions: Intracranial pressure monitoring may reduce early mortality in severe traumatic brain injury, though the evidence remains inconclusive due to heterogeneity and confounding. Current data do not support routine use of decompressive craniectomy to improve survival or function. High-quality trials and individual patient data meta-analyses are needed to guide practice.