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Background <p>Decompressive craniectomy (DC) is a last-resort treatment for severe traumatic brain injury (TBI) with refractory intracranial hypertension. Randomized controlled trials (RCTs)&#xa0;report&#xa0;mixed and sometimes conflicting results, leaving uncertainties regarding indications, timing, and long-term benefits. This study explored&#xa0;DC practices and outcomes in a contemporary Swedish setting contextualised&#xa0;in modern RCT evidence.</p> Methods <p>This retrospective multicentre study included 299 TBI patients who underwent DC between 2008 and 2022 across four Swedish neurosurgical centres. Clinical, radiological, surgical, and outcome data (6-months Glasgow Outcome Scale) were collected. Differences across centres and between adults/children were analysed.</p> Results <p>Annual DC rate remained stable over 15&#xa0;years, modestly declining from 3.6 to 3.2 per million inhabitants. Significant regional differences were observed in timing, indications, and techniques. Proportion of primary versus secondary DC and surgery timing remained unchanged, though bifrontal DC decreased. Patients were young (median age 37), predominantly male (76%), severely injured (GCS M &lt; 6), and 48% had unreactive pupils. Radiological improvement in mass effect post-DC (midline shift, basal cisterns) was significant (<i>p</i> &lt; 0.001). Re-operation for haemorrhage occurred in 10%,&#xa0;complementary decompression, surgical-site infection, and subdural hygroma each occurred in ~ 5%. At 6&#xa0;months, 60% had unfavourable outcomes and 11% were deceased. Higher age, lower GCS, comorbidities, impaired pupillary reactivity and obliterated basal cisterns independently predicted unfavourable outcome.</p> Conclusions <p>Landmark RCTs appear to have had limited influence on Swedish DC practice, which remains variable across centres. Real-world outcomes were more favourable than in recent RCTs and other acute brain injuries.</p>

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Decompressive craniectomy in traumatic brain injury: insights from a 15-year multicentre cohort in Sweden

  • 期刊论文

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  • 发表日期：

    2026年2月26日

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  • Francisco Leal-Méndez,
  • Klas Holmgren,
  • Alba Corell,
  • Tijana Nesic,
  • Peter Lindvall,
  • Bjartur Sæmundsson,
  • Robert Nilsson,
  • Per Enblad,
  • Fartein Velle,
  • Anders Lewén,
  • Richard Ågren,
  • Alexander Fletcher-Sandersjöö,
  • Teodor Svedung-Wettervik

摘要

Background

Decompressive craniectomy (DC) is a last-resort treatment for severe traumatic brain injury (TBI) with refractory intracranial hypertension. Randomized controlled trials (RCTs) report mixed and sometimes conflicting results, leaving uncertainties regarding indications, timing, and long-term benefits. This study explored DC practices and outcomes in a contemporary Swedish setting contextualised in modern RCT evidence.

Methods

This retrospective multicentre study included 299 TBI patients who underwent DC between 2008 and 2022 across four Swedish neurosurgical centres. Clinical, radiological, surgical, and outcome data (6-months Glasgow Outcome Scale) were collected. Differences across centres and between adults/children were analysed.

Results

Annual DC rate remained stable over 15 years, modestly declining from 3.6 to 3.2 per million inhabitants. Significant regional differences were observed in timing, indications, and techniques. Proportion of primary versus secondary DC and surgery timing remained unchanged, though bifrontal DC decreased. Patients were young (median age 37), predominantly male (76%), severely injured (GCS M < 6), and 48% had unreactive pupils. Radiological improvement in mass effect post-DC (midline shift, basal cisterns) was significant (p < 0.001). Re-operation for haemorrhage occurred in 10%, complementary decompression, surgical-site infection, and subdural hygroma each occurred in ~ 5%. At 6 months, 60% had unfavourable outcomes and 11% were deceased. Higher age, lower GCS, comorbidities, impaired pupillary reactivity and obliterated basal cisterns independently predicted unfavourable outcome.

Conclusions

Landmark RCTs appear to have had limited influence on Swedish DC practice, which remains variable across centres. Real-world outcomes were more favourable than in recent RCTs and other acute brain injuries.