A survey of neurosurgical management and prognostication of traumatic brain injury following the RESCUEicp trial.

PURPOSE

Decompressive craniectomy remains controversial because of uncertainty regarding its benefit to patients; this study aimed to explore current practice following the RESCUEicp Trial, an important study in the evolving literature on decompressive craniectomies.

MATERIALS AND METHODS

Neurosurgeons in New Zealand, Australia, USA and Nepal were sent a survey consisting of two case scenarios and several multi-choice questions exploring their utilisation of decompressive craniectomy following the RESCUEicp Trial.

RESULTS

One in ten neurosurgeons (n=6, 10.3%) were no longer performing decompressive craniectomies for TBI following the RESCUEicp Trial and two fifths (n=23, 39.7%) were less enthusiastic. Most neurosurgeons would not operate in the face of severe disability (n=46, 79.3%) or vegetative state/death (n=57, 98.3%). Neurosurgeons tended give more optimistic prognoses than the CRASH prognostic model. Those who suggested more pessimistic prognoses and those who use decision support tools were less likely to advise decompressive surgery.

CONCLUSIONS

RESCUEicp has had a notable impact on neurosurgeons and their management of TBI. Although there remains no clear clinical consensus on the contraindications for decompressive craniectomy, most neurosurgeons would not operate if severe disability or vegetative state (the rates of which are increased by such surgery) seemed likely. Whilst unreliable, prognostic estimates still have an impact on clinical decision making and neurosurgical management. Wider use of decision support tools should be considered.