Refractory Intracranial Hypertension · Decompressive Craniectomy Indications

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] ICP threshold/duration + tiers exhausted + mass lesion
   ICP threshold and duration? Tier-1/2 therapy exhausted? Concomitant mass lesion needing evacuation? (Stepped therapy: tier 1 (analgesia-sedation, osmotherapy, CSF drainage, head elevation) → tier 2 (intensified osmotherapy, mild hyperventilation, neuromuscular blockade, hypothermia/barbiturates if needed).)
   • ICP persistently >25 mmHg (1–12 h) despite tier-1/2 therapy, refractory → Refractory ICP >25 → last-tier craniectomy
   • Early, diffuse injury, only moderate ICP >20 (>15 min), stepped therapy not yet exhausted → Early moderate ICP → craniectomy not recommended
   • Concomitant subdural/intracerebral hematoma needing evacuation with marked swelling → Evacuate mass + swelling → primary craniectomy
2. [End] Refractory ICP >25 → last-tier craniectomy
   Last-tier decompressive craniectomy (RESCUEicp): refractory ICP >25 unresponsive to tiers 1–2 → unilateral/bilateral frontotemporoparietal large craniectomy (12–15 cm) + expansile duraplasty; lowers mortality but raises the rate of vegetative state/severe disability, requires full informed consent and shared decision with family.
3. [End] Early moderate ICP → craniectomy not recommended
   Early, diffuse injury, ICP >20 but stepped therapy not exhausted (DECRA) → early (especially bifrontal) craniectomy not recommended (worse 6-month outcome); continue escalating medical therapy, reserve craniectomy as a last resort.
4. [End] Evacuate mass + swelling → primary craniectomy
   Primary craniectomy: after evacuating a mass (subdural/intracerebral hematoma), if brain swelling is marked and bone flap replacement is risky → primary craniectomy leaving the flap out (RESCUE-ASDH supports this for acute subdural). Assess timing of later cranioplasty.

Source guidelines & references

• Decompressive craniectomy for traumatic refractory intracranial hypertension (RESCUEicp NEJM 2016; DECRA NEJM 2011; BTF guideline)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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