Report on the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury

Peter J. Hutchinson, Tamara Tajsic, Angelos G. Kolias

University of Cambridge, Cambridge, UK

The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK on the 28th and the 29th September 2017.

In the last few years, two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published (DECRA and RESCUEicp), with their results generating  debate  amongst  clinicians  and  researchers  working  in  the  field of  TBI. Hence, it was felt necessary to provide guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus‐based approach. The meeting was organised under the auspices of the WFNS, AO Neuro, and the NIHR Global Health Research Group on Neurotrauma at the University of Cambridge.

Fifty delegates, known for their considerable experience in managing patients with TBI and notable contributions to TBI research, convened in Cambridge for a two-day meeting. A large and diverse group of experts from Africa, Asia, Australia/Oceania, Europe, North America, and South America reviewed and discussed existing evidence and ongoing trials aiming to produce a consensus statement.

On day one, we heard excellent talks from Franco Servadei (WFNS president) on the historical perspectives of DC, Marek Czosnyka (University of Cambridge, UK) on the physiological perspectives of intracranial pressure and Giuseppe Citerio (University of Milano Bicocca, Italy) on intensive care management of TBI and intracranial hypertension, before moving on to hear about the BEST-TRIP, DECRA and RESCUEicp trials from the trial CIs (Randall Chesnut, University of Washington, USA;  Jamie Cooper, Monash University, Australia; Peter Hutchinson, University of Cambridge, UK). A talk by Angelos Kolias (University of Cambridge, UK) on ongoing and proposed trials concluded the session. The contributors then split into 6 working groups to discuss specific consensus topics:

1. Primary DC for mass lesions; facilitated by Indira Devi (National Institute for Mental Health and Neurosciences, Bangalore, India) and Jeffrey Rosenfeld (Monash University, Australia).
2. Secondary DC for intracranial hypertension; facilitated by Ivan Timofeev (University of Cambridge, UK) and Jamie Ullman (Hofstra North Shore-LIJ School of Medicine, USA)
3. Surgical technique; facilitated by Tariq Khan (Northwest School of Medicine, Peshawar, Pakistan) and David Okonkwo (University of Pittsburgh, USA)
4. Peri-operative care in DC; facilitated by Nino Stoccheti (University of Milan, Italy) and David Menon (University of Cambridge, UK)
5. Cranial reconstruction following DC; facilitated by Corrado Iaccarino  (University of Parma, Italy) and Vicknes Waran (University of Malaya, Kuala Lumpur, Malaysia)
6. Decompressive craniectomy in low and middle income countries; facilitated by Anthony Figaji (University of Cape Town, South Africa) and Andrés Rubiano (MEDITECH Foundation, Neiva, Huila, Colombia)

Small group discussions continued into the second day of the meeting when each working group prepared and presented a list of proposed recommendations for each of the above topics. All delegates discussed the proposed recommendations before anonymous voting took place with the use of a real-time interactive voting system. This session was chaired by Alex Valadka, AANS president. In the final session, chaired by Shelly Timmons (Penn State University) and Randall Chesnut, the agreed consensus recommendations were drafted. 

All delegates contributed to a truly collaborative and inclusive process of discussing and agreeing recommendations for a complex and difficult clinical question. Additionally, particular attention was paid to the role of craniectomy in low and middle income countries, as there is a growing realisation that guidelines and recommendations need to address the management of patients in resource-limited settings, where the greatest burden of neurotrauma is. The consensus statement will be published later this year.