Decompressive craniectomy in adults with moderate to severe traumatic brain injury: A systematic review and meta-analysis of randomised controlled trials

Objective The aim of this study was to evaluate the impact of decompressive craniectomy (DC) on functional outcomes, mortality, and quality of life in adults with moderate to severe traumatic brain injury (TBI). Design Systematic review and meta-analysis of randomised controlled trials (RCTs). Data sources We searched MEDLINE, Embase, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov from inception to August 1, 2026, for RCTs comparing DC with medical or surgical management in adults with moderate to severe TBI. Review methods Two reviewers independently extracted data and assessed risk of bias using the Cochrane Risk of Bias 2 tool. Certainty of evidence was evaluated with the Grading of Recommendations, Assessment, Development, and Evaluation framework. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using random-effect models. A trial sequential analysis was performed to assess the robustness of the findings. Results Eight RCTs including 1326 patients met the eligibility criteria. Seven trials, including 1296 patients, reported neurological outcomes. DC did not reduce the risk of unfavourable neurological outcome, defined as Glasgow Outcome Scale scores of 1–3 or Glasgow Outcome Scale–Extended scores of 1–4, at the longest available follow-up (3–12 months) (RR: 1.00, 95% CI: 0.83–1.20; I 2 = 68%; low certainty). Overall mortality did not differ significantly between groups (RR: 0.84, 95% CI: 0.59–1.19; I 2 = 65%; low certainty). Subgroup analyses suggested a possible mortality benefit when DC was performed for refractory intracranial hypertension or when compared with medical management, however, with no improvement in functional neurological outcome. Conclusions In adults with moderate to severe TBI, DC does not reduce unfavourable neurological outcomes or overall mortality. A possible mortality benefit in selected subgroups cannot be excluded, but this may occur at the cost of survival with severe disability. Decisions should be individualised based on each patient’s balance between survival and quality of life considerations.