A1 Refereed original research article in a scientific journal
The effectiveness of decompressive craniectomy size in traumatic brain injury; an international, observational, comparative effectiveness study
Authors: Vreeburg, Rick J.G.; Singh, Ranjit D.; Yue, John K.; van Dijck, Jeroen T.J.M.; den Boogert, Hugo F.; Posti, Jussi P.; Moojen, Wouter A.; Peul, Wilco C.; Maas, Andrew I.R.; de Ruiter, Godard C.W.; van Essen, Thomas A.; the CENTER-TBI participants and investigators
Publication year: 2026
Journal: Brain and Spine
Article number: 106019
Volume: 6
ISSN: 2772-5294
DOI: https://doi.org/10.1016/j.bas.2026.106019
Publication's open availability at the time of reporting: Open Access
Publication channel's open availability : Open Access publication channel
Web address : https://doi.org/10.1016/j.bas.2026.106019
Self-archived copy’s web address: https://research.utu.fi/converis/portal/detail/Publication/523078155
Self-archived copy's licence: CC BY
Self-archived copy's version: Publisher`s PDF
Introduction: Guidelines recommend large decompressive craniectomies (DC) in traumatic brain injury (TBI), yet the optimal size remains debated. Real-world practice often differs from guideline recommendations and generalizability of prior evidence to a broader TBI population is uncertain.
Research question: What is the comparative effectiveness of DC size on 12-month functional outcome in TBI?
Material and methods: We selected participants enrolled in the CENTER-TBI diagnosed with TBI who received a hemicraniectomy. Effect of DC size on functional outcome was evaluated with random-effects logistic regression, associating center case-mix adjusted DC sizes to GOSE. Center preference was quantified with the median odds ratio (MOR).
Results: Among 4509 patients enrolled in CENTER-TBI, 295 underwent a hemicraniectomy. DC size varied from 37 cm2 to 165cm2 (IQR 96 cm2-123cm2, ellipsoid calculation), with a two-times higher probability of receiving a 27 cm2 larger (IQR increase) DC for a similar patient in one center versus another random center (adjusted MOR for DC size 1·7). Only 4 patients received a DC ≥ 12 × 15 cm (cm) or 15 cm in diameter, while 0 patients received a DC ≤ 6 × 8 cm. Larger DC size was not associated with more favorable 12-month GOSE scores (aOR 0.73 for 27 cm2 increase in DC size, 95%CI 0.47-1.1).
Discussion and conclusion: DC size varied widely across European centers. Recommended DC sizes were rarely reached, as were very small DC sizes. Larger versus smaller DC was associated with similar outcomes, however heterogeneity in DC indication may have attenuated observable treatment effects. Neurosurgeons may continue to prefer larger over smaller decompressions.
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Funding information in the publication:
CENTER-TBI was supported by the European Union 7th Framework Programme for Research (grant no. 602150; A.I.R.M.), Hannelore Kohl Stiftung (Germany), and OneMind (United States). Patient travel and stipend expenses were supported by One Mind (Staglin Family and General Peter Chiarelli). Dr. Yue reported grants from the Neurosurgery Research and Education Foundation and Bagan Family Foundation Research Fellowship (award no. A139203, to the University of California, San Francisco) outside the submitted work. Dr. Maas reported grants from the European Union 7th Framework Programme for Research during the conduct of the study. Dr. Peul reported grants from European Committee Grant CENTER-TBI and grants from the Netherlands Brain Foundation during the conduct of the study. Dr. van Essen reported grants from the European Union 7th Framework Programme for Research or CENTER-TBI and the Niels Stensen Fellowship during the conduct of the study. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
