In September of this year, the results of the Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) trial—an international multicenter randomized control trial (RCT)

J Thorac Dis 2016;8(11):E1505-E1507 jtd.amegroups. com In September of this year, the results of the Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) trial—an international multicenter randomized control trial (RCT) by Hutchinson and colleagues was reported in the New England Journal of Medicine (1). This study was organized as a collaboration between the University of Cambridge Departments of Neurosurgery/Neuro-intensive Care and the European Brain Injury Consortium, and enrolled 409 patients with medically refractory intracranial hypertension after traumatic brain injury (TBI) from 52 centers in 20 countries. Undoubtedly, it is one of the most encouraging clinical researches in the field of TBI in the past five years. The results showed that, in contrast to medical care, decompressive craniectomy (DC) in patients with TBI and refractory intracranial hypertension can not only immediately and constantly reduce intracranial pressure (ICP) but, even more importantly, result in a nearly 20 percent reduction in mortality at 6 and 12 months. Unfortunately, DC also caused higher rates of vegetative state, lower severe disability, and upper severe disability than medical care. Therefore, the long-awaited large study will again provoke some new thoughts about the role of DC in the management of refractory hypertension after TBI. DC is a straightforward procedure that for more than a century has been widely used to treat medically refractory intracranial hypertension of patients with severe TBI (2). Although a series of clinical studies demonstrated that DC is the most effective treatment in reducing ICP, the effect on outcome of severe TBI has yet to be clearly established (3,4). In the 4th edition guidelines of management of severe TBI that just emerged on September of this year, DC as a new topic was included for the first time (5). Base on the results of the Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury (DECRA) study which is the first and previously only RCT to compare DC to medical management in severe TBI patients (6), new guidelines present the level IIA recommendation for the debates surrounding the relative merits of these two treatment strategies (5). Although the DECRA study indicated that DC may be associated with a worse functional outcome in patients with diffuse TBI, the trial results have been widely criticized and some commentators stated that “no conclusions regarding management of the use of DC in patients with TBI should be drawn from this trial and clinical practice should not be changed on the basis of these results” (7,8). Therefore, the guidelines also show the expectation on the results of the RESCUEicp trial. As with the DECRA study, the latest RESCUEicp study was also well planned and of high quality RCT that compared DC with standard medical management. However, there were some inherent differences between these two studies. First, enrolled population. In contrast to the DECRA study, the patients enrolled in the RESCUEicp study had the wider range of Glasgow Coma Scale (GCS) scores (3–15 versus 3–8) and more commonly encountered types of patients with TBI (diffuse TBI or traumatic intracranial mass lesion versus diffuse TBI only). Second, timing of DC. In the RESCUEicp study, DC was undertaken as last-tier (life-saving) therapy when all medical therapy failed to reduce ICP, so more rigorous criteria about threshold for ICP (25 mmHg at least 1 hour) was set. While, In the DECRA study, DC was performed as a second-tier (early) therapy (neuro-protective) in Commentary