Decompressive craniectomy (DC) is highly effective in relieving intracranial hypertension, however patient selection, intracranial pressure threshold, timing, and long-term functional outcomes, are all subject to controversy. Recently, recommendations were made to update the Brain Trauma Foundation guidelines in regards to the use of DC, based on the DECRA and RESCUEicp clinical trials. Neither the updated recommendations, nor the aforementioned trials, provide a method in incorporating individualized patient or surrogate decision maker preferences into decision making.
In this manuscript, we aim to redress the gap of not incorporating patient preferences in such value-laden decision making as in the case of DC for refractory post-traumatic intracranial hypertension. We propose a decision aid based on principles of Decision Theory, and specifically of Expected Utility Theory.
We show that a. Early secondary DC as studied in DECRA, and based on the 1-year outcome data, is associated with decreased expected utility for all possible preference rankings of outcomes; b. Recommending a late secondary DC vs. tier-3 medical therapy, as studied in RESCUEicp, should be informed by individualized patient preference rankings of outcomes as elicited via shared decision-making.
The 1-year outcomes from DECRA and RESCUE have served as the basis for updated guidelines. However, unaided interpretation of trial data may not be adequate for individualized decision making; we suggest that the latter can be significantly supported by decision aids such as the one described here and based on expected utility theory.

Copyright © 2021. Published by Elsevier Inc.