The effectiveness of decompressive craniectomy size in traumatic brain injury; an international, observational, comparative effectiveness study

Rick J.G. Vreeburg; Ranjit D. Singh; John K. Yue; Jeroen T.J.M. van Dijck; Hugo F. den Boogert; Jussi P. Posti; Wouter A. Moojen; Wilco C. Peul; Andrew I.R. Maas; Godard C.W. de Ruiter; Thomas A. van Essen; Peter Ylén; et al.; CENTER-TBI participants and investigators

doi:10.1016/j.bas.2026.106019

The effectiveness of decompressive craniectomy size in traumatic brain injury; an international, observational, comparative effectiveness study

Rick J.G. Vreeburg^*
, Ranjit D. Singh
, John K. Yue
, Jeroen T.J.M. van Dijck
, Hugo F. den Boogert
, Jussi P. Posti
, Wouter A. Moojen
, Wilco C. Peul
, Andrew I.R. Maas
, Godard C.W. de Ruiter
, Thomas A. van Essen
, Peter Ylén
, et al.
, CENTER-TBI participants and investigators

^*Corresponding author for this work

Leiden University
University of California, San Francisco
University of Turku
University of Antwerp
Karolinska Institutet
University of Pecs
University of Oslo
University Hospital Northern Norway
Medical University of Vienna
University Hospital Nancy
Assistance Publique – Hôpitaux de Paris
Vita-Salute San Raffaele University
Radboud University Nijmegen
University of Szeged
ARTTIC Innovation GmbH
Innsbruck Medical University
NIHR Surgical Reconstruction and Microbiology Research Centre
AOU Città della Salute e della Scienza di Torino - Orthopedic and Trauma Center
University of Southern Denmark
Monash University
University of Trnava
Quesgen Systems Inc.
Umeå University
University Medical Center Hamburg-Eppendorf
University of Cambridge
University of Milan
Hospital of Cruces
Niguarda Hospital
San Gerardo Hospital
RWTH Aachen University

Research output: Contribution to journal › Article › Scientific › peer-review

2 Citations (Scopus)

Abstract

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.

Original language	English
Article number	106019
Journal	Brain and Spine
Volume	6
DOIs	https://doi.org/10.1016/j.bas.2026.106019
Publication status	Published - 2026
MoE publication type	A1 Journal article-refereed

Funding

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.

Keywords

CENTER-TBI
Decompressive craniectomy
Large
Size
Small
Traumatic brain injury

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10.1016/j.bas.2026.106019Licence: CC BY

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Vreeburg, R. J. G., Singh, R. D., Yue, J. K., van Dijck, J. T. J. M., den Boogert, H. F., Posti, J. P., Moojen, W. A., Peul, W. C., Maas, A. I. R., de Ruiter, G. C. W., van Essen, T. A., Ylén, P., et al., & CENTER-TBI participants and investigators (2026). The effectiveness of decompressive craniectomy size in traumatic brain injury; an international, observational, comparative effectiveness study. Brain and Spine, 6, Article 106019. https://doi.org/10.1016/j.bas.2026.106019

@article{5b8572be038b4e9b9339ed3a48caed7d,

title = "The effectiveness of decompressive craniectomy size in traumatic brain injury; an international, observational, comparative effectiveness study",

abstract = "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 {\texttimes} 15 cm (cm) or 15 cm in diameter, while 0 patients received a DC ≤ 6 {\texttimes} 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.",

keywords = "CENTER-TBI, Decompressive craniectomy, Large, Size, Small, Traumatic brain injury",

author = "Vreeburg, \{Rick J.G.\} and Singh, \{Ranjit D.\} and Yue, \{John K.\} and \{van Dijck\}, \{Jeroen T.J.M.\} and \{den Boogert\}, \{Hugo F.\} and Posti, \{Jussi P.\} and Moojen, \{Wouter A.\} and Peul, \{Wilco C.\} and Maas, \{Andrew I.R.\} and \{de Ruiter\}, \{Godard C.W.\} and \{van Essen\}, \{Thomas A.\} and Cecilia {\AA}kerlund and Krisztina Amrein and Nada Andelic and Lasse Andreassen and Audny Anke and Anna Antoni and G{\'e}rard Audibert and Philippe Azouvi and Azzolini, \{Maria Luisa\} and Ronald Bartels and P{\'a}l Barz{\'o} and Romuald Beauvais and Ronny Beer and Bellander, \{Bo Michael\} and Antonio Belli and Habib Benali and Maurizio Berardino and Luigi Beretta and Morten Blaabjerg and Peter Bragge and Alexandra Brazinova and Vibeke Brinck and Joanne Brooker and Camilla Brorsson and Andras Buki and Monika Bullinger and Manuel Cabeleira and Alessio Caccioppola and Emiliana Calappi and Calvi, \{Maria Rosa\} and Peter Cameron and Lozano, \{Guillermo Carbayo\} and Marco Carbonara and Simona Cavallo and Giorgio Chevallard and Arturo Chieregato and Giuseppe Citerio and Hans Clusmann and Peter Yl{\'e}n and \{et al.\} and \{CENTER-TBI participants and investigators\}",

note = "{\textcopyright} 2026 The Authors.",

year = "2026",

doi = "10.1016/j.bas.2026.106019",

language = "English",

volume = "6",

journal = "Brain and Spine",

issn = "2772-5294",

publisher = "Elsevier",

}

Vreeburg, RJG, Singh, RD, Yue, JK, van Dijck, JTJM, den Boogert, HF, Posti, JP, Moojen, WA, Peul, WC, Maas, AIR, de Ruiter, GCW, van Essen, TA, Ylén, P, et al. & CENTER-TBI participants and investigators 2026, 'The effectiveness of decompressive craniectomy size in traumatic brain injury; an international, observational, comparative effectiveness study', Brain and Spine, vol. 6, 106019. https://doi.org/10.1016/j.bas.2026.106019

TY - JOUR

T1 - The effectiveness of decompressive craniectomy size in traumatic brain injury; an international, observational, comparative effectiveness study

AU - Vreeburg, Rick J.G.

AU - Singh, Ranjit D.

AU - Yue, John K.

AU - van Dijck, Jeroen T.J.M.

AU - den Boogert, Hugo F.

AU - Posti, Jussi P.

AU - Moojen, Wouter A.

AU - Peul, Wilco C.

AU - Maas, Andrew I.R.

AU - de Ruiter, Godard C.W.

AU - van Essen, Thomas A.

AU - Åkerlund, Cecilia

AU - Amrein, Krisztina

AU - Andelic, Nada

AU - Andreassen, Lasse

AU - Anke, Audny

AU - Antoni, Anna

AU - Audibert, Gérard

AU - Azouvi, Philippe

AU - Azzolini, Maria Luisa

AU - Bartels, Ronald

AU - Barzó, Pál

AU - Beauvais, Romuald

AU - Beer, Ronny

AU - Bellander, Bo Michael

AU - Belli, Antonio

AU - Benali, Habib

AU - Berardino, Maurizio

AU - Beretta, Luigi

AU - Blaabjerg, Morten

AU - Bragge, Peter

AU - Brazinova, Alexandra

AU - Brinck, Vibeke

AU - Brooker, Joanne

AU - Brorsson, Camilla

AU - Buki, Andras

AU - Bullinger, Monika

AU - Cabeleira, Manuel

AU - Caccioppola, Alessio

AU - Calappi, Emiliana

AU - Calvi, Maria Rosa

AU - Cameron, Peter

AU - Lozano, Guillermo Carbayo

AU - Carbonara, Marco

AU - Cavallo, Simona

AU - Chevallard, Giorgio

AU - Chieregato, Arturo

AU - Citerio, Giuseppe

AU - Clusmann, Hans

AU - Ylén, Peter

AU - et al.

AU - CENTER-TBI participants and investigators

PY - 2026

Y1 - 2026

N2 - 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.

AB - 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.

KW - CENTER-TBI

KW - Decompressive craniectomy

KW - Large

KW - Size

KW - Small

KW - Traumatic brain injury

UR - https://www.scopus.com/pages/publications/105034932519

U2 - 10.1016/j.bas.2026.106019

DO - 10.1016/j.bas.2026.106019

M3 - Article

C2 - 42006920

AN - SCOPUS:105034932519

SN - 2772-5294

VL - 6

JO - Brain and Spine

JF - Brain and Spine

M1 - 106019

ER -

The effectiveness of decompressive craniectomy size in traumatic brain injury; an international, observational, comparative effectiveness study

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