Unraveling key determinants of cranial decompression in isolated severe traumatic brain injury: insights from a national trauma database

Severe isolated traumatic brain injury (TBI) represents a complex and understudied population. Limited evidence exists on predictors of cranial decompression. This study aims to quantify the rate and identify factors associated with cranial decompression in severe isolated TBI using a large national database. Data from the 2019–2021 American College of Surgeons Trauma Quality Program was analyzed. Severe TBI was defined as a head Abbreviated Injury Scale (AIS) score ≥ 3. Demographics, vitals, comorbidities, and in-hospital complications were assessed using multivariable models to identify predictors of cranial decompression. A total of 303,766 adults with severe isolated TBI were included (mean age 59.8; 64.2% male; 75.0% white). Cranial decompression was performed in 13.5% (<i>n</i> = 41,045). Univariate analysis showed significant differences in demographics, mechanism of injury, ICU admission, CT findings, midline shift, cerebral monitoring, blood product use, and complications. Multivariable analysis revealed that males, younger age, falls as the mechanism of injury, higher GCS, ICU admission, CT findings, need for cerebral monitoring, presence of midline shift, thromboembolism prophylaxis, and requirement for blood product transfusions, were strong predictors of cranial decompression. This study provides valuable insights into the independent predictors for the need of cranial decompression in severe isolated TBI patients.