A systematic review of mortality and long-term functional outcomes after decompressive craniectomy for acquired brain injury: The missing rehabilitation reporting

Davide Giannuzzi; Claudia Lombardo; Pierluigi Contaldi; Maria Caputo; Francesco Pambianco; Gianpaolo Ronconi; Francesco Signorelli; Francesco Doglietto; Augusto Fusco; Davide Giannuzzi; Claudia Lombardo; Pierluigi Contaldi; Maria Caputo; Francesco Pambianco; Gianpaolo Ronconi; Francesco Signorelli; Francesco Doglietto; Augusto Fusco

doi:10.3934/Neuroscience.2026023

AIMS Neuroscience

2026, Volume 13, Issue 3: 510-529. doi: 10.3934/Neuroscience.2026023

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Review

A systematic review of mortality and long-term functional outcomes after decompressive craniectomy for acquired brain injury: The missing rehabilitation reporting

1.
High-Intensity Neurorehabilitation, Department of Neuroscience, Sensory Organs and Thorax, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
2.
Department of Geriatrics and Orthopaedics, Catholic University of the Sacred Heart, Rome, Italy
3.
Department of Neurology, Carpi Hospital, 41012 Modena, Italy
4.
Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
5.
Department of Neuroscience, Catholic University of the Sacred Heart, Rome, Italy
6.
Physical and Rehabilitation Medicine, Department of Ageing, Orthopaedic and Rheumatological Sciences, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
7.
Neurosurgery, Department of Neuroscience, Sensory Organs and Thorax, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy

Received: 27 March 2026 Revised: 10 July 2026 Accepted: 24 July 2026 Published: 09 September 2026

Background
Decompressive craniectomy (DC) is a surgical procedure for refractory intracranial hypertension following severe acquired brain injury (sABI) and is an effective, life-saving treatment. However, there is significant controversy regarding its impact on long-term functional outcome. Furthermore, the role of postoperative rehabilitation in shaping recovery after DC has been largely overlooked in the literature.
Objectives
To systematically review randomized controlled trials (RCTs) evaluating the long-term functional outcomes of DC in patients with sABI, stratified by underlying etiology, with particular attention to the assessment tools employed, their alignment with the International Classification of Functioning, Disability and Health (ICF) framework, and the reporting of post-operative rehabilitation data.
Methods
We searched PubMed and Scopus for all RCTs related to DC published between 2000 and 2024. Eligible studies included adults (≥18 years) who underwent DC for acute brain injury and reported at least one functional outcome measure (GOS-E, mRS, GOS, or Barthel Index). Outcomes were dichotomized into favorable and unfavorable categories. A narrative summary was performed because of the substantial clinical and methodological heterogeneity.
Results
We included 16 RCTs (1803 participants) in our analysis. The etiologies included traumatic brain injury, intracerebral hemorrhage, acute subdural hematoma, and malignant cerebral infarction. DC was associated with lower overall mortality compared to those not receiving it (24% vs. 31%). However, in 8 RCTS, a higher proportion of patients with DC had unfavorable functional outcomes. All outcome scales mapped exclusively to the ICF domain of “Activities and Participation”, while any assessment of cognitive function, emotional well-being, social participation, or quality of life was reported. Rehabilitation was largely unmeasured rather than necessarily absent: Only one study reported any rehabilitation data, limited to the number of patients admitted to inpatient rehabilitation. Most RCTs reported outcomes at 6 months or before; only one RCT extended the follow-up period to 24 months.
Conclusions
DC is an effective, life-saving procedure that reduces mortality and has an etiology-dependent effect on functional outcomes. Available functional outcome measures do not adequately capture the multifaceted nature of recovery following severe brain injury. Crucially, the post-DC rehabilitation trajectory is not captured by current trials; this argues for the routine, prospective collection of rehabilitation data in future RCTs to determine the contribution of postoperative rehabilitation to long-term functional recovery rather than against the use of a life-saving procedure.
- decompressive craniectomy,
- outcome,
- functional outcome,
- rehabilitation scales,
- acquired brain injury
Citation: Davide Giannuzzi, Claudia Lombardo, Pierluigi Contaldi, Maria Caputo, Francesco Pambianco, Gianpaolo Ronconi, Francesco Signorelli, Francesco Doglietto, Augusto Fusco. A systematic review of mortality and long-term functional outcomes after decompressive craniectomy for acquired brain injury: The missing rehabilitation reporting[J]. AIMS Neuroscience, 2026, 13(3): 510-529. doi: 10.3934/Neuroscience.2026023

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Abstract

Background

Decompressive craniectomy (DC) is a surgical procedure for refractory intracranial hypertension following severe acquired brain injury (sABI) and is an effective, life-saving treatment. However, there is significant controversy regarding its impact on long-term functional outcome. Furthermore, the role of postoperative rehabilitation in shaping recovery after DC has been largely overlooked in the literature.

Objectives

To systematically review randomized controlled trials (RCTs) evaluating the long-term functional outcomes of DC in patients with sABI, stratified by underlying etiology, with particular attention to the assessment tools employed, their alignment with the International Classification of Functioning, Disability and Health (ICF) framework, and the reporting of post-operative rehabilitation data.

Methods

We searched PubMed and Scopus for all RCTs related to DC published between 2000 and 2024. Eligible studies included adults (≥18 years) who underwent DC for acute brain injury and reported at least one functional outcome measure (GOS-E, mRS, GOS, or Barthel Index). Outcomes were dichotomized into favorable and unfavorable categories. A narrative summary was performed because of the substantial clinical and methodological heterogeneity.

Results

We included 16 RCTs (1803 participants) in our analysis. The etiologies included traumatic brain injury, intracerebral hemorrhage, acute subdural hematoma, and malignant cerebral infarction. DC was associated with lower overall mortality compared to those not receiving it (24% vs. 31%). However, in 8 RCTS, a higher proportion of patients with DC had unfavorable functional outcomes. All outcome scales mapped exclusively to the ICF domain of “Activities and Participation”, while any assessment of cognitive function, emotional well-being, social participation, or quality of life was reported. Rehabilitation was largely unmeasured rather than necessarily absent: Only one study reported any rehabilitation data, limited to the number of patients admitted to inpatient rehabilitation. Most RCTs reported outcomes at 6 months or before; only one RCT extended the follow-up period to 24 months.

Conclusions

DC is an effective, life-saving procedure that reduces mortality and has an etiology-dependent effect on functional outcomes. Available functional outcome measures do not adequately capture the multifaceted nature of recovery following severe brain injury. Crucially, the post-DC rehabilitation trajectory is not captured by current trials; this argues for the routine, prospective collection of rehabilitation data in future RCTs to determine the contribution of postoperative rehabilitation to long-term functional recovery rather than against the use of a life-saving procedure.

Abbreviations

Decompressive Craniectomy

Control

intracerebral haemorrhage

RCT

Randomized Controlled Trials

ICF

International Classification of Functioning, Disability and Health

GOS-E

Glasgow Outcome Scale Extended

mRS

modified Rankin Scale

GOS

Glasgow Outcome Scale

mBI

modified Barthel index

Barthel Index

ICP

intracranial pressure

TBI

traumatic brain injury

GCS

Glasgow Coma Scale

RoB2

Risk of Bias 2

ASDH

acute subdural haematoma

LSCHI

large su-pratentorial cerebral haemorrhagic infarction

mMCAI

malignant middle cerebral artery infarction

mCAI

malignant cerebral artery infarction

yes

not described

Conflict of interest

The authors declare no conflict of interest.

Authors' contributions

Conceptualization, F.S., F.D. and A.F.; methodology, F.S., F.D. and A.F.; collect the information, C.L., P.C. and F.P.; writing-original draft preparation, C.L., M.C. and F.P.; writing-review and editing, D.G., P.C. and M.C.; visualization, G.R., F.D. and A.F.; supervision, G.R., F.D. and A.F. All authors have read and agreed to the published version of the manuscript.

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