Craniectomy for Traumatic Intracranial Hypertension

To the Editor: The RESCUEicp trial showed that among patients with traumatic intracranial hypertension, decompressive craniectomy, as compared with medical therapy, reduced mortality and increased rates of vegetative state, lower severe disability, and upper severe disability. Can the authors indicate whether patients in the surgical group had already undergone cranioplasty (replacement of the bone flap over the defect) when functional outcome was assessed at 6 months? Cranioplasty improves cerebral perfusion and reverses abnormal physiological features of cerebro-spinal fluid caused by decompressive craniectomy,^1,2 and in clinical practice it is often associated with improvement in neurologic status.³

If patients in the surgical group did not undergo cranioplasty before the outcome assessment at 6 months, the benefit of decompressive craniectomy may have been underestimated. Would the authors consider reporting the rate of cranioplasty at 6 months among patients in the surgical group? Also, would they consider performing a post hoc subgroup analysis to shed light on whether cranioplasty changes the effect of initial decompressive surgery on functional outcome at 6 months?