The prophylactic hemicraniectomy score: Predicting need for decompressive craniectomy after traumatic brain injury due to refractory intracranial hypertension

Background Decompressive craniectomy (DC) is performed in severe traumatic brain injury (sTBI) to treat medically refractory intracranial hypertension. We sought to identify factors present early in admission to predict at risk for treatment-refractory intracranial hypertension requiring DC.Methods Adults with sTBI at our facility from 2016 to 2023 were identified from the National Trauma Database local registry. Patients with DC within 24 h of admission were excluded. Measured primary outcome was DC. After univariable analysis, multivariable logistic regression was performed to identify predictive variables to develop a predictive score.Results 205 patients met inclusion criteria; 30 patients (14.6 %) underwent DC. Patients in the DC cohort were significantly younger (median = 29 years-old, interquartile range [IQR] = 22.0-45.3 versus39 years, IQR = 25.0-59.0; p = 0.021). Initial ICP was higher in the DC cohort (median = 20.3 mmHg, IQR = 13-31.6 versus 10.7 mmHg, IQR = 7.1-13.9; p  17.8 mmHg. Higher score (0-3) was associated with increased odds of DC in a stepwise fashion (OR = 9.11, 95CI = 3.5-23.7, p Conclusions The PH score can predict secondary DC using three variables: first-to-second CT head instability, presence of midline shift, and initial ICP over 17.8 mmHg. This may serve as a risk-stratification tool to identify patients at high risk for DC and with prospective external validation may inform on patients who would benefit from earlier DC.