Despite the controversy, debridement decompression is still widely used in neurocritical patients with malignant intracranial hypertension. However, in April 2011, an article entitled “Debridement flap decompression for diffuse traumatic brain damage” by Cooper DJ et al, an Australian scholar, was published in the New England Journal of Medicine, which has attracted the attention and heated discussion of scholars both nationally and internationally. This is the first randomized, controlled, prospective study to evaluate the efficacy of DEcompressive CRAniectomy (DECRA) for the treatment of heavy traumatic brain injury in adults with craniocerebral trauma. The study concluded that early treatment with bilateral frontotemporoparietal decompression was effective in reducing intracranial pressure and shortening the duration of treatment in the ICU for adults with severe diffuse traumatic brain damage, but the number of patients with poor prognosis was significantly higher. How can the results of this study be accurately interpreted? Do clinicians need to change the current treatment strategy for severe craniocerebral trauma? That is, when treating patients with malignant increased intracranial pressure after heavy craniocerebral trauma, should they abandon or insist on debulking decompression as a life-saving tool for heavy craniocerebral trauma? After the publication of the article, many scholars have interpreted the study and also expressed different views and opinions. Combining the literature and the author’s experience, the main controversial issues of the study are interpreted and discussed as follows. I. Indications: The patients enrolled in the DECRA study were those with diffuse post-injury brain swelling who did not require surgery for intracranial hemorrhage, and these 155 cases accounted for only 4.5% of the 3478 cases of heavy craniocerebral trauma in the same period. This indicates that the number of patients enrolled in this study is only a very limited number of patients with craniocerebral trauma. In clinical practice, more patients requiring surgical management and treatment with debridement decompression are those with different types of combined intracranial hemorrhage or/and cerebral edema and cerebral infarction. Compagnone et al. reported the results of a multicenter study of a group of 729 patients with occupying intradural lesions after craniocerebral trauma, in which one third of the patients were treated with debridement decompression along with hematoma removal. In contrast, 35% (1222 patients) of the excluded patients in the DECRA study had occupying hemorrhage. This indicates that the subjects in the DECRA study were not universal in clinically common craniocerebral trauma. In addition, one of the quantitative criteria for the selection of debulking decompression in DECRA was the definition of intractable intracranial pressure increase as intracranial pressure >20 mmHg, intermittent or sustained for more than 20 minutes during the 1-h period after first-line treatment after injury, whereas the control group also had only a mild increase in intracranial pressure. servadei noted that for such a short period of intracranial pressure of about 20 mmHg, most neurosurgeons and neuro Timmons SD et al. also concluded that the intracranial pressure in both groups in this study was only mildly elevated and therefore no conclusions should be drawn based on their results. Komotar et al. and Honeybul et al. both concluded that the patients in the DECRA study, did not presence of intractable intracranial hypertension. Balestreri et al. reported a correlation between an intracranial pressure threshold of 25 mmHg and patient prognosis, and Hutchinson et al. and Simard et al. concluded that treatment with debridement decompression may have a good outcome in those with intractable intracranial hypertension exceeding 25 mmHg after injury. Second, the timing of surgery and surgical modality: the ability to control intracranial pressure early and effectively plays a key role in restoring cerebral perfusion effectively and improving prognosis. the mean time to injury-randomized grouping in DECRA was 35.2h (23.3-52.8h), and the mean time to grouping after-operation mean time to injury-surgery was 2.3 h (1.4-3.8 h), and the mean injury-surgery interval was 37.5 h. Timmons et al. suggest that this interval is too long and that any possible differences in outcome between the two treatment groups are lost. In contrast, the ongoing European multicenter study (the Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure, RESCUEicp) has criteria of any time post-injury If intracranial pressure is >25 mmHg for 1 to 12 h in the post-injury period, then randomized groups are started for treatment with decompression of the flap or standardized medical therapy. Timmons SD et al. also questioned the surgical approach of DECRA, suggesting that the use of a modified bifrontal debridement decompression procedure in the study may have limited the efficacy of this procedure in reducing intracranial pressure.In their discussion, the DECRA investigators analyzed the possible reasons for the poor prognosis of the surgical group, considering the surgical approach used in the study, which may be one of the potential factors, and emphasized that the results of the study suggest that the procedure can only be used for patients with specific types of craniocerebral trauma and not necessarily for patients with other disorders or other types of craniocerebral trauma. Most scholars in China and abroad advocate that unilateral or bilateral, frontotemporal or frontotemporoparietal decompression should be selected by integrating the patient’s clinical, imaging, and monitoring findings, and emphasize the importance of dural dissection and reduction sutures. III. Differences in subgroups: There are numerous prognostic factors affecting heavy craniocerebral trauma, among which those with post-injury pupillary dilatation and loss of light reflex (except for optic nerve injury) are often indicative of brain herniation and secondary brainstem injury, and are predictors of poor patient prognosis. in DECRA, the proportion of those with bilateral pupillary dilatation and loss of light radiation was significantly higher in the surgical group than in the control group (27%:12%, p=0.04) , and there were also more people with loss of pupillary dilatation to light response on one side than in the control group (27%:12%). Although the authors of this study acknowledged this as a limitation of the study, they concluded that the other clinical indicators were comparable and that the surgical group did not show good outcomes after removal of the pupillary abnormality. Timmons et al. and Komotar et al., however, concluded that the presence of this difference was one of the factors affecting the efficacy of the two groups. Moreover, patients in the surgical group had more severe injuries (77%:67% of those with Marshall grade III in both groups) and lower preoperative GCS (mean score of 5:6). Although the analysis of these two factors alone did not have a significant impact on prognosis, the lower number of cases was a possible factor. However, a significant adverse effect on prognosis has been demonstrated in the CRASH study when these two factors are present together. Therefore the presence of the above mentioned grouping differences is one of the reasons for the poor prognosis in the surgical group. In addition Komotar et al, Marion, Honeybul et al and the author noted that 15 cases (19%) in the non-operative group in that study were treated with delayed (after 72h) debridement decompression as a life-saving measure after randomization grouping and another 4 cases (5%) were treated with decompression surgery within 72h of admission (conflicting with the study plan). In contrast, these 19 cases represented 23% of the non-operative group, and the outcome of their treatment was not separately accounted for. Although it cannot be speculated that the prognosis of these 19 cases would have been poor if they had not been treated with debridement decompression, the prognosis of 15 of them treated with life-saving DC should have been classified as poor at least if they had continued with nonoperative treatment, so that the prognosis of the two groups would have been different at 6 months after injury. Fourth, the limitations of monitoring indicators: DECRA study is the core content of the control of intracranial pressure, the determination of intracranial pressure and the assessment of the difference in efficacy between the two groups are based on the numerical changes of intracranial pressure, the lack of monitoring and assessment indicators of cerebral blood flow in this study, so in the discussion can only speculate that the main reason for the poor efficacy of the surgical group may be caused by the displacement of large pieces of brain tissue after decompression surgery, causing axonal injury . Although the use of intracranial pressure monitoring has been included in the guidelines for the management of craniocerebral trauma, and there are studies showing that effective control of intracranial pressure will result in good outcomes, there are also studies showing that severe hypoxia may occur in patients with TBI when ICP and CPP are normal. Decreased oxygen levels in the brain tissue are then a key factor in the poor prognosis of patients. Therefore, Romero and Hautefeuille et al. concluded that the monitoring and evaluation index of the DECRA study was too homogeneous and that there should be monitoring and evaluation of cerebral blood flow in order to make an accurate assessment of the efficacy of debulking decompression and to analyze the root cause of the differences in prognosis. Because of the lack of direct evidence, the authors of the DECRA study can only speculate that the displacement of large pieces of brain tissue after decompression causing axonal injury, the surgical procedure and postoperative complications may all be related to the poor prognosis of the surgical group. V. Non-strictness of double-blinding: The authors of the DECRA study acknowledged that the physicians in the surgical and non-surgical groups were not likely to be double-blind in their grouping of treatment modalities. komotar et al. also pointed out that this non-strict double-blind grouping of treatment could also affect the outcome of both groups. VI. Future research directions and clinical application prospects: As a long-established surgical method, debridement decompression expands the compensatory space by removing part of the skull and decompression suturing the dura mater, allowing the swollen brain tissue to be relieved of pressure through the outward expansion of the decompression window, thus creating the basic conditions for the recovery of neurological function. Recent experimental and clinical studies over the past decade or so have shown that early decompression of the flap can help control the increase in intracranial pressure after craniocerebral trauma at an early stage, thus creating conditions for interrupting the vicious cycle of cerebral edema and cerebral ischemia after the increase in intracranial pressure and thus aggravating the increase in intracranial pressure. Although there is uncertainty about the efficacy of debulking decompression in the treatment of heavy craniocerebral trauma, a large number of studies have shown that the early use of this procedure not only can effectively control intracranial hypertension, but also can achieve good results.