To the Editor: A NEW OBJECTIVE IN SIGHT The authors1 reviewed the high-quality results from both the DECRA and the RescueICP Trials in order to provide guidelines for the management of severe traumatic brain injury and intracranial hypertension, improving outcomes and survival. We agree with the authors1 on the necessity for new evidence that pins down the results from existing studies and fills important gaps in knowledge, which impact patient outcomes. In the DECRA Trial, published in 2011, the age median was 23 yr for the craniectomy group, and 24 yr for the standard treatment group. In this trial, researchers evaluated functional outcomes at 6 mo by GOSE, classifying patients as functionally independent if GOSE 5 or higher. 70% of patients in the craniectomy group had unfavorable outcomes, compared with 51% in the standard treatment group, which contradicted the study hypothesis.2 In the RescueICP 6-mo results, authors favor the decompressive craniectomy group, given that they had lesser mortality (26.9% vs 48.9%) and, according to them, better functional outcomes (42.9% vs 34.6).3 However, the cut point for favorable outcomes in this trial was a GOSE 4 or higher. For many researchers, including those involved in the DECRA Trial, a score of 4 corresponds to an unfavorable outcome, given that these patients are mostly dependent for daily activities. If good outcomes were defined as a GOSE 5 or higher, difference between groups would be much less pronounced (14.1% vs 12.8% of 389 evaluated patients). When reviewing outcomes by age depicted in the article appendix, decompressive craniectomy seems to favor patients under 40 yr (good outcomes in 51.4% vs 36.2% of patients with standard treatment), while patients over 40 had better outcomes in the standard treatment group (31.1% vs 22% with craniectomy). However, these results were not published in the final analysis because of the borderline statistical significance of the advantage of decompressive craniectomy (P = .025). Similarly, at 12 mo, the RescueICP Trial showed better outcomes with decompressive craniectomy. This group had lesser mortality (30.4% vs 52%) and better functional outcomes (45.4% vs 32.4%). Again, when we increase the cut point for favorable outcomes to GOSE 5, the differences between both groups are less noticeable (16.6% vs 13.6% of 373 evaluated patients). To guide treatment and avoid futile interventions, the neurosurgical team must have practical knowledge of patient prognosis stratified by individual characteristics, pathologic entity, physical exam, and imaging. The construction of a predictive score might include the sum of the database analysis for DECRA and RescueICP Trials, in a similar way to the analysis of IMPACT and CRASH Trials, which originated the current predictive scores.4 It should include variables such as age, comorbidities, associated trauma, GCS after reanimation, pupillary reaction, time of intracranial hypertension and time of low cerebral perfusion pressure.5-7 Imaging evaluation, including CT scoring such as Marshall, Rotterdam and Helsinki, can guide the surgeon according to severity of brain injury.8,9 The presence or absence of cerebral edema in 1 or all 4 lobes (or 8 if it is bilateral), Stockholm Score for evaluation of diffuse axonal injury on early MRI10 and early prognostic markers obtained from multimodal neuromonitoring including ICP, O2 tissular pressure, intracerebral temperature, cerebral blood flow and reactivity, pressure-volume curves, autoregulation, oxygen extraction, might provide useful data for a predictive score indicating the necessity for early or late neurosurgical intervention. This way we could avoid extending the lifespan of severely disabled patients or of those in vegetative state.11-13 We consider that is not only convenient to extend observation times to 24 mo as recommended by the guidelines, but with the parameters mentioned earlier a prognostic score could be constructed that constitutes a valuable tool in the process for decision making in a medical board (constituted by neurosurgeons, anesthesiologists, and intensivists). This way a sensible recommendation can be made to the family that takes into account the ethical implications of a decompressive craniectomy, based in a good chance for survival and good outcomes for the patient in an individualized manner. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.