Treatment is simple – immediate descent. Even if HACE starts at night descent must still be started immediately as any delay could prove to be fatal. This could be difficult because the person will be confused and staggering, and so will need people to assistthem. Descent should be to the last point when the person woke up and felt well. This is likely to be the place where the person slept two nights ago because cases of HACE generally only develop when a person with mild symptoms of AMS proceed upwards. This
should be at the least 500m. Once a lower place has been reached maximum rest is advised.
In March of 2011, investigators from Australia and several other countries published the results of the DECRA trial in the New England Journal of Medicine. This was a randomized trial comparing decompressive craniectomy to best medical therapy run between 2002 and 2010 to assess the optimal management of patients with medically refractory ICP following diffuse non-penetrating head injury. The study investigators found that decompressive craniectomy was associated with worse functional outcomes, as measured by a standard metric, than best medical care. There were no differences in deaths between groups. However, the results of the DECRA trial have been rejected or at least questioned by many practicing neurosurgeons, and an concurrently published editorial raises several study weaknesses. First, the threshold for defining increased ICP, and the time allowed before declaring ICP medically refractory, are not what many practicing physicians would consider increased or refractory. Second, out of almost 3500 potentially eligible patients, only 155 patients were enrolled, showing that the study cannot be generalized to all patients with severe non-penetrating brain injury. Lastly, despite being randomized, more patients in the craniectomy arm had fixed and dilated pupils than patients in the medical therapy arm, a potential confounding factor.