Decompressive craniectomy in traumatic brain injury rationale and practice

Despite the growing fund of knowledge on the pathophysiology of traumatic brain injury, the outcomes of severe TBI remain abysmal. While the necrotic and apoptotic cascades triggered off by the primary traumatic insult remain refractory to treatment, the secondary sequelae of increased intracranial pressure remain within the therapeutic realm. The benefit of evacuation of mass producing hematomas is beyond dispute. The management of brain edema however remains suboptimal despite the best medical management. The role of surgical evacuation of edema inducing contusions recalcitrant to osmotherapy is explored in this paper. The role of decompressive craniectomy in the control of refractory hypertension and the rationale and timing of the procedure are discussed.