I do not intend to be pretentious, nor to belittle the much larger issues Robert Oppenheimer raised, but my title paraphrases him when he said, recalling the Bhaga-vad Gita, "I am become death ... the destroyer of worlds," referring to his role in the successful construction of the atomic bomb. This concept bears on one of the difficult questions neurosurgeons must ask when faced with the patient with a large middle cerebral artery (MCA) territory infarction and impending herniation. With medical treatment, death is rapid in up to 80% of patients. Decom-pressive craniectomy, however, significantly reduces this to perhaps 30%, but at what cost? Are we creating misery for our patients and their families? Neurosurgeons, patients and their families, not to mention society as a whole from the utilitarian perspective, would benefit from knowing the answer to this question in advance of embarking on surgery.
展开▼
