Editorial: What is the role for decompressive craniectomy in severe traumatic brain injury? Re: Decompressive craniectomy: Surgical control of intracranial hypertension may improve outcome

摘要

The Brain Trauma Foundation Guidelines for the management of severe traumatic brain injury relegate decompressive craniectomy (DC) to the second tier of therapy for severe traumatic brain injury (TBI) along with barbiturates and induced hypothermia. Improved outcome following decompressive craniectomy is categorized as Class III evidence in the latest edition of these guidelines and it is mentioned as an option in the evidence-based guidelines for the surgical management of acute subdural haematoma. Bilateral DC has thus usually been used as a last resort therapy for patients with uncontrolled intracranial pressure (ICP) due to brain swelling. However, this may be too late if we are to prevent poor outcomes or death and achieve the best advantage of this operation. Unilateral DC is also frequently used after evacuation of an acute subdural haematoma where there is severe brain swelling and vascular engorgement. There have been many series of DC published. In two recent publications, good outcomes in 30% of patients were reported following DC in a retrospective mixed series of extra-axial haematomas and refractory intracranial hypertension and better than expected outcome was reported following mostly unilateral DC for malignant swelling due to severe head injury.