Decompressive craniectomy in head injury

PURPOSE OF REVIEW: To examine the evidence for the role of decompressive craniectomy in the management of traumatic brain injury. RECENT FINDINGS: This review highlights the importance of brain swelling and raised intra-cranial pressure (ICP) as of the one fundamental pathophysiological processes following traumatic brain injury. The role of protocol driven therapy in controlling raised intra-cranial pressure is discussed, with the staged application of medical interventions (including hypothermia and barbiturates). If these measures fail to control ICP, a surgical option - removal of the skull (decompressive craniectomy) can be considered. The evidence for this operation is reviewed in terms of data published in peer-reviewed journals since 1997. This evidence consists pre-dominantly of case series with no definitive Class I evidence and demonstrates a wide range of outcomes with no clear consensus regarding the indications for the operation. SUMMARY: Decompressive craniectomy is currently being applied in the management of traumatic brain injury with a wide range of outcomes reported in the literature. Current opinion on the role of this operation is therefore divided and it is now appropriate to proceed to prospective randomised studies.