Decompressive Craniectomy in Diffuse Traumatic Brain Injury

In the patient with a severe traumatic brain injury (TBI), it is of the utmost importance to control intracranial hypertension, and to maintain cerebral prefusion.  There are several strategies to accomplish this, but a secondary therapy is a decompressive craniectomy. The New England Journal did a randomized trial on 155 adults with severe TBI and diffuse injury, looking at decompressive craniectomy versus best medical therapy.  On the one hand, the craniectomy had a shorter ICU length of stay, less overall procedures and less time of elevated intracranial hypertension (ICH).  While achievement of these results is important, other endpoints paint a different picture.  These include that the overall mortality did not change, and the GCS scores at 6 months (the so called extended Glascow Outcome Scale), were worse in the craniectomy group of patients. Unfortunately, this study reinforces why this procedure is so infrequently performed. N Engl J Med 2011; 364:1493-1502
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