Management of Severe Traumatic Brain Injury by Decompressive Craniectomy

The recent article by Münch et al. (3) described the use of unilateral decompressive craniectomy (and mass evacuation) in 49 patients with traumatic brain injury. All patients had unilateral mass lesions with midline shift. In 31 patients, decompressive craniectomy and mass evacuation were performed a median of 3.8 hours after injury. In 18 patients, surgery was performed after failed conservative therapy for intracranial hypertension (median interval after injury, 39.7 hr). Although a significant decrease in midline shift occurred after craniectomy, the outcomes in this series were disappointing, with 59% of patients having poor outcomes 6 months after surgery. The authors concluded that decompressive craniectomy did not demonstrate a beneficial effect on patient outcomes in comparison with the results in the Traumatic Coma Data Bank. We believe that the use of decompressive craniectomy to treat patients with head injuries requires further scrutiny, ideally in the context of a randomized, control trial. The distinction between a prophylactic and a therapeutic craniectomy must be borne in mind, however, in evaluating the effects of decompressive surgery (2).