Balancing the short-term benefits and long-term outcomes of decompressive craniectomy for severe traumatic brain injury

ABSTRACT

Introduction: The role of decompressive craniectomy in the management of neurological emergencies remains controversial. There is evidence available that it can reduce intracranial pressure, but it will not reverse the effects of the pathology that precipitated the neurological crisis, so there has always been concern that any reduction in mortality will result in an increase in the number of survivors with severe disability.

Areas covered: The results of recent randomised controlled trials investigating the efficacy of the procedure are analyzed in order to determine the degree to which the short-term goals of reducing mortality and the long-term goals of a good functional outcome are achieved.

Expert opinion: Given the results of the trials, there needs to be a change in the clinical decision-making paradigm such that decompression is reserved for patients who develop intractable intracranial hypertension and who are thought unlikely to survive without surgical intervention. In these circumstances, a more patient-centered discussion is required regarding the possibility and acceptability or otherwise of survival with severely impaired neurocognitive function.

KEYWORDS:

• Decompressive craniectomy
• neurotrauma
• evidence-based medicine
• disability paradox
• clinical experience

Article Highlights

• The use of decompressive craniectomy remains controversial.

• There appears little doubt that surgical decompression achieves the short goal of reducing intracranial pressure.

• Surgical intervention will not reverse the effects of the pathology that precipitated the neurological crisis.

• Surgical intervention will increase the number of survivors with either severe disability or in a vegetative state.

• An ethical debate is required regarding the acceptability or otherwise of this outcome to the individual and society as a whole.

Declaration of Interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants, or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.