The use of decompressive craniectomy for the management of severe head injuries

The aim of Neurosurgical care is to minimise the secondary brain damage that occurs after a severe head injury. This includes the evacuation of an intracranial space occupying haematoma, the reduction of intracranial volume, external ventricular drainage with hydrocephalus, and conservative therapy to reduce intracranial pressure (ICP) and to maintain tissue oxygen P(ti)O-2. When conservative treatment fails, a decompressive craniectomy might be successful in lowering ICP. From September 1997 until April 1999 we operated on 128 patients with severe head injuries. 19 patients (15%) were treated by means of a decompressive craniectomy. The prognosis after decompression depends on clinical signs and symptoms on admission, patients' age and the existence of major extracranial injuries. Our guidelines for decompressive craniectomy after failure of conservative intervention and evacuation of space occupying hematomas included: a patient's age below 50 years without multiple trauma or a patient's age below 30 years in the presence of major extracranial injuries; severe brain swelling on CT scan (primary brainstem injuries were excluded). In 8 patients conservative ITU treatment had failed.