Decompressive Craniectomy in Traumatic Brain Injury: A Review Article

An evaluation of the performance of medical helmets used in healthcare for the protection of vulnerable patients

Introduction

Medical helmets (MHs) are used by individuals with an increased vulnerability to falls and are essentially unregulated in the UK; therefore, their impact performance is unproven. This study investigated the performance of a selection of medical helmets available to clinicians using general techniques to determine their protective performance against impacts. Additionally, clinicians have stated that medical helmets need to consider focal vulnerabilities to impact (often a postsurgical site of a decompressive craniectomy); therefore, novel techniques were specifically employed for measuring the protection of a focal site.

Materials and Methods

A freefall drop test methodology was used to assess six medical helmets (MH1-6) and two sports helmets (SH1 and SH2). The headform was instrumented with six degrees of freedom instrumentation to quantify global kinematics metrics related to injury risk (peak linear acceleration (PLA), peak angular velocity (PAV), peak angular acceleration (PAA), head injury criterion (HIC), and brain injury criterion (BrIC)), and a thin-film contact pressure measurement system was used to quantify the contact area (above a threshold of 560 kPa) focal to the impact. Due to the advanced nature of these measurements, a novel biofidelic headform was used to more accurately represent local deformation. Additionally, impact performance was plotted against two proxy measures of comfort.

Results

The difference in performance between the worst and best helmets ranged from 90% to 2844%, showing a substantial variation. HIC, PLA, and PAA showed the largest range, whereas PAV showed the smallest range. Nonetheless, there was good agreement between each kinematic metric regarding the rank order of the medical helmets. The contact pressure was a consistent outlier. Each metric included at least one injury threshold, which MH4 and MH6 consistently exceeded (15/18 occasions).

Discussion

MH2 and MH3 were the only medical helmets comparable to sports helmets in terms of both comfort and performance. MH1 showed excellent performance metrics but exhibited possible discomfort, while MH4 was above average across both measurement categories. MH4 and MH6 were significantly deficient compared to the sample of helmets. These results highlight the need for standardisation.

Skip Island Craniotomy: A Technique for Managing Superior Sagittal Sinus Injury in Emergency Neurosurgery

Superior sagittal sinus (SSS) injury can be a life-threatening condition. It is rarely injured by means of penetrating and nonpenetrating traumatic brain injury (TBI). Injury to the SSS can be a surgical challenge and thus provides a conundrum to neurosurgeons on its management in an acute emergency setting. We present a series of two cases that were successfully treated by a novel skip island craniotomy technique after suffering a penetrating and nonpenetrating TBI-related SSS injury, respectively. Both patients had a short period of ITU stay before being managed on the neurosurgery ward and went on to have no neurological deficits. The operative wounds healed well, and overall cosmesis was unaffected. Postoperative computed tomography head scans with 3D reconstruction in bone window demonstrate the island-like pattern with interval burr holes.

Bifrontal Craniectomy: A High-Yield Surgical Training Tool

Bifrontal decompressive craniectomy (DC), which was once a popular technique for treating midline mass lesions, has seen a notable decline in its therapeutic use within modern neurosurgery. Despite its diminished clinical use, the procedure offers considerable value as an educational tool for surgical training. This study used a Thiel-embalmed cadaver to demonstrate the bifrontal DC procedure, including a Souttar incision, strategic (MacCarty, zygomatic, and apical) keyhole/burr hole placement, superior sagittal sinus suturing, left frontal lobe decortication, and microscopic visualization of the anterior cranial fossa. The procedure demonstrated educational value in three ways: first, wide anatomical exposure enables a detailed discussion of tissue handling. Second, an efficient training paradigm that allows multiple surgical techniques to be taught within a limited timeframe. Third, it offers risk management training focusing on superior sagittal sinus protection. While bifrontal DC has selective therapeutic applications, its potential as a teaching tool is undervalued. The procedure's wide exposure creates an ideal platform for surgical education, allowing residents to develop skills in a structured environment. We advocate its use in training programs by focusing on its educational benefits rather than its limited therapeutic role.

Single-centre real-life observational study on mortality and outcomes: decompressive craniectomy and brain death in traumatic brain injury, haemorrhage, and other cerebral diseases

BACKGROUND

Decompressive hemicraniectomy (DHC) is used after severe brain damages with elevated, refractory intracranial pressure (ICP). In a non age-restricted population, mortality rates and long-term outcomes following DHC are still unclear. This study's objectives were to examine both, as well as to identify predictors of unfavourable outcomes.

METHODS

We undertook a retrospective observational analysis of patients aged 18 years and older who underwent DHC at the University Hospital of Bonn between 2018 and 2020, due to traumatic brain injury (TBI), haemorrhage, tumours or infections. Patient outcomes were assessed by conducting telephone interviews, utilising questionnaires for modified Rankin Scale (mRS) and extended Glasgow Outcome scale (GOSE). We evaluated the health-related quality of life using the EuroQol (EQ-5D-5L) scale.

RESULTS

A total of 144 patients with a median age of 58.5 years (range: 18 to 85 years) were evaluated. The mortality rate was 67%, with patients passing away at a median of 6.0 days (IQR [1.9-37.6]) after DHC. Favourable outcomes, as assessed by the mRS and GOSE were observed in 10.4% and 6.3% of patients, respectively. Cox regression analysis revealed a 2.0% increase in the mortality risk for every year of age (HR = 1.017; 95% CI [1.01-1.03]; p = 0.004). Uni- and bilateral fixed pupils were associated with a 1.72 (95% CI [1.03-2.87]; p = 0.037) and 3.97 (95% CI [2.44-6.46]; p < 0.001) times higher mortality risk, respectively. ROC-analysis demonstrated that age and pupillary reactivity predicted 6-month mortality with an AUC of 0.77 (95% CI [0.69-0.84]). The only parameter significantly associated with a better quality of life was younger age.

CONCLUSIONS

Following DHC, mortality remains substantial, and favourable outcomes occur rarely. Particularly in elderly patients and in the presence of clinical signs of herniation, mortality rates are notably elevated. Hence, the indication for DHC should be set critically.

Decompressive Craniectomy: From Ancient Practices to Modern Neurosurgery

Decompressive craniectomy (DC) is a neurosurgical strategy that expels a parcel of the cranium to relieve pressure on a swollen or herniating brain. This review article explores the history of DC, from its ancient roots in trepanning to its contemporary applications. It then examines the mechanisms by which DC reduces intracranial pressure (ICP) and improves cerebral blood flow. The article highlights the efficacy of DC in treating patients with severe traumatic brain injury (TBI), stroke, and other conditions that cause increased ICP. However, it also acknowledges the potential complications of DC, such as infection and bleeding. The ethical considerations surrounding DC are explored in detail, particularly the challenging decision-making process for patients who are unable to give consent. A specific focus is given to the use of DC in pediatric patients, where the developing brain is especially vulnerable to pressure changes.

Early Decompression in Acute Spinal Cord Injury : Review and Update

Spinal cord injury (SCI) has a significant negative effect on the quality of life due to permanent neurologic damage and economic burden by continuous treatment and rehabilitation. However, determining the correct approach to ensure optimal clinical outcomes can be challenging and remains highly controversial. In particular, with the introduction of the concept of early decompression in brain pathology, the discussion of the timing of decompression in SCI has emerged. In addition to that, the concept of "time is spine" has been added recently, and the mortality and complications caused by SCI have been reduced by providing timely and professional treatment to patients. However, there are many difficulties in establishing international clinical guidelines for the timing of early decompression in SCI because policies for each country and medical institution differ according to the circumstances of medical infrastructure and economic conditions in the surgical treatment of SCI. Therefore, we aim to provide a current review of timing of early decompression in patient with SCI.

The Evaluation of Skin Turgor in Relation to Changes in Intracranial Pressure in Patients After Decompressive Hemicraniectomy

Introduction

Decompressive hemicraniectomies have been the mainstay of treating medically refractory elevated intracranial pressures (ICPs). Afterward, ICP continues to be monitored. However, the reliability of monitoring the ICP in a patient after craniectomy has been shown to be variable, at best. We propose the use of a durometer to investigate a temporal relationship between skin turgor and elevated ICP.

Methods

Patients were included via the following criteria: age >18 and unilateral decompressive craniectomy, with an external ventricular drain (EVD) in place. Patients were excluded if they were younger than 18, underwent bilateral decompressive craniectomy, or did not have an ICP monitor. Skin turgor over the skin flap was measured with a durometer over the center of the defect. ICPs were monitored using an EVD. The optic nerve sheath diameter (ONSD) was measured with ultrasound with the eye closed and Tegaderm (3M, Saint Paul, MN) covering the eyelid. The optic nerve was measured 3 mm behind the globe, and the diameter of the optic nerve at the widest point was recorded. The Neurological Pupil index (NPi) was recorded with a pupillometer.

Results

Fourteen patients were included, with over 100 data points for ICP, skin turgor, ONSD, and NPi. Five patients went on to have elevated ICP after decompressive hemicraniectomy. The correlation coefficient (R) for ONSD to ICP correlation was 0.62. The R for ICP to skin turgor was 0.31. The data shows that a skin turgor of >9 is related to increasing ICP within 24 hours, a skin turgor of 6-9 is a warning, and a skin turgor of <6 is normal.

Conclusion

A temporal relationship between skin turgor and ICP exists, which could be used to predict impending elevations in ICP sooner than an ICP monitor can determine. By using this in conjunction with traditional methods of evaluating these patients, we could sooner act on elevations in ICP and potentially improve outcomes.

Treatment Trends and Inpatient Mortality in Isolated Severe Traumatic Brain Injury Using the National Trauma Data Bank

OBJECTIVE

Severe traumatic brain injury remains a leading cause of morbidity and mortality. Despite recommendations from the Brain Trauma Foundation, there is wide variability in treatment paradigms for severe TBI. We aim to elucidate the variability of treatment, particularly neurosurgical procedures and how it affects mortality.

METHODS

Adult Patients (<65 years) with a severe isolated TBI who were treated at an ACS Level 1 trauma center were identified in the National Trauma Database for the years 2007 through 2016. ICD-9 procedure codes were used to identify primary treatment approaches: intracranial pressure monitoring and cranial surgery (craniotomy/craniectomy).

RESULTS

Among the 25,327 patients with severe isolated traumatic brain injury, 14.0% and 18.0% of total patients underwent intracranial pressure monitoring or cranial surgery, respectively. Intracranial pressure monitoring reduced the odds of mortality, OR 0.89 (0.81, 0.98), but not to the extent of cranial surgery, OR 0.71 (0.65, 0.77).

CONCLUSION

BTF guidelines recommend placement of intracranial pressure monitor for severe TBI, however only 14 % of patients with isolated, severe TBI underwent intracranial pressure monitoring from 2007 to 2016. Intracranial pressure monitoring and cranial surgery decreases the odds of inpatient mortality in patients with severe TBI.

Prediction of early mortality after primary decompressive craniectomy in patients with severe traumatic brain injury

Objectives

Traumatic brain injury (TBI) is a worldwide major health problem associated with a high rate of morbidity and mortality. Intracranial hypertension following TBI is the main but not the only cause of early mortality. Decompressive craniectomy (DC) is used to decrease the intracranial pressure (ICP) and prevent brain herniation following TBI; however, the clinical outcome after DC for patients with TBI generates continuous debate. Prediction of early mortality after DC will help in making the surgery decision.

The aim of this study is to predict early mortality after DC based on the initial clinical and radiological findings.

Methods

In this study, 104 patients with severe traumatic brain injury have been treated by decompressive craniectomy and were retrospectively analyzed. Patients were divided into two groups; group I involved 32 patients who died within 28 days while group II involved 72 patients who survived after 28 days. The relationship between initial Glasgow Coma Scale score (GCS), pupil size and reactivity, associated injuries, and radiological findings were analyzed as predictor factors for early mortality.

Results

A total of 104 patients with severe TBI have been treated by DC and were analyzed; the early mortality occurred in 32 patients, 30.77%. There is a significant difference between groups in gender, mean GCS, Marshall scale, presence of isochoric pupils, and lung injury.

After stratification, odds of early mortality increases with the lower GCS, higher Marshall scale, lung injury, and abdominal injury while male gender and the presence of isochoric pupils decrease the odds of mortality. After univariate regression, the significant impact of GCS disappears except for GCS-8 which decreases the odds of mortality in comparison to other GCS scores while higher Marshall scale, presence of isochoric pupils, and lung injury increase the odds of mortality, but most of these effects disappear after multiple regressions except for lung injury and isochoric pupils.

Conclusion

Prediction of early mortality after DC is multifactorial, but the odds of early mortality after decompressive craniectomy in severe traumatic brain injury are progressively increased with the lower GCS, higher Marshall scale, and the presence of lung or abdominal injury.

Decompressive Craniectomy for Traumatic Brain Injury: In-hospital Mortality-Associated Factors

Objective  Determine predictors of in-hospital mortality in patients with severe traumatic brain injury (TBI) who underwent decompressive craniectomy. Materials and Methods  This retrospective study reviewed consecutive patients who underwent a decompressive craniectomy between March 2017 and March 2020 at our institution, and analyzed clinical characteristics, brain tomographic images, surgical details and morbimortality associated with this procedure. Results  Thirty-three (30 unilateral and 3 bifrontal) decompressive craniectomies were performed, of which 27 patients were male (81.8%). The mean age was 52.18 years, the mean Glasgow coma scale (GCS) score at admission was 9, and 24 patients had anisocoria (72.7%). Falls were the principal cause of the trauma (51.5%), the mean anterior-posterior diameter (APD) of the bone flap in unilateral cases was 106.81 mm (standard deviation [SD] 20.42) and 16 patients (53.3%) underwent a right-sided hemicraniectomy. The temporal bone enlargement was done in 20 cases (66.7%), the mean time of surgery was 2 hours and 27 minutes, the skull flap was preserved in the subcutaneous layer in 29 cases (87.8%), the mean of blood loss was 636.36 mL,and in-hospital mortality was 12%. Univariate analysis found differences between the APD diameter (120.3 mm vs. 85.3 mm; p = 0.003) and the presence of midline shift > 5 mm ( p = 0.033). Conclusion  The size of the skull flap and the presence of midline shift > 5 mm were predictors of mortality. In the absence of intercranial pressure (ICP) monitoring, clinical and radiological criteria are mandatory to perform a decompressive craniectomy.

Protocol-Based Early Decompressive Craniectomy in a Resource-Constrained Environment: A Tertiary Care Hospital Experience

OBJECTIVES

Decompressive craniectomy (DC) is an emergency life-saving procedure used to treat refractory intracranial hypertension (RICH). The authors aim to analyze their experience with protocol-based early DC (<24 h) in RICH cases diagnosed based on clinical and radiological evidence, without preoperative intracranial pressure monitoring done over 10 years.

MATERIALS AND METHODS

This is a retrospective, observational study which includes 58 consecutive patients who underwent protocol-based early DC by the senior author at a single institution between 2007 and 2017. Background variables and outcome in the form of Glasgow Outcome Score-Extended (GOS-E) at 6 months and 1 year were analyzed.

RESULTS

Fourteen patients had traumatic brain injury (TBI), 17 had intracranial hemorrhage (ICH), 14 had malignant cerebral infarcts (MCI), and the reminder 13 patients had other causes. At 6 months, the mortality rate was 22.4%. Good recovery, moderate disability, and severe disability were seen in 13.8%, 17.2%, and 43.1% of patients, respectively. Two patients were in vegetative state. The cutoff for favorable/unfavorable outcome was defined as GOS-E 4-8/1-3. By this application, 63.8% of patients had favorable outcome at 6 months. The favorable outcome in patients of TBI, ICH, and MCI was 57.1%, 58.8%, and 85.7%, respectively.

CONCLUSIONS

DC helps in obtaining a favorable outcome in selected patients with a defined pathology. The diagnosis of RICH based on clinical and radiological parameters, and protocol-based early DC, is reasonably justified as the way forward for resource-constrained environments. The risk of vegetative state is small.

Comparative Radiographic Factors Predicting Functional Outcome After Decompressive Craniectomy in Severe Traumatic Brain Injury

OBJECTIVES

Decompressive craniectomy (DC) is a last-tier therapy in the treatment of raised intracranial pressure after traumatic brain injury (TBI). We report the association of comparative radiographic factors in predicting functional outcomes after DC in patients with severe TBI.

METHODS

A retrospective analysis of a prospectively maintained database of cases between 2015 and 2018 at an academic tertiary care hospital was carried out. Univariate and multivariable regression analyses were performed for an array of comparative radiographic variables (pre- and post-DC) in relationship to functional outcome according to Glasgow Outcome Scale Extended (GOSE) at 180 days. GOSE was further dichotomized into favorable (GOSE:5-8) and unfavorable (GOSE:0-4) functional outcomes. All associations were reported as odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Statistical analysis included a cohort of 43 patients with a median age of 30.5 years (range: 18-62 years). The median GOSE at 180 days was 7. Multivariable regression analysis after adjusting for confounding variables (age, sex, comorbidities, site of surgery and size of decompression) showed that comparative radiographic findings of midline shift (MLS) > 10 mm (OR 3.2 (95% CI 1.25-8.04); P = 0.01); external cerebral herniation (ECH) > 2.5 cm (OR 2.5 [95% CI 1.18-5.2]; P = 0.02); and effacement of basal cisterns (OR 3.9 [95%CI 1.1-13.9]; P = 0.03), were significant independent predictors of poor functional outcome at 180 days after DC for severe TBI. However, the presence of infarction (OR 2.7 [95%CI 0.43-17.2]; P = 0.28) and absence of gray-white matter differentiation (OR 0.18 [95%CI 0.03-1.2]; P = 0.07) did not reach statistical significance.

CONCLUSIONS

The comparative radiographic findings that include MLS > 10mm, ECH > 2.5cm, and effacement of basal cisterns are predictive of poor functional outcome in severe TBI.

Treatment of CSF leakage and infections of dural substitute in decompressive craniectomy using fascia lata implants and related anatomopathological findings

PURPOSE

Decompressive craniectomy (DC) is widely used to treat raised intracranial pressure (ICP) in cranial trauma and stroke. It is accompanied by numerous complications. The aim of our study is to assess the surgical treatment of infections related to the use of a dural substitute with concurrent CSF leakage performed at our institution.

MATERIAL AND METHODS

A retrospective analysis of a series of 72 patients who underwent DC between 2011 and 2017 was performed. Seven cases (9%) showed infection related to the use of xenograft (bovine pericardium) and coexisting CSF leakage. Epidural/subdural empyemas were observed in seven cases; three in conjunction with an intracerebral abscess. For reconstruction, free anterolateral thigh fascia lata flaps were used, based on the size of the defect.

RESULTS

After removal of the dural substitute and the implant of free fascia lata, infection and CSF leaks resolved in all. An anatomopathological examination of the implant at the later time of cranioplasty (CP) showed the tissue had become vascularized exhibiting integration with the native dura. No complications related to the harvesting of the fascia lata were observed.

CONCLUSIONS

Fascia lata is a validated source of autologous grafts; it is cost-free and would appear to be the biological material most similar to the dura mater. The implanted material appears to maintain a lasting vitality when covered over with a well-vascularized scalp, even after a period of months, achieving a successful suppression of infection. Subsequent skull reconstruction is performed safely and easily using artificial bone.

Repositioning of an anti-depressant drug, agomelatine as therapy for brain injury induced by craniotomy

Traumatic brain injury (TBI) leads to the disruption of blood-brain barrier integrity and therefore results in increased brain water content (brain edema). Brain edema is a significant factor for increased intracranial pressure (ICP), which ultimately causes functional disability and death. The decompressive craniotomy (DC) is a surgical procedure widely used for treating increased ICP following TBI. The life-saving craniotomy itself results in brain injury. The objective of this study is to investigate the effect of agomelatine against craniotomy induced brain injury. The craniotomy was performed by a variable speed micro-motor dental driller of 0.8 mm drill bit. The present study, in addition to blood-brain permeability, brain water content (edema) and histological examination of the brain, also estimated locomotor activity, oxidant, and antioxidant parameters. Results show that the craniotomy induced increase in the blood-brain barrier permeability, brain water content (edema), oxidative stress (lipid peroxide and nitric oxide) and impaired antioxidant mechanisms (superoxide dismutase, catalase, and reduced glutathione) in rats. The craniotomy was also found to increase neuronal cell death indicated by augmented chromatolysis and impaired locomotor activity. Administration of agomelatine after the craniotomy ameliorated histopathological, neurochemical and behavioral consequences of craniotomy. Thus agomelatine is effective against brain injury caused by craniotomy.

Factors associated with the development and outcome of hydrocephalus after decompressive craniectomy for traumatic brain injury

Posttraumatic hydrocephalus (PTH) is common in patients undergoing decompressive craniectomy (DC) for traumatic brain injury (TBI), but the incidence, mechanisms, and risk factors have not been fully elucidated. This study aimed to determine the incidence of and the factors associated with PTH. We retrospectively reviewed patients who underwent DC for TBI at our institute between January 2014 and December 2018. We identified and compared the demographic, clinical, and radiological data, and 12-month functional outcome (as assessed by the Glasgow Outcome Scale [GOS]) between patients who developed PTH and those who did not. Logistic regression analyses were performed to identify risk factors for PTH. Additionally, the influence of PTH on unfavorable functional outcome was analyzed. PTH developed in 18 (18.95%) of the 95 patients who survived at 1 month after DC. A multivariate analysis indicated that postoperative intraventricular hemorrhage (odds ratio [OR] 4.493, P = 0.020), postoperative subdural hygroma (OR 4.074, P = 0.021), and postoperative hypothermia treatment (OR 9.705, P = 0.010) were significantly associated with PTH. The 12-month functional outcome significantly differed between the patients who developed PTH and those who did not (P = 0.049). Patients who developed PTH had significantly poorer 12-month functional outcomes than those who did not (P = 0.049). Another multivariate analysis indicated that subdural hemorrhage (OR 6.814, P = 0.031) and the presence of at least one dilated pupil before DC (OR 8.202, P = 0.000) were significantly associated with unfavorable functional outcomes (GOS grades 1-3). Although the influence of PTH (OR 5.122, P = 0.056) was not statistically significant in the multivariate analysis, it had a great impact on unfavorable functional outcomes. PTH considerably affects functional outcomes at 12 months after DC for TBI. Furthermore, postoperative imaging findings such as intraventricular hemorrhage and subdural hygroma can predict the development of PTH; therefore, careful observation is required during the follow-up period.

Decompressive craniectomy for severe traumatic brain injury in children: analysis of long-term neuropsychological impairment and review of the literature

OBJECTIVE

The effectiveness of decompressive craniectomy (DC) in the context of neurocritical care in adult patients has been recently under debate. The aim of our study was to evaluate the impact of decompressive craniectomy in severe traumatic brain injury (TBI) in children, focusing on short and long-term neurological and neuropsychological outcomes.

METHODS

Retrospective review of the medical records of children admitted at a level I trauma center, between January 2012 and December 2015, submitted to DC due to severe TBI. Additionally, an extensive review of literature on this subject was carried out.

RESULTS

Sixteen patients underwent DC for TBI at our institution during the evaluated period. 62.5% were males and the mean age was 12 years. Road traffic accident (RTA) was the main mechanism of trauma (62.5%). Average Glasgow Coma Scale (GCS) at admission was 5.2, whereas 75% of the patients presented with pathological pupillary reaction. Initial computed tomography (CT) showed skull fractures in 62.5% and acute subdural hemorrhage (ASH) in 56.3% of the patients. The mean intracranial pressure (ICP) was 27.2 mmHg prior to surgery, and the mean time window between admission and DC was 36.3 h. Unilateral DC was performed in 68.8% of the cases. The average Glasgow Outcome Scale (GOS) at 6-month follow-up was 3.7, whereas 70% of the survivors presented good recovery (GOS 4-5). Abnormal pupillary reaction at hospital admission increased 3-fold the risk of long-term neuropsychological disturbances. Follow-up evaluation revealed cognitive abnormality in 55.6% of the patients. The overall mortality at 6-month follow-up was 37.5%.

CONCLUSION

The present study indicates towards a potential benefit of DC in children with severe TBI; nevertheless, our data demonstrated a high incidence of neuropsychological impairment in the long-term follow-up. Psychological and cognitive assessment should be computed in prognosis evaluation in future prospective studies.

The History of Decompressive Craniectomy in Traumatic Brain Injury

Decompressive craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.

Acute neurosurgical management of traumatic brain injury and spinal cord injury in French armed forces during deployment

This article aims to describe the French concept regarding combat casualty neurosurgical care from the theater of operations to a homeland hospital. French military neurosurgeons are not routinely deployed to all combat zones. As a consequence, general surgeons initially treat neurosurgical wounds. The principle of this medical support is based on damage control. It is aimed at controlling intracranial hypertension spikes when neuromonitoring is lacking in resource-limited settings. Neurosurgical damage control permits a medevac that is as safe as can be expected from a conflict zone to a homeland medical treatment facility. French military neurosurgeons can occasionally be deployed within an airborne team to treat a military casualty or to complete a neurosurgical procedure performed by a general surgeon in theaters of operation. All surgeons regardless of their specialty must know neurosurgical damage control. General surgeons must undergo the required training in order for them to perform this neurosurgical technique.