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The Importance of Major Extracranial Injuries and Decompressive Craniectomy for the Management of Severe Head Injuries

Meier, Ullrich; König, Alexander; Gräwe, Alexander


Neurosurgical therapy aims to minimize the secondary brain damage that occurs after severe head injury. This includes the evacuation of intracranial space-occupying bleeding, reduction of intracranial volumes, external ventricular drainage in hematocephalus, and conservative therapy to influence increased intracranial pressure (ICP) and a decreased oxygen partial pressure [p(ti)o2]. When conservative treatment fails, a decompressive craniectomy might be successful in lowering ICP. From September 1997 until September 2002, 559 patients with severe head injuries were operated on. Eighty patients (14%) were treated by means of a decompressive craniectomy. The prognosis after decompression depends on the clinical signs and symptoms on admission, the patient's age, and the existence of major extracranial injuries. The guidelines used at this institution for decompressive craniectomy after failure of conservative intervention and evacuation of space-occupying hematomas include patient age less than 50 years without multiple trauma, patient age less than 30 years in the presence of major extracranial injuries, severe brain swelling on a computed tomography scan, the exclusion of a primary brainstem lesion or injury, and intervention before irreversible brainstem damage. Secondarily, intervention is undertaken after monitoring ICP and p(ti)o2 for an interval up to 48 hours after the accident before irreversible brainstem damage or generalized brain damage has occurred.

In 1880, Bergmann described a decompressive craniectomy, and in 1908, Cushing published a case report about a subtemporal decompressive craniectomy for relief of intracranial pressure (ICP). There is still a controversy about the value of operative decompression after severe head injuries with traumatic brain edema. 1–4

The aim of neurosurgical therapy after severe head injuries is the minimization of the secondary brain damage. General principles of neurosurgical therapy are the evacuation of space-occupying hematomas, the reduction of intracranial volume, the drainage of hematocephalus, and conservative therapy focused on ICP, cerebral perfusion pressure, and brain tissue po2. In intractable intracranial hypertension, which is refractory to conservative interventions, a decompressive craniectomy is indicated in a few patients. Indications for decompressive craniectomy, course of disease, and prognostic criteria are analyzed and compared with the literature. 5–7

Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany

Address correspondence and reprint requests to Ullrich Meier, MD, PhD, Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straβe 7, D-12683 Berlin, Germany. E-mail:

© 2003 Lippincott Williams & Wilkins, Inc.