Immediate Decompression for Traumatic Brain Injury: Definition & Procedure

Emergency Decompressive Craniectomy for Severe TBI

Immediate decompression surgically reduces life-threatening intracranial pressure (ICP) in acute traumatic brain injury.

Indications

• Refractory ICP >20-25 mmHg despite maximal medical therapy (sedation, osmotherapy, hyperventilation, CSF drainage).
• Clinical deterioration: unilateral fixed/dilated pupil, dropping GCS.
• Imaging: mass effect, midline shift >5mm, cisternal compression.

Surgical Techniques

Procedure	Description	Key Feature
Craniotomy	Bone flap removed, replaced after swelling subsides	Temporary; bone stored in freezer/abdomen
Craniectomy	Bone flap removed, not replaced immediately	Allows prolonged expansion; later cranioplasty
Hemicraniectomy	Large unilateral bone + dura removal	For malignant hemispheric infarction or severe unilateral TBI
Bifrontal craniectomy	Both frontal bones removed	For diffuse bilateral swelling

Goals

• Reduce ICP → improve cerebral perfusion pressure (CPP).
• Prevent herniation and secondary ischemic injury.
• Create space for brain expansion.

Risks & Considerations

• Hemorrhage, infection, hydrocephalus, syndrome of the trephined (sinking skin flap).
• Patient selection critical: age, GCS, pupil reactivity, comorbidities.
• DECRA, RESCUEicp trials: benefit in selected patients; not universal.

Decision by neurosurgeon + intensivist; time-sensitive.