Management of Severe Traumatic Brain Injury by Decompressive Craniectomy

Abstract

In Reply: We thank Drs. Whitfield and colleagues for their interest in our article (1) and for the description of their broad experience with therapeutic decompressive craniectomy. In contrast to our series, Whitfield et al.’s patients with exhausted conservative ICP management capacity achieved better overall 6-month outcomes after undergoing bifrontal decompressive craniectomies. We agree with the authors that decompressive craniectomy is a valuable therapeutic strategy in selected patients. The timing of the operative procedure nevertheless remains controversial. In our series, patients who underwent prophylactic surgery did significantly better 6 months after surgery than did patients with delayed decompression due to high ICP, strengthening the potential impact of prophylactic decompressive surgery in patients with head trauma. To identify the patients who are most likely to benefit from prophylactic or therapeutic surgery, randomized, controlled trials should be performed. The implementation of multimodal monitoring strategies in the management of the patient will improve the definition of strict inclusion criteria for therapeutic surgery. For the objective assessment of evidence of decompressive craniectomy, a combination of standard monitoring parameters such as ICP, mean arterial blood pressure, CPP, and novel monitoring strategies (e.g., regional cerebral blood flow [2], RAP, slow-wave activity) is most valuable. Peter Horn Elke Münch