The Surgical Approach to the Management of Increased Intracranial Pressure After Traumatic Brain Injury

Increased intracranial pressure occurring after severe traumatic brain injury is a common and potentially devastating phenomenon. It has been clearly demonstrated that increased intracranial pressure that is refractory to initial medical measures is a poor prognostic sign. Current optimal management is based on a sequential, target-driven approach combining both medical and surgical treatment strategies. The surgical measures in current common practice include external ventricular drain insertion and decompressive craniectomy. There is evidence that both of these measures reduce intracranial pressure but the effect on outcome, particularly in the long term, is equivocal. Current Brain Trauma Foundation guidelines recommend timely evacuation of mass lesions and there is clear guidance regarding the indications for intracranial pressure monitoring; however, decompressive craniectomy is only cautiously recommended as a possible option for selected patients. In this review, we highlight the ongoing debate about the use of decompressive craniectomy to control intracranial pressure after traumatic brain injury; included is a summary of review of the most recent literature on the effect of decompressive craniectomy on increased intracranial pressure after traumatic brain injury and associated long-term outcome. The RESCUEicp and DECRA studies are discussed in detail. It is hoped that these 2 randomized controlled trials, which are evaluating the short- and longer-term outcomes of decompressive craniectomy, will provide conclusive evidence regarding the role of decompressive craniectomy in managing increased intracranial pressure after trauma.