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What is the role of surgery in Traumatic Brain Injury?
The Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury (DECRA) clinical trial studied whether early decompressive craniectomy in patients with diffuse TBI and refractory ICP improved outcome.
DECRA showed that intervention decreased ICP and length of stay but was associated with more unfavorable outcomes.
What are the indications for surgery in epidural hematoma, acute subdural hematoma, and traumatic parenchymal lesions?
Epidural hematoma:
Volume >30 cm 3 regardless of the patient’s GCS score; coma (GCS score <9) with anisocoria; and signs of herniation and elevated ICP.
Subdural hematoma (SDH):
Acute, thickness >10 mm or a midline shift >5 mm regardless of the patient’s GCS score; all patients in coma (GCS score <9) with an SDH <10 mm thick and a midline shift <5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg.
Traumatic parenchymal lesions:
GCS scores of 6 to 8 with frontal or temporal contusions >20 cm 3 in volume with midline shift of at least 5 mm and/or cisternal compression on CT scan, and patients with any lesion >50 cm 3 in volume.
