Neurosurgical Treatment of Traumatic Brain Injury and the Role of Decompressive Hemicraniectomy

Traumatic brain injury (TBI) remains one of the leading causes of morbidity and mortality worldwide [1]. Severe injuries, defined by a Glasgow Coma Scale (GCS) score between 3 and 8, are often associated with space-occupying lesions and secondary processes such as edema and hematoma expansion. Because of the rigid nature of the dura mater and the skull, these processes may lead to an elevation of the intracranial pressure (ICP), which in turn results in a vicious cycle of reduced cerebral blood flow, ischemia, and further ICP elevation, potentially culminating in herniation [2]. It is therefore no surprise that neurosurgical techniques to evacuate hematomas and reduce elevated ICP were established millennia ago, with signs of skull trepanation, the earliest forerunner of modern craniotomies, found in skeletons dating back to the neolithic period [3]. Despite our better understanding of the heterogeneity and complexity of TBI in the last decades, neurosurgical intervention has remained the mainstay of its treatment, and procedures such as decompressive craniectomies (DCs) to reduce refractory ICP, initially reported by Kocher and Cushing over a century ago [4], are still performed today. Moreover, in the era of broadly available imaging and modern monitoring techniques, the utilization of cranial computed tomography (CT) scans and ICP monitoring devices has led to a faster and more accurate diagnosis of cranial pathologies following TBI, permitting swift and precise surgeries. In this chapter, such cranial injuries and their state-of-the-art neurosurgical treatment will be described.