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Exploring the limits of survivability: rational indications for decompressive craniectomy and resection of cerebral contusions in adults.

In 1901, Kocher (25) astutely described the mechanism of action of decompressive craniectomy (DC): “If there is no CSF [cerebrospinal fluid] pressure, but brain pressure exists, then pressure relief must be achieved by opening the cranium. Relief of pressure by trephination is clearly indicated in all cases of brain pressure” and “There are two problems regarding the effectiveness of the measure: in the early stage, it is not easy to diagnose increased brain pressure; and in the late stage, the performance of the procedure alone will be of no further use.” In 1905, Cushing (12) published a case of DC in a patient with a brain tumor that was exerting a mass effect and causing intracranial hypertension. He went on to advocate the use of subtemporal DC in traumatic brain injury (TBI) (13). Since then, DC has been performed to relieve increased intracranial pressure (ICP) regardless of the etiology, including traumatic head injury, edema resulting from vasospasm secondary to subarachnoid hemorrhage, encephalitis, intracerebral hematoma, cerebral venous and dural sinus thrombosis, cerebellar infarction, and supratentorial strokes with resultant massive edema.