# Decompressive craniectomy: A primer for acute care practitioners

## TL;DR

This paper explains decompressive craniectomy, a life-saving but complex surgical procedure for severe brain swelling, and offers guidance for its ethical and practical use.

## Contribution

The paper provides a focused primer on secondary decompressive craniectomy and emphasizes ethical and multidisciplinary considerations.

## Key findings

- Decompressive craniectomy can prevent brain herniation and save lives in cases of severe intracranial hypertension.
- The procedure is not universally beneficial and can lead to severe disability or 'ruin deaths' if misapplied.
- The paper highlights the importance of ethical discussions and multidisciplinary collaboration in decision-making.

## Abstract

Decompressive craniectomy (DC) involves surgical removal of the skull that overlies swollen, imperiled, brain. This is done to combat intracranial hypertension and mitigate a vicious cycle of secondary brain injury. If, instead, this pathophysiology goes uninterrupted, it can mean brain herniation and brain stem death. As such, DC can save lives when all else fails. Regardless, it is no panacea and can also “ruin deaths,” and leave patients profoundly disabled. DC is not a new procedure; however, this therapy is increasingly noteworthy due to advances in neurocritical care, alongside ethical concerns. We cover the physiological rationale, the surgical basics, the trial data, and focus on secondary decompression (for refractory intracranial pressure (ICP)) rather than primary decompression (i.e. during evacuation of an intracranial mass). Given that DC should not be undertaken indiscriminately, we conclude by introducing ways in which to discuss DC with families and colleagues. Our goal is to provide a primer and common resource for the multidisciplinary team. We aim to increase not only knowledge but wisdom, prudence, collegiality, and family-focused care.