The role of surgery in traumatic brain injury.

PURPOSE OF REVIEW: To identify the surgical indications in the treatment of posttraumatic intracranial hematomas and to evaluate the role of external decompression in severe posttraumatic intracranial hypertension. RECENT FINDINGS: An evidence-based review resulted recently in the publication of Guidelines for Surgical Management of Traumatic Brain Injury. Unfortunately all published surgical studies are at the level of simple options with no standards. We know that a number of patients harbouring small epidural/subdural hematomas can be managed conservatively when the lesions are less than 10 mm of thickness and with a midline shift of less than 5 mm. With exception of these few cases, the current practice is that a large number of patients with posttraumatic hematomas are operated either within 24 h from injury (with acute subdural hematomas as the prevailing lesion) or later (with parenchymal hematomas as the prevailing lesion). According to a recent European study, about one third of these patients are also decompressed. SUMMARY: A surgical approach is frequent in posttraumatic intracranial hematomas in spite of a low level of evidence. One of the surgical options either in association with hematoma evacuation or in isolation is the technique of bone flap decompression.