Decompressive Craniectomy - Tough Trade-offs with Skull Removal

When a patient's brain is swelling, with nowhere to go but through the small opening at the base of her skull, herniation can crush the brainstem and can be rapidly fatal.  



In such cases, neurosurgeons sometimes remove a portion of the skull, so the brain can bulge through the opening.  The operation, called decompressive craniectomy, was performed on, among others, former U.S. Rep. Gabrielle Giffords and U.S. Sen. Mark Kirk.  (NY Times)



But decompressive craniectomy raises difficult questions regarding trade-offs between quantity and quality of life. Despite many successful recoveries, some remarkable, significant numbers of patients who receive the operation die, or are left profoundly disabled. Some are minimally responsive, with no cognitive function; others are severely disabled with impaired cognitive and motor function, but can communicate.



“All of us have seen miracles in people we’ve done this on, but the truth is we’re also probably creating a larger population of patients who are significantly disabled,” said Dr. Karin M. Muraszko, the chairwoman of the neurosurgery department at the University of Michigan.



It is difficult for surgeons to know which patients might recover and which are likely to be left barely functional. But the decision must be made under unyielding time pressure, in emergency rooms and intensive-care units and battlefield hospitals.  “We don’t want to save lives if we’re saving people to a state where they can’t function,” said Dr. S. Andrew Josephson, a neurologist and the chairman of the ethics committee at the University of California San Francisco Medical Center.