Over the past three decades there has been considerable interest in the use of decompressive craniectomy in the management of neurological emergencies. An increasing number of observational cohort studies have described use of the procedure, most commonly following severe traumatic brain injury and ischemic stroke and more recently in the context of subarachnoid hemorrhage, intracranial infection and in certain inflammatory conditions. Many of these studies have demonstrated that surgical decompression can lower the intracranial pressure in the context of medically intractable intracranial hypertension and many investigators have emphasized the life saving nature of the surgical procedure. However, surgical intervention will not reverse the effects of the pathological condition that precipitated the clinical deterioration and for many years, the concern has been that many survivors will be left with severe disability and dependency. An outcome that patients and their families may find to be unacceptable.

These concerns prompted researchers to conduct several prospective, multicenter, randomized controlled trials, initially in the context of ischemic stroke and more recently in the context of severe traumatic brain injury. The results of these trials have provided good evidence on which to base clinical practice; however, they have in some ways made the clinical decision-making paradigm more difficult.
The trials have clearly demonstrated the survival advantage gained by surgical intervention however this has come at an almost direct translation into the number of dependent survivors.

These results would appear to question the ongoing use of the procedure however there remain a number of issues that require consideration. Firstly, there is little doubt that certain patients recover from a life threatening neurological crisis and go on to make a good functional recovery. Secondly, many patients learn to adapt to a level of disability that they might previously have thought to be unacceptable. Finally, the role of decompressive craniectomy in the context of other conditions such as subarachnoid haemorrhage has yet to be evaluated by way of formal clinical trials.

The aim of this Research Topic is to evaluate the evidence currently available for efficacy of the procedure in the various neurological emergencies. Authors are encouraged to submit original research papers related to decompressive specifically regarding key issues such as appropriate patient selection, surgical timing, clinical outcome and morbidity not only of the surgical decompression but also the reconstructive cranioplasty.

Keywords: Decompressive craniectomy, long term outcome

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