title: Wartime decompressive craniectomy: technique and lessons learned.
abstract: OBJECTIVE
  Decompressive craniectomy (DC) with dural expansion is a life-saving neurosurgical procedure performed for recalcitrant intracranial hypertension due to trauma, stroke, and a multitude of other etiologies. Illustratively, we describe technique and lessons learned using DC for battlefield trauma.
  
  
  METHODS
  Neurosurgical operative logs from service (October 2007 to September 2009) in Afghanistan that detail DC cases for trauma were analyzed. Illustrative examples of frontotemporoparietal and bifrontal DC that depict battlefield experience performing these procedures are presented with attention drawn to the L.G. Kempe hemispherectomy incision, brainstem decompression techniques, and dural onlay substitutes.
  
  
  RESULTS
  Ninety craniotomies were performed for trauma over the time period analyzed. Of these, 28 (31%) were DCs. Of the 28 DCs, 24 (86%) were frontotemporoparietal DCs, 7 (25%) were bifrontal DCs, and 2 (7%) were suboccipital DCs. Decompressive craniectomies were performed for 19 penetrating head injuries (13 gunshot wounds and 6 explosions) and 9 severe closed head injuries (6 war-related explosions and 3 others).
  
  
  CONCLUSIONS
  Thirty-one percent of craniotomies performed for trauma were DCs. Battlefield neurosurgeons use DC to allow for safe transfer of neurologically ill patients to tertiary military hospitals, which can be located 8-18 hours from a war zone. The authors recommend the L.G. Kempe incision for blood supply preservation, large craniectomies to prevent brain strangulation over bone edges, minimal brain debridement, adequate brainstem decompression, and dural onlay substitutes for dural closure.
authors.affiliation: Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA. brian.ragel@gmail.com
authors.forename: Brian T
authors.initials: BT
authors.lastname: Ragel
authors.forename: Paul
authors.initials: P
authors.lastname: Klimo
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Martin
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Teff
authors.forename: Hans E
authors.initials: HE
authors.lastname: Bakken
authors.forename: Rocco A
authors.initials: RA
authors.lastname: Armonda
mesh_terms: D000293:Adolescent; D000328:Adult; D055826:Afghan Campaign 2001-; D000346:Afghanistan; D001930:Brain Injuries / Q000601:surgery*; D002675:Child, Preschool; D056424:Decompressive Craniectomy / Q000379:methods*; D004388:Dura Mater / Q000601:surgery; D013502:General Surgery / Q000379:methods; D038421:Hemispherectomy / Q000379:methods; D006801:Humans; D019586:Intracranial Hypertension / Q000601:surgery; D008887:Military Medicine / Q000379:methods; D019635:Neurosurgical Procedures / Q000379:methods; D013524:Surgical Flaps; D016896:Treatment Outcome; D014857:Warfare; D014948:Wounds, Gunshot / Q000601:surgery; D014950:Wounds, Penetrating / Q000601:surgery