Inadequate decompressive craniectomy following a wartime traumatic brain injury-an illustrative case of why size matters

Traumatic brain injury has been called the "signature injury" of the wars in Iraq and Afghanistan, andthe management of severe and penetrating brain injury has evolved considerably based on the experiences of militaryneurosurgeons. Current guidelines recommend that decompressive hemicraniectomy be performed with large, frontotemporoparietal bone flaps, but practice patterns vary markedly. The following case is illustrative of potential clinicalcourses, complications, and efforts to salvage inadequately-sized decompressive craniectomies performed for combatrelated severe and penetrating brain injury. The authors follow this with a review of the current literature pertaining todecompressive craniectomy, and finally provide their recommendations for some of the technical nuances of performing decompressive hemicraniectomy after severe or penetrating brain injury.