Basic techniques and pitfalls in the surgical treatments of traumatic brain injuries

In cases with traumatic brain injury TBI , main purposes of surgery is to control intracranial pressure ICP , increased by both intracranial hematomas and edema. In this paper, basic techniques, variations and pitfalls of surgical treatments for TBI are presented. In acute epidural hematoma, the whole area of the hematoma should be involved in the craniotomy in order to remove the hematoma and to access the bleeding point. Craniotomy, consisting of a couple of bone windows across the dural sinus, is useful for dural tenting to obtain effective hemostasis in cases with dural sinus injuries. In acute subdural hematoma, large craniotomy is generally selected concerning subsequent decompressive craniectomy. In such craniotomy／craniectomy, injuries of dural sinuses and／or bridging veins should be carefully avoided, and the middle fossa should be effectively decompressed. In cases with urgent tentorial herniation, one burr-hole craniectomy or trephination is useful to achieve quick ICP reduction by partial hematoma evacuation. Since ICP reduction is only temporary only by such procedures, subsequent craniotomy is required. Contusion necrotomy is applied in cases with uncontrollable intracranial hypertension and／or clinical deterioration mainly due to contusional hematomas. In cases with severe TBI without significant intracranial hematomas, uni-or bilat-eral decompressive craniectomy may be required as the need arises from ICP monitoring, such as acute brain swelling. Surgical treatments for TBI are simple, and advanced technical skills may not be required. Since combined procedures are often required in various clinical settings, mastering basic surgical techniques is important as well as avoiding pitfalls.