Any TBI that requires brain surgery can cause further damage to the brain if left untreated. Pressure on the brain is harmful because the skull is fixed and cannot expand; therefore, when the brain swells, it can be compressed up against the hard bony structure of the skull. This can lead to irreparable damage if this pressure is not relieved.

Initial treatment of a TBI consists of evaluating and maintaining airway, breathing, and circulation, any of which may be compromised by TBI. In severe cases, this may involve CPR resuscitation. Once the initial crisis has passed, treatment can focus on stabilizing the patient.

Surgery for TBI may be performed immediately, as in epidural hematomas and hemorrhage, or may be performed hours or days after the initial injury, as may be the case in subdural hematomas. One of the indications of the need for surgery is an increase in intracranial pressure.

Swelling in the brain is monitored and treated aggressively, as brain edema (swelling) can have dire consequences. If swelling increases intracranial pressure, or ICP, the brain will be compressed against the immovable skull, preventing blood from circulating adequately and causing brain damage. An ICP monitor can be inserted through the skull to provide a constant pressure reading, which can help to determine when surgery becomes necessary.

Craniotomy

A craniotomy is a surgical procedure to open the skull in order to access the brain for surgical repair. The following describes the general steps undertaken during a craniotomy:

• The patient is placed under general anesthesia
• The hair on the patient’s scalp is shaved (this may only involve a portion)
• The neurosurgeon incises through the scalp over the area where the brain injury is believed to be
• A hole is cut in the skull in order to access the brain
• The neurosurgeon repairs any damaged blood vessels, removes any blood clots, or removes foreign objects or bone fragments
• After the repair is done, the piece of bone that was removed is replaced and muscle and skin are stitched up
• Drains may be placed in the brain to allow drainage of any blood that collects

After surgery, the patient will be moved to an ICU bed. The patient may be on a ventilator and may remain on one for some time after surgery. When the patient is on a ventilator, physicians can keep the patient sedated to allow the brain to begin to heal. Additionally, having the patient on a ventilator allows physicians to carefully monitor levels of oxygen and carbon dioxide, and adjust these as needed. The patient’s ICP may be monitored closely after surgery to ensure that there are no complications, such as bleeding or swelling, that may cause the pressure to rise.

Possible complications of craniotomy include a reaction to anesthetic, bleeding, infection, permanent brain damage, brain swelling, stroke, and seizures.