Jim Wilson/The New York Times
Dr. Geoffrey T. Manley of San Francisco General Hospital held a cranial prosthesis to be fitted in a patient who suffered traumatic brain injury after falling from a window.
SAN FRANCISCO — Following the crash of Asiana Airlines Flight 214 here, one of the first victims rushed to San Francisco General Hospital and Trauma Center was a teenage girl, unconscious and gravely injured.
Her brain was quickly swelling, with nowhere to go but through the small opening at the base of her skull. Such an event, known as "herniation," crushes the brainstem and can be rapidly fatal.
Unable to reduce the swelling with medications, neurosurgeons decided to remove a large portion of the girl's skull. Once they had done so, her brain bulged through the opening. The operation relieved the pressure and saved her brain, but it was not enough to save her life. The girl, whose parents asked that she not be named to protect her privacy, died of the other injuries she sustained in the crash.
The operation, called decompressive craniectomy, is a remarkable but controversial feat, increasingly used to treat victims of head trauma who once might not have been saved. Malala Yousafzai, the 16-year-old Pakistani schoolgirl targeted by the Taliban, and Gabrielle Giffords, the former Democratic congresswoman from Arizona, each underwent decompressive craniectomies after being shot in the head. Senator Mark Kirk, Republican of Illinois, had the procedure a year ago after suffering a severe stroke. He returned to work in January.
The brutality of the procedure vividly illustrates the adage that surgery is barbarism with a purpose. But decompressive craniectomy also raises difficult questions regarding trade-offs between quantity and quality of life. Despite many successful recoveries, some remarkable, significant numbers of patients who receive the operation die, or are left profoundly disabled. Some are minimally responsive, with no cognitive function; others are severely disabled with impaired cognitive and motor function, but can communicate.
"All of us have seen miracles in people we've done this on, but the truth is we're also probably creating a larger population of patients who are significantly disabled," said Dr. Karin M. Muraszko, the chairwoman of the neurosurgery department at the University of Michigan.
It is difficult for surgeons to know which patients might recover and which are likely to be left barely functional. But the decision must be made under unyielding time pressure, in emergency rooms and intensive-care units and battlefield hospitals.
"We don't want to save lives if we're saving people to a state where they can't function," said Dr. S. Andrew Josephson, a neurologist and the chairman of the ethics committee at the University of California San Francisco Medical Center.
Skull removal to address cerebral swelling for traumatic brain injury and severe stroke first became widespread in the 1970s. Over the years, surgeons have refined the technique to the point where death is averted in about half the cases.
In the past decade, the operation, also known as hemicraniectomy, has grown more common for injured soldiers as military neurosurgeons have moved their operating theaters closer to the battlefield. "Hemicraniectomy is a game changer for how we handle those combat casualties," said Dr. Rocco A. Armonda, a neurosurgeon at Washington Hospital Center and Georgetown University Hospital.
Dr. Armonda, a retired colonel, was part of the first neurosurgery team on the battlefield in Iraq in 2003, performing what he calls "neuro-rescue." "Hemicraniectomy is now a standard element of that resuscitation," he said.
The surgery is no doubt macabre. Even experienced surgeons speak of it with a sense of wonder.
Once part of the skull is removed, it can remain off for several months, or however long it takes for the swelling to subside completely. The bone is stored in a freezer or sewn into the patient's abdomen for safekeeping. If the skull is too damaged to preserve, a prosthesis is fitted.
Yet the uncertainty of the eventual outcome continues to give physicians pause.
"I'd say our enthusiasm peaked around 2008 or 2009," said Dr. Geoffrey T. Manley, one of the neurosurgeons who performed the procedure on the injured airline passenger here last week. "Our exuberance was tempered by our complication rate, and we started looking at the procedure more critically."
Yet Dr. Manley said he did not regret performing the surgery on the young passenger: "I believe we have to give everybody a chance."
In 2011, The New England Journal of Medicine published results of a randomized trial that compared decompressive craniectomy with the best drug therapy in patients with traumatic brain injury and diffuse swelling who underwent the surgery within 72 hours of their injury. The study found that patients who had the surgery and survived were more severely disabled than those who received standard treatments. There was no difference in the mortality rate between the two groups.
"What we need to work out better with more trials and research is, 'Can we predict the patients who will do well with craniectomy and those who won't?'" said Dr. Jeffrey V. Rosenfeld, a neurosurgeon at the Alfred Hospital in Melbourne, Australia, and an author of the study. "We have a rough idea, but we still get surprises. We can do a beautiful craniectomy and a patient still ends up very disabled.
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