Polytrauma Considerations.

Decompressive craniectomy (DC) is essential in the neurosurgeon's armamentarium. For the patient with severe traumatic brain injury, DC may be performed early-at the time of emergent intervention for a mass lesion--or later, to address medically refractory raised intracranial pressure (ICP). Superimposed polytrauma complicates the calculus. Multidisciplinary engagement, with attention to resuscitation, is critical, given particular vulnerability to secondary insult. Timing of DC may not conform to traditional clinical paradigms. The physiologic effect of DC on the injured brain must be considered. The physical craniectomy defect may limit positioning for additional procedures and has implications for determination of brain death.