Decompressive craniectomy: Surgical indications in developed versus developing countries

There continues to be a debate regarding the role of decompressive craniectomy in the management of neurological crises. There is now clear evidence from recent randomized controlled trials that surgical decompression reduces mortality. However, in most of the trials this reduction in mortality was almost directly translatable into an increase in the number of survivors with either severe disability or in a vegetative state. The implications that these findings have for the ongoing use of the procedure in high income countries are significant given the socioeconomic implications of converting death into survival with complete dependency. However, there are limitations when applying the results of these trials to patients who require surgical intervention in low and middle income countries. There are significant and evolving differences in terms of global epidemiological disease patterns, prehospital care, in-hospital diagnostic facilities and rehabilitation facilities. The implications of performing "life-saving" surgery differ depending on the resources available and the application of outcome data from well-funded trials and the impact that use of such surgical techniques has on health care resources will vary markedly.