What surgical option may be used to decrease ICP when medical therapy fails?

• A. Decompressive craniectomy
• B. Craniotomy for hematoma evacuation
• C. Ventriculostomy
• D. Burr hole trephination

Answer: (A)

When intracranial pressure remains high despite maximal medical therapy, the skull’s rigid enclosure means the swollen brain has nowhere to expand, so pressure stays dangerously elevated. Decompressive craniectomy removes a large portion of the skull to create extra space for the swollen brain, allowing it to expand outward and thereby lower ICP and improve cerebral perfusion. This approach is used in select patients with malignant or diffuse cerebral edema after severe TBI when other medical measures fail, and it can be life-saving, though it comes with risks and often requires later cranioplasty to replace the removed bone.

Other options address different problems or are less definitive for refractory ICP. Evacuating a hematoma targets a specific mass lesion causing pressure, not diffuse swelling. Ventriculostomy drains CSF to reduce ICP but may not control ongoing global edema. Burr hole trephination provides only limited, temporary decompression and is not the standard solution for persistent intracranial hypertension.