Damage Control Neurosurgery

Damage control neurosurgery (DCNS) was developed to prevent secondary injuries from swelling and low blood

flow in patients with traumatic brain injury (TBI).  According to Rocco Armonda at the National Naval Medical 

Center, “If you can open the skull early enough to prevent secondary injuries like low blood flow, the chances

of recovery are better than ever.”  Survival rates with this technique have increased from 10% to about 50%,

and also increased the number of patients who are able to function independently afterward. 

DCNS works by removing a section of the patient’s skull to allow the brain to swell rather than putting pressure 

on the brainstem and also evacuate any intracranial hematomas.  Rather than relying on a single surgery, DCNS

follows up with micro-balloons and medications to ensure that blood flow is reaching the brain, and once 

swelling abates, the bone flap or a hard acrylic implant is inserted in a cranioplasty procedure.

For this to be effective, time is of the essence, and the initial surgery should be done no more than 60 minutes

after the patient arrives.   This rapid approach is what sets DCNS apart from standard neurosurgery procedures. 

 Fortunately, it is also a procedure that may be done in rural or military settings by a generalist when the

patient is far from a trauma center, with following care provided by a trauma team.

Below are images showing CTscans before and after a bilateral craniectomy.  As the brain was able to expand

afterward, the intercranial pressure has been reduced.  Images from Ruf, 2003.

Before craniotomy (Ruf, 2003)After craniotomy


In the early 1900’s, the concept of DCS had been created by Schroeder and Halstead, but the technology at the

time was not up to the task.  It was attempted again during World War II, and finally in 1978, a temporary 

packing method to prevent hepatic hemorrhage was found to be effective. 

The general principles of damage control surgery (DCS) were published in 1993, consisting of laparotomy, 

secondary resuscitation, and delayed definitive surgery (usually 24-72 hours later).  In 2003, a team of eight 

neurosurgeons and neurologists stationed near Fallujah decided to try this for traumatic brain injuries and 

developed the DCNS procedure. 

After being pioneered in the front lines of Iraq, this approach to caring for traumatic brain injuries is starting to 

make inroads in the United States.  This new technique is important, as 1.4 million Americans suffer such brain 

injuries each year.  Here, surgeons practice craniotomies on a cadaver (image from Rosenfeld, 2004).

 Here, surgeons practice craniotomies on a cadaver.


There is a five-stage approach for DCS: patient selection, DCS, restoration of the physiology in the ICU,

definitive surgery, and cranioplasty.

In some cases, dural expansion may also be needed, and pericranium, temporalis fascia or synthetic dura can

be used to do this.  Once the initial surgery is complete, care strategy is very similar to that given to stroke

patients, with micro-balloons and medications to increase blood flow, and approximately six weeks thereafter, 

a plate or bone flap is inserted and the wound closed.

Craniectomy vs. craniotomy?

These procedures are similar, but craniectomies remove part of the skull and craniotomies only use small holes or immediately replace the bone flap.



Coning or dilated pupils and a low GCS score may indicate that a craniotomy should be performed immediately,

even if other procedures are being done simultaneously.

Intracranial hematomas would be located with a head CT scan so that craniotomies can be done in the correct 


An intraparenchymal ICP monitor may be inserted by a neurosurgeon in the emergency room and used to 

monitor ICP in the surgery and ICU as well (or inserted by a general surgeon in a remote military hospital).  

Other means of reducing ICP include administering Mannitol and draining CSF fluid.

Focal brain oxygen tension is more accurate than mixed jugular valve oxygen saturation measurements.  This 

is monitored with probes within the cranium, so it is not used preoperatively, but can provide information on 

oxygen saturation during care in the ICU.

In the future, a test for inflammatory mediators may provide additional information about whether the brain is 

likely to have swelling.  The potential for therapeutic hypothermia in TBI patients is also being evaluated.   



I.K. Haitsma and A.I.R. Maas, Advanced monitoring in the intensive care unit: brain tissue oxygen tension. Curr. Opin. Crit. Care 8 (2002), pp. 115–120.

Hemphill, J. Claude, III, Smith, Wade S., Sonne, D. Christian, Morabito, Diane, Manley, Geoffrey T. Relationship between Brain Tissue Oxygen Tension and CT Perfusion: Feasibility and Initial Results Am J Neuroradiol 2005 26: 1095-1100.

Marius Keel, Ludwig Labler and Otmar  Trentz. “Damage Control” in Severely Injured Patients Why, When, and How? European Journal of Trauma 31:3, June 2005

Maeyane S. Moeng,  Jerome A. Loveland,  and Kenneth D. Boffard. Damage Control: Beyond the Limits of the Abdominal Cavity. A Review International TraumaCare Fall 2005, pp. 189-196.

Jeffrey Rosenfeld. Damage control neurosurgery.  Injury Volume 35, Issue 7, July 2004, Pages 655-660

Bettina Ruf, Matthias Heckmann, Ilona Schroth, Monika Hügens-Penzel, Irwin Reiss, Arndt Borkhardt , Ludwig Gortner  and Andreas Jödicke.  Early decompressive craniectomy and duraplasty for refractory intracranial hypertension in children: results of a pilot study. Critical Care 2003, 7:R133-R138