Despite the growing fund of knowledge on the pathophysiology of traumatic brain injury, the outcomes of severe TBI remain abysmal. While the necrotic and apoptotic cascades triggered off by the primary traumatic insult remain refractory to treatment, the secondary sequelae of increased intracranial pressure remain within the therapeutic realm. The benefit of evacuation of mass producing hematomas is beyond dispute. The management of brain edema however remains suboptimal despite the best medical management. The role of surgical evacuation of edema inducing contusions recalcitrant to osmotherapy is explored in this paper. The role of decompressive craniectomy in the control of refractory hypertension and the rationale and timing of the procedure are discussed.

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The pathophysiology of malignant intracranial hypertension is a deleterious cycle of increased intracranial pressure, decreased tissue perfusion, declining intracellular energy production, increasing cellular edema, and subsequent increasing intracranial pressure. Decompressive craniectomy offers an effective treatment for intracranial hypertension that is refractory to standard medical treatment. There is no standardized technique suggested for durotomy and expansile duraplasty till date. We conducted this study on a model designed from locally available materials to objectively quantify the volume expansion achieved by the various durotomy and expansion duraplasty techniques. Amongst the more popularly used techniques for durotomy and duraplasty, the apparent volume expansion achieved appears to be maximum with a horse shoe shaped incision (43 ml) as opposed to a cruciate (30 ml) or a multipinnate (36 ml) incision. However, after correcting for the volume of the outpouchings, horse shoe shaped incision looses much of it's sheen (10 cm) lagging far behind the other two duraplasty techniques. Our study has proven the generally held view that there is not much to choose from between the cruciate and multipinnate durotomy techniques in performing expansile duraplasty. A horse shoe shaped durotomy on the other hand appears to be far less fruitful.

The discovery of neural stem cells has offered a glimmer of hope to those afflicted by neurodegenerative diseases or those bearing the brunt of neurological insult. Spinal cord injuries affect young adult males predominantly and there is often pressure on the medical community to ?do something?. The hype in the lay press on this modality has fostered in many, the hope that these cells can nurture neurological recovery. Presented below, is an overview of the current state of stem cell research and the impact of this and other newer modalities on the paradigms of spinal cord injury management.

Introduction Decompressive Craniectomy is an effective option in the management of intractable intracranial hypertension. Aim and objectives Neuronal conservation can be achieved by aggressive decompression (hemicraniectomy).Material and methods In this series 12 patients with a Glasgow Coma Scale score of 8 or <8 with increased intracranial pressure underwent decompressive hemicraniectomy.Results The outcomes were prospectively evaluated. Eight patients were victims of traumatic brain injury. There were two patients who had suffered malignant Middle Cerebral Artery Infarctions, one patient had a cerebral venous thrombosis and one, an intracerebral hematoma. Four patients in this cohort died, while fi ve had good outcomes. ConclusionThe rationale and role of this relatively easy but underutilised procedure are discussed.