When To Perform Cranial Procedures

Perform only:

- After teleconsultation with neurosurgery
- Evacuation to a neurosurgeon is not available within approximately 5 hours of severe injury (see below)2,11
- Surgeon training and resources are adequate. See Appendix A (Training) and Appendix B (Resources).

Indications:

- Severe closed supratentorial brain injury with a presenting Glasgow Coma Scale (GCS) ≤ 8 AND:
  - Lateralizing cortical dysfunction such as unilateral dilated pupil or hemiparesis AND
  - Hemodynamic dysfunction indicative of impending herniation: hypertension, bradycardia, and respiratory variation (Cushing’s reflex) AND
  - Failure of maximal critical care management to stabilize the patient.2,10 This may manifest by the persistence of the above two findings despite maximal critical care interventions (Tier 1-3 interventions – see Traumatic Brain Injury and Neurosurgery in the Deployed Environment CPG), or the occurrence of a new or worsening lateralizing cortical finding (hemiparesis, rapidly expanding pupil) and/or further decline in GCS off of sedation