Gravid brain under pressure: a systematic review of decompressive craniectomy for severe traumatic brain injury in pregnancy

PURPOSE: To evaluate management strategies and outcomes of decompressive craniectomy (DC) in pregnant women with severe traumatic brain injury (TBI), specifically addressing the clinical dilemma of surgical timing and the 'simultaneous procedure' paradigm in the viable fetus. MATERIALS AND METHODS: A systematic review was conducted following PRISMA guidelines and registered with PROSPERO (CRD420251041759). Five major electronic databases were searched through 2025 for studies reporting DC outcomes in pregnancy. Data were stratified into pre-viable (<24 weeks) and viable (>24 weeks) cohorts to analyze trimester-specific management. Maternal functional recovery was assessed using the Glasgow Outcome Scale (GOS). RESULTS: Thirteen cases (mean age 25.2 years; all from motor vehicle accidents) were identified. Maternal survival was achieved in 9 of 13 patients. Among survivors, 6 of 9 achieved complete functional independence (GOS 5), while 3 of 9 remained severely disabled. For the viable cohort (n = 8), a simultaneous paradigm-performing cesarean delivery and DC in a single surgical sitting-was utilized in 6 of 8 cases. This simultaneous approach resulted in live births for all 8 neonates within the viable group. Total fetal/neonatal mortality was 2 of 13 cases, occurring exclusively in the pre-viable trimesters. Notably, intracranial pressure (ICP) monitoring was implemented in only 2 of 13 cases, identifying a significant gap in pregnancy-specific neuromonitoring. CONCLUSIONS: DC appears to be a beneficial intervention for gravid TBI, based on limited evidence showing favorable maternal survival and functional recovery. In the presence of a viable fetus, the high neonatal survival rate suggests that a 'simultaneous' surgical approach may be considered as the preferred management strategy in selected cases. This review advocates for the transition from reactive, case-by-case management to a prescriptive, multidisciplinary 'Neuro-Obstetric Trauma' protocol.