Mrs. Smith, a 24-year-old woman without prior past medical history, is admitted to the intensive care unit after a motor vehicle collision with ejection from the vehicle, during which she suffered a severe traumatic brain injury (TBI). The patient was intubated at the scene and remained intubated throughout the hospital course. The patient’s Glasgow Coma Scale after resuscitation was 6T (M4, E1, V1(T)). Serial computed tomography (CT) scans of the head revealed left frontal and temporal contusions in evolution with an increasing amount of pericontusional edema, and mass effect with midline shift of the septum pellucidum and compression of the mesencephalic cisterns (Figure 12.1). The patient was treated according to Brain Trauma Foundation guidelines with intracranial pressure (ICP) monitoring for elevated ICP. Initially the patient responded well to medical management with deep sedation, osmotherapy (mannitol and 23.4% hypertonic saline alternating resulting in a serum sodium level of 165 mmol/dL), and normothermia. Sedation holidays were omitted owing to ICPs spiking to 40 mmHg off sedation. On hospital day 5, the patient’s ICP continued to intermittently spike to 30 mmHg, and she no longer responded to osmotherapy. A repeat head CT scan revealed an interval increase in the midline shift and pericontusional cerebral edema. Given her age and active lifestyle before the injury, the family wanted “everything done.” You call the neurosurgeon and in collaboration with the neurosurgical team you walk into a meeting with the family to discuss secondary decompressive craniectomy (DC) vs. additional medical management with significant potential side effects (induced hypothermia, pentobarbital coma).