Intercontinental aeromedical transfers after decompressive craniectomy for severe traumatic brain injury: Systematic...

Traumatic brain injury (TBI) sustained abroad creates major clinical, logistical, and psychosocial challenges. Guidance on the timing and safety of aeromedical repatriation after cranial surgery remains inconsistent and largely unvalidated.

A 26-year-old foreign national presented unconscious after a hotel-balcony fall. Computed tomography showed a right frontotemporoparietal acute subdural haematoma with bilateral basifrontal contusions.

Following resuscitation, he underwent decompressive craniectomy and haematoma evacuation. After tracheostomy and neurocritical-care stabilization, multidisciplinary coordination was undertaken with his family, insurer, authorities, and receiving centre. Pre-flight assessment confirmed neurological and cardiopulmonary stability, secure airway and ventilation, and absence of pneumocephalus and pneumothorax. Three weeks after surgery, transfer by ventilator-equipped fixed-wing air ambulance was completed without reported complications.

A PRISMA 2020-aligned focused review was conducted on aeromedical transfers for patients after decompressive craniectomy for severe TBI. Of 737 records identified, 58 full-text reports were assessed, and twenty-six primary studies were included in the narrative synthesis; eight professional guidance, consensus, and regulatory documents were synthesized separately. Evidence was heterogeneous, comprising mainly retrospective military cohorts, surveys, mechanistic models, and case reports. Secondary physiological insults during transport-not elapsed postoperative time alone-were the recurring risk. Evidence relating intracranial-air volume to deterioration was inconsistent, and no universally safe volume or validated post-craniectomy interval was identified.

Long-distance repatriation after decompressive craniectomy may be feasible following structured multidisciplinary assessment, physiological optimisation, exclusion of trapped intracranial or thoracic air, and appropriate cabin-pressure and monitoring strategies. The proposed defer/conditional/ready pathway requires prospective validation.