Following the crash of Asiana Airlines Flight 214 here, one of the first victims rushed to San Francisco General Hospital and Trauma Center was a teenage girl, unconscious and gravely injured.

Her brain was quickly swelling, with nowhere to go but through the small opening at the base of her skull. Such an event, known as “herniation,” crushes the brainstem and can be rapidly fatal.

Unable to reduce the swelling with medications, neurosurgeons decided to remove a large portion of the girl’s skull. Once they had done so, her brain bulged through the opening. The operation relieved the pressure and saved her brain, but it was not enough to save her life. The girl, whose parents asked that she not be named to protect her privacy, died of the other injuries she sustained in the crash.

The operation, called decompressive craniectomy, is a remarkable but controversial feat, increasingly used to treat victims of head trauma who once might not have been saved. Malala Yousafzai, the 16-year-old Pakistani schoolgirl targeted by the Taliban, and Gabrielle Giffords, the former Democratic congresswoman from Arizona, each underwent decompressive craniectomies after being shot in the head. Senator Mark Kirk, Republican of Illinois, had the procedure a year ago after suffering a severe stroke. He returned to work in January.

The brutality of the procedure vividly illustrates the adage that surgery is barbarism with a purpose. But decompressive craniectomy also raises difficult questions regarding trade-offs between quantity and quality of life. Despite many successful recoveries, some remarkable, significant numbers of patients who receive the operation die, or are left profoundly disabled. Some are minimally responsive, with no cognitive function; others are severely disabled with impaired cognitive and motor function, but can communicate.

“All of us have seen miracles in people we’ve done this on, but the truth is we’re also probably creating a larger population of patients who are significantly disabled,” said Dr. Karin M. Muraszko, the chairwoman of the neurosurgery department at the University of Michigan.

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