Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.

No abstract

Age-related neurodegenerative diseases are a growing burden to society, and many are sporadic, meaning that the environment, diet and lifestyle play significant roles. Cerebrospinal fluid (CSF)-mediated clearing of brain waste products via perivascular pathways, named the glymphatic system, is receiving increasing interest, as it offers unexplored perspectives on understanding neurodegenerative diseases. The glymphatic system is involved in clearance of metabolic by-products such as amyloid-β from the brain, and its function is believed to lower the risk of developing some of the most common neurodegenerative diseases. Here, we present magnetic resonance imaging (MRI) data on the heart cycle’s control of CSF flow in humans which corroborates findings from animal studies. We also review the importance of sleep, diet, vascular health for glymphatic clearance and find that these factors are also known players in brain longevity.

Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions.