Complications of decompressive craniectomy for traumatic brain injury

Abstract

<jats:p>Decompressive craniectomy is widely used to treat intracranial hypertension following traumatic brain injury (TBI). Two randomized trials are currently underway to further evaluate the effectiveness of decompressive craniectomy for TBI. Complications of this procedure have major ramifications on the risk-benefit balance in decision-making during evaluation of potential surgical candidates. To further evaluate the complications of decompressive craniectomy, a review of the literature was performed following a detailed search of PubMed between 1980 and 2009. The author restricted her study to literature pertaining to decompressive craniectomy for patients with TBI. An understanding of the pathophysiological events that accompany removal of a large piece of skull bone provides a foundation for understanding many of the complications associated with decompressive craniectomy. The author determined that decompressive craniectomy is not a simple, straightforward operation without adverse effects. Rather, numerous complications may arise, and they do so in a sequential fashion at specific time points following surgical decompression. Expansion of contusions, new subdural and epidural hematomas contralateral to the decompressed hemisphere, and external cerebral herniation typify the early perioperative complications of decompressive craniectomy for TBI. Within the 1st week following decompression, CSF circulation derangements manifest commonly as subdural hygromas. Paradoxical herniation following lumbar puncture in the setting of a large skull defect is a rare, potentially fatal complication that can be prevented and treated if recognized early. During the later phases of recovery, patients may develop a new cognitive, neurological, or psychological deficit termed syndrome of the trephined. In the longer term, a persistent vegetative state is the most devastating of outcomes of decompressive craniectomy. The risk of complications following decompressive craniectomy is weighed against the life-threatening circumstances under which this surgery is performed. Ongoing trials will define whether this balance supports surgical decompression as a first-line treatment for TBI.</jats:p>

Importance of Early Cranioplasty in Reversing the “Syndrome of the Trephine/Motor Trephine Syndrome/Sinking Skin Flap Syndrome”

“…The conversion of the cranium from a ''closed box'' to an ''open box'' alters the barometric pressure, cerebrospinal fluid (CSF) flow and the cerebral blood flow (CBF). However, this alteration carries benefits as well as risks [1]. Numerous complications may arise as a result of the pathophysiological events that accompany removal of a large piece of skull bone, and these complications arise in a sequential fashion at specific time points following the surgical decompression.…”

“…Subsequently, there develop new cognitive, sensorimotor, neurological and psychological deficits which are incorporated in the syndrome complex called the sinking skin flap syndrome (SSFS), also called the syndrome of the trephined (ST), or the motor trephine syndrome (MTS). In the longer term, a persistent vegetative state is the most devastating of outcomes of decompressive craniectomy [1,2].…”

Bilateral Supratentorial Epidural Hematomas: a Rare Complication in Adolescent Spine Surgery

“…In contrast, spontaneous intracranial epidural hematoma has been infrequently reported in association with cranial decompression, 10) coagulopathy, 13) sphenoid sinusitis, 12) ruptured middle meningeal artery psudoaneurysm, 4) or cranial metastasis. 6) However, spontaneous intracranial epidural hematoma as a complication of spine surgery is extremely unusual, with only one such case described in an adolescent, 11) who underwent resection of a thoracic spine lesion and developed acute supratentorial epidural hematoma postoperatively.…”

Cerebral venous overdrainage: an under-recognized complication of cerebrospinal fluid diversion

“…81 In a study in cats Shapiro et al showed that when a portion of the skull is removed, the compliance (pressure volume index) of the brain increases and the CSF outflow resistance decreases; 78,79 therefore, according to the Davson formula above, 23 since CSF outflow resistance approaches 0, again ICP becomes dependent on cerebral venous pressure. 67 Moreover, dural open-ing after craniectomy further increases brain compliance and decreases CSF outflow resistance.…”

“…31 A well-known complication after craniectomy is ventriculomegaly. 81 In 2007 Waziri et al reported an 88% incidence of communicating hydrocephalus in their cohort of 17 patents who had undergone hemicraniectomy, half of whom required ventriculoperitoneal shunts. 90 The study excluded patients who had undergone hemicraniectomy for subarachnoid hemorrhage, intraventricular hemorrhage, or infection, that is, confounding variables that may have contributed independently to hydrocephalus.…”