Decompressive Craniectomy

Abstract

Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies is retrospective, the recent publication of several randomized prospective studies prompts a reevaluation of the utility of DC. We review the literature concerning the use of DC in TBI, MCA infarction, and SAH and address the evidence regarding common questions pertaining to the timing of and laterality of the procedure. We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.

Newly Suggested Surgical Method of Decompressive Craniectomy for Patients With Middle Cerebral Artery Infarction

“…Appropriate sizing of the craniectomy is of utmost importance because a small craniectomy may cause transcraniectomy defect brain herniation and venous compression along the bony margin with consequent venous infarction and exacerbated edema. 13 Thus, decompressive craniectomy has generally been performed with removal of a large bone flap with a diameter of 12 cm (including the frontal, parietal, temporal bones, and parts of the occipital squama) with additional temporal bone removal so that the floor of the middle cerebral fossa could be explored. 4,9,14 This technique has been recommended and performed as a current "thought to be" standardized method.…”

Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases

“…21,59 Decompressive craniectomy, however, remains controversial. Its efficacy is currently being investigated with respect to survival and quality of life in multicenter, prospective, randomized trials in the setting of traumatic brain injury 22 and middle cerebral artery infarction.…”

Effect of cranioplasty on functional and neuro -psychological recovery after severe acquired brain injury: fact or fake? Considerations on a single case

“…Cranioplasty improved CBF velocities in all major intracranial arteries, not only on the side of the lesion adjacent to the cranioplasty, but also in distant regions, such as the contralateral hemisphere (Khrisnan et al, 2006). Thus, the neurological improvement after cranioplasty may be due to the increase in CBF velocities in all vessels, on both the lesional and the non-lesional side, resulting from elimination of the effects of atmospheric pressure on the brain (Schirmer et al, 2008). In the patient here described, intensive and multidisciplinary rehabilitation programs were initiated early and then continued uninterruptedly, even throughout the patient's limited period of impaired consciousness.…”