Decompressive Craniectomy in Severe Traumatic Brain Injury: The Intensivist’s Point of View

Abstract

Introduction: Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical–surgical consultation.

Critical Care Experience With Clinical Cerebral Autoregulation Testing in Adults With Traumatic Brain Injury

“…We observed a temporal association between cerebral autoregulation results and decompressive craniectomy/external ventricular drain placement. At our institution, decompressive craniectomy (primary or secondary) [ 18 ] is typically performed for patients with intracranial hypertension, and external ventricular drains are used for intermittent cerebrospinal fluid drainage (also known as "burping" of cerebrospinal fluid). Kolias et al [ 19 ] demonstrated in a case series that decompressive craniectomy after TBI led to a reduction in ICP and improved CBF.…”

Decompressive Craniectomy at the National Hospital of Niamey: Prospective Study of the Epidemioclinical Profil, Indications, Surgical Techniques, and Results in a Context of Limited Resources

“…The rst known written account of this decompressive surgery was provided by Annandale in 1894, but Thomas Kocher rst used it in 1901 to treat RICH. [2,14,16,47] In 1905, Harvey Cushing published a detailed report on subtemporal and suboccipital decompression to relieve RICH in patients with inoperable brain tumors. [20] DC lost popularity during the 1970s due to disappointing results.…”

Acute Computer Tomography Findings in Pediatric Accidental Head Trauma-Review

“…Oedema can be vasogenic or cytotoxic, the latter being more frequently associated with TBI. 13 It can lead to increased intracranial pressure and herniation. 14 Herniation is the result of mass effect of either primary lesions (eg subdural haematoma, intracerebral haemorrhage) or secondary ones (eg cerebral oedema) that force the brain to “slide” through anatomical “gateways”.…”