Recent Updates on Controversies in Decompressive Craniectomy and Cranioplasty: Physiological Effect, Indication, Complication, and Management

Abstract

Decompressive craniectomy (DCE) and cranioplasty (CP) are surgical procedures used to manage elevated intracranial pressure (ICP) in various clinical scenarios, including ischemic stroke, hemorrhagic stroke, and traumatic brain injury. The physiological changes following DCE, such as cerebral blood flow, perfusion, brain tissue oxygenation, and autoregulation, are essential for understanding the benefits and limitations of these procedures. A comprehensive literature search was conducted to systematically review the recent updates in DCE and CP, focusing on the fundamentals of DCE for ICP reduction, indications for DCE, optimal sizes and timing for DCE and CP, the syndrome of trephined, and the debate on suboccipital CP. The review highlights the need for further research on hemodynamic and metabolic indicators following DCE, particularly in relation to the pressure reactivity index. It provides recommendations for early CP within three months of controlling increased ICP to facilitate neurological recovery. Additionally, the review emphasizes the importance of considering suboccipital CP in patients with persistent headaches, cerebrospinal fluid leakage, or cerebellar sag after suboccipital craniectomy. A better understanding of the physiological effects, indications, complications, and management strategies for DCE and CP to control elevated ICP will help optimize patient outcomes and improve the overall effectiveness of these procedures.

Astrocytoma Mimicking Herpetic Meningoencephalitis: The Role of Non-Invasive Multimodal Monitoring in Neurointensivism

“…Identification and treatment of the underlying cause, as well as the use of drugs to lower ICH, are common components of its management [20]. In refractory cases, surgical intervention (decompressive craniectomy) may be required to alleviate head pressure [21,22].…”

Letter to the Editor: Commentary on Predictor of the Postoperative Swelling After Craniotomy for Spontaneous Intracerebral Hemorrhage: Sphericity Index as a Novel Parameter (Korean J Neurotrauma 2023;19:333-347)

“… 5 7) Surgeons may need to perform decompressive craniectomy or attempt aggressive medical treatments, such as barbiturate coma therapy, to resolve this problem. 4 6) Therefore, if it were possible to predict whether edema will worsen in advance, based only on the shape of the hematoma, it may be possible to prevent secondary injury caused by edema by performing decompressive craniectomy before worsening. Further, for patients with a low risk of edema, minimally invasive surgery may be performed more safely.…”