The Role of Decompressive Craniectomy in Limited Resource Environments

Abstract

Decompressive craniectomy (DC) is a neurosurgical procedure useful to prevent and manage the impact of high intracranial pressure (ICP) that leads to brain herniation and brain's tissue ischemia. In well-resourced environment this procedure has been proposed as a last tier therapy when ICP is not controlled by medical therapies in the management of different neurosurgical emergencies like traumatic brain injury (TBI), stroke, infectious diseases, hydrocephalus, tumors, etc. The purpose of this narrative review is to discuss the role of DC in areas of low neurosurgical and neurocritical care resources. We performed a literature review with a specific search strategy in web repositories and some local and regional journals from Low and Middle-Income Countries (LMICs). The most common publications include case reports, case series and observational studies describing the benefits of the procedure on different pathologies but with several types of biases due to the absence of robust studies or clinical registries analysis in these kinds of environments.

Decompressive Craniectomy in Traumatic Brain Injury: An Institutional Experience of 131 Cases in Two Years

“…6 In some cases, hypertension is refractory to first-and second-level therapeutic measures, 7 and requires emergency surgical intervention with decompressive craniectomy (DC). The DC procedure involves removal of portions of the cranial vault 8 and subsequent durotomy to increase space that allows the swollen cerebral hemisphere to expand beyond normal cranial limits to immediately alleviate elevated ICP 9 while avoiding internal herniation and brainstem compression. 2 The increased space can lead to improved cerebral compliance, a reduction in ICP, and an increase in CPP that together increase both cerebral blood flow and cerebral microvascular perfusion.…”

Protocol-based early decompressive craniectomy in a resource-constrained environment: A tertiary care hospital experience

“…There is lack of formal prehospital setup, insurance coverage, neurocritical care, and neurorehabilitation in LMICs. [ 7 8 ] Continuous ICP monitoring may facilitate the diagnosis of RICH, but its effectiveness in improving outcomes has been questioned by the BEST TRIP trial. [ 11 ] At our center, early DC is offered to patients with RICH diagnosed on the basis of clinical and radiological evidence without ICP monitoring.…”

“…It noted a common trend of benefit from the DC procedure in majority of the reviewed literature but was unable to draw statistically significant conclusions from the same because of low methodological quality of these studies. [ 8 ]…”

“…[ 2 3 4 6 ] The role of DC in countries with low neurocritical care and neurosurgical resources is under scanner. [ 7 8 9 ] Low- and middle-income countries (LMICs) cannot afford the higher costs associated with protocol-based ICP monitoring as a requisite for diagnosing RICH for all ABI patients. Alternatively, protocol-based early DC could be offered to patients with RICH diagnosed based on clinical and radiological features.…”

“…[ 10 11 ] Early DC (done within 24 h of insult) may be helpful to improve the long-term outcome of patients with RICH due to any underlying cause. [ 7 8 9 ] The aim of this retrospective, cross-sectional, observational study is to analyze our experience with protocol-based early DC without preoperative ICP monitoring in patients with clinical and radiological features of RICH over a period of 10 years.…”