Decompressive Craniectomy: An Update
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Craniectomy is a valuable technique in the management of evacuatable mass lesions and elevated intracranial pressure (ICP). This review will examine the indications for and benefits of craniectomy in patients with traumatic brain injury (TBI). Recent data have questioned the utility of surgical decompression in the management of refractory intracranial hypertension; however, decompressive craniectomy (DC) remains a common practice at many trauma centers. Recent data have also questioned the use of invasive ICP monitors. However, despite this study, ICP monitors are standard of care in most major centers. Further research is needed before abandoning decompression for refractory elevated ICP or invasive ICP monitoring. While most patients with TBI are managed non-operatively, many patients do require decompression for refractory elevated ICP or evacuatable mass lesions. Current guidelines help direct patient selection for DC, and specific indications for DC vary by the type of intracranial hemorrhage. DC can be lifesaving in patients with severe or progressive intracranial hemorrhage.
KeywordsIntracranial hemorrhage Decompressive craniectomy Craniectomy Craniotomy Traumatic brain injury Elevated intracranial pressure
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- 1.Faul M, Xu L, Wald M, Coronado V. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths, 2002–2006. 2010. http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf. Accessed 9 Mar 2015.
- 2.Coronado V, Xu L, Basavaraju S, McGuire L, Wald M, Faul M, et al. Surveillance for traumatic brain injury: related deaths—United States, 1997–2007. 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6005a1.htm?s_cid=ss6005a1_w. Accessed 9 Mar 2015.
- 5.Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, et al. Guidelines for the management of severe traumatic brain injury VIII. Intracranial pressure thresholds. J Neurotrauma. 2007;24(1):S55–8.Google Scholar
- 6.Narayan RK, Greenberg RP, Miller JD, Enas GG, Choi SC, Kishore PR, et al. Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg. 1981;54(6):751–62.CrossRefPubMedGoogle Scholar
- 7.Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, et al. Guidelines for the management of severe traumatic brain injury II. Hyperosmolar therapy. J Neurotrauma. 2007;24(1):S14–20.Google Scholar
- 8.Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, et al. Guidelines for the management of severe traumatic brain injury. XI. Anesthetics, analgesics, and sedatives. J Neurotrauma. 2007;24(1):S71–6.Google Scholar
- 10.• Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, et al. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012;367(26):2471–81. This article describes a trial examining outcomes with ICP monitor use, which did not show an improved mortality with invasive ICP monitor use. Google Scholar
- 12.Jallo J, Narayan R. General principals of craniocerebral trauma and traumatic hematomas. In: Sekhar L, Fessler R, editors. Atlas of neurosurgical techniques: brain. New York: Thieme Publishers; 2011. p. 899–901.Google Scholar
- 17.•• Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg. 2006;104(4):469–79. This article describes a single institution study with many good functional outcomes after decompressive craniectomy. Google Scholar
- 22.•• Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011;364(16):1493–502. This article describes a randomized trial for DC with medically refractory ICP, showing decreased post-operative GOS scores in the DC patients. Google Scholar
- 23.• Kurland DB, Khaladj-Ghom A, Stokum JA, Carusillo B, Karimy JK, Gerzanich V, et al. Complications associated with decompressive craniectomy: a systematic review. Neurocrit Care 2015;23(2):292–304. Excellent review covering complications after DC and cranioplasty. Google Scholar