Indications for Decompressive Craniectomy

Czech version

Authors: J. Mraček
Authors‘ workplace: LF UK a FN Plzeň ; Neurochirurgická klinika
Published in: Cesk Slov Neurol N 2016; 79/112(1): 7-21
Category: Minimonography
doi: https://doi.org/10.14735/amcsnn20167

Overview

The fundamental idea behind decompressive craniectomy (DC) is a surgical solution to the conflict of an increasing intracranial content within the fixed-volume intracranial cavity. The expanding intracranial content is caused by brain edema caused by a variety of pathologies. In spite of DC renaissance over the recent years and some evidence of its effectiveness, its use is not yet generally accepted. Traumatic brain injury is by far the most frequent indication for DC. However, the evidence of its effectiveness is limited. Data on the role of secondary decompression in patients with refractory intracranial hypertension after conservative treatment failure are expected to be released soon. Bifrontal early DC is not superior to medical management in patients with diffuse traumatic injury. Primary decompression in patients with acute subdural haematoma has been investigated in a randomized trial. The most conclusive evidence is in patients with malignant middle cerebral artery infarction. In spite of this, the surgery is still underutilized and the frequency of its use does not correspond with the incidence of malignant infarction. When decompression is performed within 48 hours of stroke onset in patients younger than 60 years, it reduces mortality and improves functional outcome. DC is also a lifesaving procedure in patients over 60 years of age for whom it improves chances of survival without total dependency. Decompression should be considered in patients with cerebral venous thrombosis that causes intractable intracranial hypertension. Furthermore, patients with bilateral mydriasis can also profit from the procedure. DC with or without hematoma evacuation might reduce mortality in patients with large supratentorial intracerebral hemorrhage who are in coma or have refractory intracranial hypertension. Even though the DC can be effective in selected subgroups of patients with subarachnoid hemorrhage, current guidelines, do not specify the role of decompression in these patients.

Key words:
decompressive craniectomy – indications – traumatic brain injury – malignant infarction – subarachnoidal hemorrhage – intracerebral hemorrhage – cerebral venous thrombosis

The author declares he has no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.

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