Decompressive craniectomy

Decompressive craniectomy is a surgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury. Use of the surgery is controversial. Though the procedure is considered a last resort, some evidence suggests that it does improve outcomes by lowering intracranial pressure (ICP), the pressure within the skull. Raised intracranial pressure is very often debilitating or deadly because it causes compression of the brain restricts cerebral blood flow. The aim of decompressive craniectomy is to reduce this pressure. The part of the skull that is removed is called a bone-flap. A study has shown that the larger the removed bone-flap is, the more ICP is reduced.

In addition to reducing ICP, studies have found that decompressive craniectomy improved cerebral perfusion pressure and cerebral blood flow in head injured patients.

In severely head injured children, a study has shown that decompressive craniectomy resulted in good recovery in all children in the study, suggesting the procedure has an advantage over non-surgical treatment in children. . In one of the largest studies on pediatric patients, Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients for accidental trauma after craniectomy when followed for more than 5 years. Only 3 patients were dependent on caregivers. . This is the only prospective randomised controlled study to date to support the potential benefit of decompressive craniectomy following traumatic brain injury. Two prospective randomised controlled trials are currently run in an attempt to provide Class I evidence on the role of surgical decompression in the treatment of raised intracranial pressure after severe head injury. The RESCUEicp study is an international multicentre trial, coordinated by the University of Cambridge Academic Neurosurgery Unit and the European Brain Injury Consortium (EBIC) and the DECRA trial is run and coordinated by the Australian centres.

Infections such as meningitis or cerebral abscess can occur after decompressive craniectomy.

The procedure is recommended especially for young patients in whom ICP is not controllable by other methods. Age of greater than 50 years is associated with a poorer outcome after the surgery.

Decompressive craniectomy is also used to manage large cerebral infarctions, associated with "malignant" oedema and intracranial hypertension. The pooled evidence from the three recent randomised controlled trials in Europe supports the retrospective observations that early (within 48 hours)application of decompressive craniectomy after "malignant" stroke may result in improved survival and functional outcome in patients under the age of 55, compared to conservative management alone.