Listen to this articleDecompressive craniectomy (crani- + -ectomy) is a neurosurgical 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, stroke, Chiari Malformation, and other conditions associated with raised intracranial pressure. Use of the surgery is controversial.
The procedure evolved from a primitive form of surgery known as trephining or trepanning. The older procedure, while common in prehistoric times, was deprecated in favor of other, less invasive treatments as they were developed; although it was still performed with some frequency prior to the twentieth century, its resurgence in modern form became possible only upon the development of precision cutting tools, cranial drills, and sophisticated post-operative care such as antibiotics.
Complications
Infections such as meningitis or brain abscess can occur after decompressive craniectomy.
Children
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.[11] 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 five years. Only three patients were dependent on caregivers. This is the only prospective randomly controlled study to date to support the potential benefit of decompressive craniectomy following traumatic brain injury.
Follow-up treatment
After a craniectomy, the risk of brain injury is increased, particularly after the patient heals and becomes mobile again. Therefore, special measures must be taken to protect the brain, such as a helmet or a temporary implant in the skull.
When the patient has healed sufficiently, the opening in the skull is usually closed with a cranioplasty. If possible, the original skull fragment is preserved after the craniectomy in anticipation of the cranioplasty.
Ongoing trials
The RESCUEicp study is an international multicenter trial that finished recruitment in March 2014. The aim of this study is to determine the effectiveness of decompressive craniectomy, compared to medical management alone, to treat brain swelling and improve outcome. This study is coordinated by the University of Cambridge Academic Neurosurgery Unit[16] and the European Brain Injury Consortium (EBIC).
The RESCUE-ASDH study Official RESCUE-ASDH Trial Site is a multicenter, pragmatic, parallel group randomised trial that aims to compare the clinical and cost-effectiveness of decompressive craniectomy versus craniotomy for the management of adult head-injured patients undergoing evacuation of an acute subdural haematoma (ASDH). The trial has started recruiting, and is expected to run until 2020. This study is coordinated by the University of Cambridge Academic Neurosurgery Unit.
