Decompressive craniectomy

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Intervention:
Decompressive craniectomy
ICD-10 code:
ICD-9 code: 01.2
Other codes:

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 and stroke. Use of the surgery is controversial.[1] 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.[1][2][3] Raised intracranial pressure is very often debilitating or deadly because it causes compression of the brain and 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.[4]

In addition to reducing ICP, studies have found decompressive craniectomy to improve cerebral perfusion pressure[1][3] and cerebral blood flow in head injured patients.[1]

Decompressive craniectomy is also used to manage large strokes, associated with "malignant" edema and intracranial hypertension. The pooled evidence from three 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.[5]

The procedure is recommended especially for young patients in whom ICP is not controllable by other methods.[1] Age of greater than 50 years is associated with a poorer outcome after the surgery.[3]

Infections such as meningitis or cerebral abscess can occur after decompressive craniectomy.[6]

[edit] 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.[7] 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.[8] This is the only prospective randomised controlled study to date to support the potential benefit of decompressive craniectomy following traumatic brain injury.[9]

[edit] Trials

Two prospective randomised controlled trials are currently being 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[1] is an international multicentre trial, coordinated by the University of Cambridge Academic Neurosurgery Unit[2] and the European Brain Injury Consortium (EBIC)[3] and the DECRA trial[4] is run and coordinated by the Australian centres[5].

[edit] References

  1. ^ a b c d e Kunze, E; Meixensberger J, Janka M, Sorensen N, Roosen K (1998). "Decompressive craniectomy in patients with uncontrollable intracranial hypertension". Acta Neurochirurica (Supplement) 71: 16–18. PMID 9779131. 
  2. ^ Aarabi, B; Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, and Eisenberg HM (2006). "Outcome following decompressive craniectomy for malignant swelling due to severe head injury". Journal of Neurosurgery 104 (4): 469–479. PMID 16619648. 
  3. ^ a b c Schneider, GH; Bardt T, Lanksch WR, Unterberg A (2002). "Decompressive craniectomy following traumatic brain injury: ICP, CPP and neurological outcome". Acta Neurochirurica (Supplement) 81: 77–79. PMID 12168363. 
  4. ^ Skoglund, TS; Eriksson-Ritzen C, Jensen C, Rydenhag B (2006). "Aspects on decompressive craniectomy in patients with traumatic head injuries". Journal of Neurotrauma 23 (10): 1502–1059. PMID 17020484. 
  5. ^ Vahedi K, Hofmeijer J, Juettler E, et al (2007). "Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials". Lancet neurology 6 (3): 215–22. doi:10.1016/S1474-4422(07)70036-4. PMID 17303527. 
  6. ^ Albanese, J; Leone M, Alliez JR, Kaya JM, Antonini F, Alliez B, Martin C (2003). "Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year". Critical Care Medicine 31 (10): 2535–2538. PMID 14530763. 
  7. ^ Hejazi, N; Witzmann A, Fae P. "Unilateral decompressive craniectomy for children with severe brain injury. Report of seven cases and review of the relevant literature". European Journal of Pediatrics 161 (2): 99–104. PMID 11954760. 
  8. ^ Jagannathan, J; Okonkwo DO, Dumont, AS (April, 2007). "Outcome following decompressive craniectomy in children with severe traumatic brain injury: a 10-year single-center experience with long-term follow up". Journal of Neurosurgery Pediatrics 106 (4): 268–275. PMID 17465359. 
  9. ^ Sahuquillo J, Arikan F (2006). "Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury". Cochrane Database of Systematic Reviews (1): CD003983. doi:10.1002/14651858.CD003983.pub2. PMID 16437469. 
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