Abstract
Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.
Highlights
In medicine, there is increasing awareness that outcome must be evaluated in terms of quality of life and cost effectiveness, rather than merely extending the survival of a patient
The syndrome can manifest in myriad ways and the most common symptoms identified in a recent systematic review were motor weakness (61.1%) followed by cognitive deficits (44.4%), language deficits (29.6%), altered level of consciousness (27.8%), headache (20.4%), psychosomatic disturbances (18.5%), seizures or electroencephalographic changes (11.1%), and cranial nerve deficits (5.6%) [50]
Decompressive craniectomy for intractable intracranial hypertension due to stroke or traumatic brain injury is a proven treatment for reducing mortality and there is some evidence, albeit controversial [55], that it improves the fraction of good grade survivors
Summary
Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. Surgeons should be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. As soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter
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