Decompressive craniectomy: indications and techniques

Abstract

Introduction: Decompressive craniectomy (DC) is a surgical method indicated for immediate reduction of intracranial pressure (ICP) in general facing brain swelling, acute subdural hematoma, and some non-traumatic diseases. The technique consists of craniectomy and expansion of the dura-mater to accommodate the swollen brain. Literature review: several studies with DC indications show distinct results. There is no evidence to justify its routine use in adults with serious traumatic brain injury (TBI); however, it is indicated in children. Discussion: the refractoriness of intracranial hypertension (ICH) towards clinical measures is an indirect finding of cerebral auto-regulation loss, which configures the presence of Brain Swelling (BS), or swelling of the brain. DC is indicated in cases of BS, being bi- (Marshall III) or unilateral (Marshall IV). The technique requires broad bone removal, greater than the usually used in bruises and contusions. The incision in ‘T’- Kemp is preferred for allowing broad access to the frontotemporoparietal regions and great bone decompression. After craniectomy, dural diaeresis followed by duroplastia is conducted and, finally with the replacement of the bone flap to its original location after bulging reduction. Conclusion: DC is effective in immediately reducing ICP, avoiding ICH, which is a factor for poor prognosis. Its usefulness is especially observed if carried out prematurely in TBI victims with ICH when compared to being carried out