Abstract
While studies have demonstrated that decompressive craniectomy after stroke or TBI improves mortality, there is much controversy regarding when decompressive craniectomy is optimally performed. The goal of this paper is to synthesize the data regarding timing of craniectomy for malignant stroke and traumatic brain injury (TBI) based on studied time windows and clinical correlates of herniation. In stroke patients, evidence supports that early decompression performed within 24 h or before clinical signs of herniation may improve overall mortality and functional outcomes. In adult TBI patients, published results demonstrate that early decompressive craniectomy within 24 h of injury may reduce mortality and improve functional outcomes when compared to late decompressive craniectomy. In contrast to the stroke data, preliminary TBI data have demonstrated that decompressive craniectomy after radiographic signs of herniation may still lead to improved functional outcomes compared to medical management. In pediatric TBI patients, there is also evidence for better functional outcomes when treated with decompressive craniectomy, regardless of timing. More high quality data are needed, particularly that which incorporates a broader set of metrics into decision-making surrounding cranial decompression. In particular, advanced neuromonitoring and imaging technologies may be useful adjuncts in determining the optimal time for decompression in appropriate patients.
Highlights
Decompressive craniectomy has been used to treat elevated intracranial pressure (ICP) resulting from various etiologies, especially ischemic and traumatic brain injuries
20 Avg 20.5 ± 8.3 h 5 (25) modified Rankin scale (mRS) score ≤3: mRS score ≤3: When compared to medical management, the DC group demonstrated an increase in the number of patients with moderate disability by more than half and demonstrated a reduction in the mortality rate by more than half
Hospital mortality rates and Glasgow Outcome Scale at 6 month follow up were comparable between all groups; the 6 month mortality rate was significantly less for the maximal medical management group compared to the early and late decompressive craniectomy groups (29, 48.8, 42.9%, respectively [p = 0.02]) (21)
Summary
Decompressive craniectomy has been used to treat elevated intracranial pressure (ICP) resulting from various etiologies, especially ischemic and traumatic brain injuries. DECIMAL (Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarcts) was published in 2007 It assigned 38 patients to undergo surgery or medical management within 30 h of their initial stroke (8) (see Table 1). DESTINY (Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery) was published in 2007 It enrolled 32 patients within 36 h of stroke (9). Because the above studies were underpowered to assess differences in functional outcomes, the HAMLET (Hemicraniectomy After MCA Infarction With Life Threatening Edema Trial) trial was initiated This third RCT was published in 2009 and was crucial in adding to the body of literature regarding decompressive surgery following acute ischemic stroke (10).
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