Decompressive Craniectomy
OVERVIEW
- can be prophylactic or therapeutic
- increases intracranial compliance and prevents/treats elevated ICP (especially if dura opened)
INDICATIONS
- malignant infarction of the MCA (high grade evidence)
- refractory intracranial hypertension following TBI
- cerebral swelling associated with:
-> vasospasm following SAH
-> hypertensive bleeds
-> encephalitis
-> cerebral venous thrombosis
BENEFITS
- lacks systemic side effects of other treatments
- may decrease ICU time and complications
- lowers ICP
COMPLICATIONS/RISKS
- infection
- collections (subgaleal and subdural)
- bleeding
- seizures
- hygroma
- brain herniation through craniotomy
- venous thrombosis from herniation through defect and occlusion of venous circulation
- sinking flap syndrome
- paradoxical subtentorial herniation with LP or CSF drainage (due to atmospheric pressure)
- intracranial pressure gradient
- hydrocephalus
- bone flap resorption
- worsening of brain injury
OUTCOME DATA
- improved hospital survival in TBI and malignant infarction (some data showing improved quality of survival, awaiting DECRA – ANZICS and RESCUE ICP – European trials)
- better outcomes in paediatric head injuries
- in malignant MCA infarction patients should be < 50 years ideally (DESTINY, HAMLET and DECIMAL)
- retrospective audit of Royal North Shore non-traumatic decompressive craniectomy: small numbers, high mortality (40%) but survivors got home, worse outcomes in SAH.
CONTROVERSIES
- long term data is lacking
- awaiting big, high quality trials
- may produce more survivors with severe disability
- less patients for organ donation
- optimal timing is uncertain (we do know that late decompression associated with worse outcome as ischaemic damage already done)
- not to be routinely used in TBI but it appears equipoise and clinical practice has already changed.
DECRA – NEJM, 2011
- -> less raised ICP
- -> shorter duration of MV
- -> shorter stay in ICU
- -> no change in duration in hospital
- -> more medical and surgical complications
- -> worse functional outcome @ 6 months (when adjusting for pupil reactivity this difference disappeared)
MY PRACTICE
- to use in early malignant MCA infarct
- to use in young patients
- not to be used in SAH
- other patients: require close liaison with neurosurgical team including in TBI
- await RESCUE-ICP trial
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
- Hitchings L, Delaney A. Decompressive craniectomy for patients with severe non-traumatic brain injury: a retrospectivecohort study. Crit Care Resusc. 2010 Mar;12(1):16-23. [PMID 20196709]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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