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

  • 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]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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