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Decompressive Craniectomy in Neurocritical Care

  • Stacy Y. Chu
  • Kevin N. ShethEmail author
Critical Care Neurology (K Sheth, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Critical Care Neurology

Opinion statement

Decompressive craniectomy (DC) involves the removal of a portion of the skull in the setting of life threatening brain edema or potentially uncontrollable intracranial pressures. Often performed on an emergent basis, evaluation and arrangement for DC should be swift and decisive. However, the evidence base for DC in the wide range of conditions for which it is currently performed is still developing. The procedure is associated with a number of complications and ethical considerations; thus, its place in contemporary practice remains controversial. While randomized trials conducted in the last decade have provided valuable data on the indications, eligibility criteria, and outcomes for DC in the treatment of traumatic brain injury and malignant middle cerebral artery infarction, important outstanding issues continue to complicate the decision to pursue DC on an individual case basis and in the number of other clinical settings presenting with brain edema and intracranial hypertension. In this review, we present the existing evidence and remaining questions regarding DC in various neurologic conditions including traumatic brain injury, ischemic stroke, subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, encephalitis, and others. We also discuss perioperative considerations and ethical issues likely to be encountered by clinicians caring for patients and families who are considering or have undergone DC.

Keywords

Decompressive craniectomy Hemicraniectomy Intracranial hypertension 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Stacy Y. Chu and Kevin N. Sheth declare no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Neff S, Subramaniam RP. Monro-Kellie doctrine. J Neurosurg. 1996;85:1195.PubMedGoogle Scholar
  2. 2.
    Timofeev I, Czosnyka M, Nortje J, et al. Effect of decompressive craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury. J Neurosurg. 2008;108:66–73.CrossRefPubMedGoogle Scholar
  3. 3.
    Hildebrandt G, Surbeck W, Stienen MN. Emil Theodor Kocher: the first Swiss neurosurgeon. Acta Neurochir. 2012;154:1105–15. discussion 15.Google Scholar
  4. 4.
    Cushing HI. Subtemporal decompressive operations for the intracranial complications associated with bursting fractures of the skull. Ann Surg. 1908;47:641–4.1.CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Kolias AG, Kirkpatrick PJ, Hutchinson PJ. Decompressive craniectomy: past, present and future. Nat Rev Neurol. 2013;9:405–15.CrossRefPubMedGoogle Scholar
  6. 6.
    Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006;58:S16–24. discussion Si-iv.Google Scholar
  7. 7.
    Compagnone C, Murray GD, Teasdale GM, et al. The management of patients with intradural post-traumatic mass lesions: a multicenter survey of current approaches to surgical management in 729 patients coordinated by the European Brain Injury Consortium. Neurosurgery. 2005;57:1183–92. discussion 92.Google Scholar
  8. 8.
    Kolias AG, Belli A, Li LM, et al. Primary decompressive craniectomy for acute subdural haematomas: results of an international survey. Acta Neurochir. 2012;154:1563–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Li LM, Kolias AG, Guilfoyle MR, et al. Outcome following evacuation of acute subdural haematomas: a comparison of craniotomy with decompressive craniectomy. Acta Neurochir. 2012;154:1555–61.CrossRefPubMedGoogle Scholar
  10. 10.
    Kolias AG, Scotton WJ, Belli A, et al. Surgical management of acute subdural haematomas: current practice patterns in the United Kingdom and the Republic of Ireland. Br J Neurosurg. 2013;27:330–3.CrossRefPubMedGoogle Scholar
  11. 11.
    Sahuquillo J, Arikan F. Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury. Cochrane Database Syst Rev 2006;25;(1):CD003983.Google Scholar
  12. 12.••
    Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011;364:1493–502. The DECRA trial was the first randomized controlled trial assessing management of diffuse TBI and intracranial hypertension with standard medical management versus medical management plus bifrontal DC.CrossRefPubMedGoogle Scholar
  13. 13.
    Randomized evaluation of surgery with craniectomy for uncontrollable elevation on intra-cranial pressure. Available at www.RESCUEicp.com. Accessed 6 Nov 2014.
  14. 14.
    Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. Malignant & middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53:309–15.Google Scholar
  15. 15.
    Moulin DE, Lo R, Chiang J, Barnett HJ. Prognosis in middle cerebral artery occlusion. Stroke. 1985;16:282–4.CrossRefPubMedGoogle Scholar
  16. 16.•
    Hofmeijer J, Kappelle LJ, Algra A, et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol. 2009;8:326–33. The HAMLET trial was one of three randomized controlled trials of DC vs best medical management for treatment of malignant MCA conducted in the early 2000s, which together form the current best evidence base for DC in this setting. HAMLET included patients randomized to treatment up to 96 h after symptom onsest and measured outcomes at 12 months.CrossRefPubMedGoogle Scholar
  17. 17.•
    Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL) trial. Stroke. 2007;38:2506–17. The DECIMAL trial was one of three randomized controlled trials of DC vs best medical management for treatment of malignant MCA conducted in the early 2000s, which together form the current best evidence base for DC in this setting. DECIMAL included patients randomized to treatment within 24 h after symptom onset and measured outcomes at 6 months.CrossRefPubMedGoogle Scholar
  18. 18.•
    Juttler E, Schwab S, Schmiedek P, et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38:2518–25. The DESTINY trial was one of three randomized controlled trials of DC vs best medical management for treatment of malignant MCA conducted in the early 2000s, which together form the current best evidence base for DC in this setting. DESTINY included patients randomized to treatment within 48 h of symptom onset and measured outcomes at both 6 and 12 months.CrossRefPubMedGoogle Scholar
  19. 19.
    Cruz-Flores S, Berge E, Whittle IR. Surgical decompression for cerebral oedema in acute ischaemic stroke. Cochrane Database Syst Rev. 2012;1, CD003435.PubMedGoogle Scholar
  20. 20.
    Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6:215–22.CrossRefPubMedGoogle Scholar
  21. 21.
    Staykov D, Gupta R. Hemicraniectomy in malignant middle cerebral artery infarction. Stroke. 2011;42:513–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35:539–43.CrossRefPubMedGoogle Scholar
  23. 23.••
    Juttler E, Unterberg A, Woitzik J, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;370:1091–100. The DESTINY II trial was a randomized controlled trial of DC vs best medical management for treatment of malignant MCA in patients older than 60 years of age, addressing a population that had not yet been addressed in previous randomized controlled trials.CrossRefPubMedGoogle Scholar
  24. 24.
    Jauch EC, Saver JL, Adams Jr HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.CrossRefPubMedGoogle Scholar
  25. 25.
    Claassen J, Carhuapoma JR, Kreiter KT, Du EY, Connolly ES, Mayer SA. Global cerebral edema after subarachnoid hemorrhage: frequency, predictors, and impact on outcome. Stroke. 2002;33:1225–32.CrossRefPubMedGoogle Scholar
  26. 26.
    Guresir E, Schuss P, Vatter H, Raabe A, Seifert V, Beck J. Decompressive craniectomy in subarachnoid hemorrhage. Neurosurg Focus. 2009;26:E4.CrossRefPubMedGoogle Scholar
  27. 27.
    Dorfer C, Frick A, Knosp E, Gruber A. Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage. World Neurosurg. 2010;74:465–71.CrossRefPubMedGoogle Scholar
  28. 28.
    Xi G, Keep RF, Hoff JT. Mechanisms of brain injury after intracerebral haemorrhage. Lancet Neurol. 2006;5:53–63.CrossRefPubMedGoogle Scholar
  29. 29.
    Morgenstern LB, Hemphill 3rd JC, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108–29.CrossRefPubMedGoogle Scholar
  30. 30.••
    Mendelow AD, Gregson BA, Fernandes HM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the international surgical trial in intracerebral haemorrhage (STICH): a randomised trial. Lancet. 2005;365:387–97. The STICH trial is the largest randomized trial comparing early surgery to initial conservative treatment in patients with spontaneous supratentorial ICH.CrossRefPubMedGoogle Scholar
  31. 31.••
    Mendelow AD, Gregson BA, Rowan EN, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013;382:397–408. The STICH II trial followed STICH to further refine the indications for surgical evacuation of spontaneous ICH, comparing early surgery vs initial conservative treatment in the subgroup of patients with superficial hematomas.CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Ma L, Liu WG, Sheng HS, Fan J, Hu WW, Chen JS. Decompressive craniectomy in addition to hematoma evacuation improves mortality of patients with spontaneous basal ganglia hemorrhage. J Stroke Cerebrovasc Dis. 2010;19:294–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Murthy JM, Chowdary GV, Murthy TV, Bhasha PS, Naryanan TJ. Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage. Neurocrit Care. 2005;2:258–62.CrossRefPubMedGoogle Scholar
  34. 34.
    Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F, Investigators I. Prognosis of cerebral vein and dural sinus thrombosis: results of the International study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004;35:664–70.CrossRefPubMedGoogle Scholar
  35. 35.
    Canhao P, Ferro JM, Lindgren AG, et al. Causes and predictors of death in cerebral venous thrombosis. Stroke. 2005;36:1720–5.CrossRefPubMedGoogle Scholar
  36. 36.
    Ferro JM, Crassard I, Coutinho JM, et al. Decompressive surgery in cerebrovenous thrombosis: a multicenter registry and a systematic review of individual patient data. Stroke. 2011;42:2825–31.CrossRefPubMedGoogle Scholar
  37. 37.
    Saposnik G, Barinagarrementeria F, Brown Jr RD, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:1158–92.CrossRefPubMedGoogle Scholar
  38. 38.
    Schwab S, Junger E, Spranger M, et al. Craniectomy: an aggressive treatment approach in severe encephalitis. Neurology. 1997;48:412–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Taferner E, Pfausler B, Kofler A, et al. Craniectomy in severe, life-threatening encephalitis: a report on outcome and long-term prognosis of four cases. Intensive Care Med. 2001;27:1426–8.CrossRefPubMedGoogle Scholar
  40. 40.
    Perez-Bovet J, Garcia-Armengol R, Buxo-Pujolras M, et al. Decompressive craniectomy for encephalitis with brain herniation: case report and review of the literature. Acta Neurochir. 2012;154:1717–24.CrossRefPubMedGoogle Scholar
  41. 41.
    Pohl D, Tenembaum S. Treatment of acute disseminated encephalomyelitis. Curr Treat Options Neurol. 2012;14:264–75.CrossRefPubMedGoogle Scholar
  42. 42.
    Ahmed AI, Eynon CA, Kinton L, Nicoll JA, Belli A. Decompressive craniectomy for acute disseminated encephalomyelitis. Neurocrit Care. 2010;13:393–5.CrossRefPubMedGoogle Scholar
  43. 43.
    Toftengi F, Larsen FS. Management of patients with fulminant hepatic failure and brain edema. Metab Brain Dis. 2004;19:207–14.CrossRefPubMedGoogle Scholar
  44. 44.
    Yamamoto S, Steers JL, Wharen Jr RE, Eckman CB, Nguyen JH. Cerebrospinal fluid drainage and cranial decompression prolong survival in rats with fulminant hepatic failure. Transplant Int. 2006;19:675–82.CrossRefGoogle Scholar
  45. 45.
    Stiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus. 2009;26:E7.CrossRefPubMedGoogle Scholar
  46. 46.
    Nalbach SV, Ropper AE, Dunn IF, Gormley WB. Craniectomy-associated Progressive Extra-Axial Collections with Treated Hydrocephalus (CAPECTH): redefining a common complication of decompressive craniectomy. J Clin Neurosci. 2012;19:1222–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Sarov M, Guichard JP, Chibarro S, et al. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke. 2010;41:560–2.CrossRefPubMedGoogle Scholar
  48. 48.
    Timofeev I, Santarius T, Kolias AG, Hutchinson PJ. Decompressive craniectomy - operative technique and perioperative care. Adv Tech Stand Neurosurg. 2012;38:115–36.PubMedGoogle Scholar
  49. 49.
    Akins PT, Guppy KH. Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care. 2008;9:269–76.CrossRefPubMedGoogle Scholar
  50. 50.
    Di Stefano C, Sturiale C, Trentini P, et al. Unexpected neuropsychological improvement after cranioplasty: a case series study. Br J Neurosurg. 2012;26:827–31.CrossRefPubMedGoogle Scholar
  51. 51.
    Kolias AG, Jones TL, Cowie CJ, et al. A report from the inaugural meeting of the British Neurosurgical Trainee Research Collaborative held in the Royal College of Surgeons of England, 19 October 2012. Br J Neurosurg. 2013;27:307–10.CrossRefPubMedGoogle Scholar
  52. 52.
    van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19:604–7.CrossRefPubMedGoogle Scholar
  53. 53.
    Nakagawa K, Bianchi MT, Nakagawa SS, Sorond FA. Aggressive care after a massive stroke in young patients: is that what they want? Neurocrit Care. 2010;13:118–22.CrossRefPubMedCentralPubMedGoogle Scholar
  54. 54.
    Klein A, Kuehner C, Schwarz S. Attitudes in the general population towards hemi-craniectomy for middle cerebral artery (MCA) infarction. A population-based survey. Neurocrit Care. 2012;16:456–61.CrossRefPubMedGoogle Scholar
  55. 55.
    Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg. 2012;117:749–54.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of NeurologyYale School of MedicineNew HavenUSA

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