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Osteoplastic decompressive craniotomy—an alternative to decompressive craniectomy

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Abstract

Background

In spite of various degrees of brain expansion, decompressive surgery is usually carried out using decompressive craniectomy (DC). After craniectomy it is necessary to perform cranioplasty, which prolongs hospitalization and is not always without complications. Hence, in situations when cranial decompression is indicated, but DC would be too radical, we do not remove the bone flap, and we perform so-called osteoplastic decompressive craniotomy (ODC). The technique is detailed.

Objective

To demonstrate the effectiveness of ODC.

Methods

Twenty patients underwent ODC for brain edema under various pathological conditions. The diagnoses were as follows: 13 subdural hematomas, 3 cerebral contusions, 2 middle cerebral artery infarcts, 1 epidural hematoma and 1 arteriovenous malformation. The effect of ODC was assessed using postoperative ICP monitoring and the midline shift on CT. The ICP threshold for the additional removal of the bone flap was 25 mmHg. Clinical outcome was evaluated 6 months after surgery using the Glasgow Outcome Scale (GOS).

Results

Postoperative ICP was up to 25 mmHg in 18 patients and exceeded 25 mmHg in 2 cases. The mean midline shift on CT was 10 mm preoperatively and 3 mm postoperatively. The decompression during ODC was sufficient in 18 patients and insufficient in 2 in whom an additional removal of the bone flap was performed. Eight survivals had a favorable outcome (GOS 4–5); 12 patients had an unfavorable outcome (GOS 1–3), and of these, 4 died.

Conclusion

Our limited study shows that ODC is effective in the treatment of intracranial hypertension in the selected subgroup of patients in whom DC would be too radical. The main advantage of this method is the elimination of further cranioplasty.

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Conflicts of interest

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Authors and Affiliations

  1. Department of Neurosurgery, Charles University Hospital and Faculty of Medicine in Pilsen, Alej Svobody 80, Pilsen, 304 60, Czech Republic

    Jan Mracek, Milan Choc, Jan Mork, Petr Vacek & Zdenek Mracek

Authors
  1. Jan Mracek
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  2. Milan Choc
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  3. Jan Mork
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  4. Petr Vacek
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  5. Zdenek Mracek
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Corresponding author

Correspondence to Jan Mracek.

Additional information

Comment

This is an interesting paper, clearly presented and well illustrated. The authors report that in this small series of patients ODC is helpful in the management of increased ICP, cerebral swelling, and brain shift. The weak point of this investigation is the definition of the indications for ODC, since this is an empirically based and intraoperatively decided procedure. It is clear that the authors “made use of years of experience” to decide intraoperatively the "degree of expansion that does not require radical removal of the bone flap," so that there seems to be more art than science in this paper. Nevertheless, the authors' goal is to show that there is one possible effective alternative to standard decompressive craniectomy (bypassing problems related to alterations of CSF dynamics and cranial reconstruction) and there is a subgroup of patients who can profit from it, if fully achieved.

Domenico d'Avella

Padova, Italy

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Mracek, J., Choc, M., Mork, J. et al. Osteoplastic decompressive craniotomy—an alternative to decompressive craniectomy. Acta Neurochir 153, 2259–2263 (2011). https://doi.org/10.1007/s00701-011-1132-0

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  • DOI: https://doi.org/10.1007/s00701-011-1132-0

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