Indications
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Elevated intracranial pressure (ICP) is one of the most common causes of death and disability following severe traumatic brain injury and ischemic stroke.
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There have been no new medical treatments for elevated ICP in more than 90 years. A decompressive craniectomy may be a useful surgical option in ICP that is refractory to medical treatment. Decompressive craniectomy is also performed as a prophylactic measure in the emergency setting during evacuation of a traumatic subdural or epidural mass lesion when the bone is not replaced in anticipation of postoperative elevated ICP as predicted by computed tomography (CT) scan or the appearance of the brain at surgery.
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Decompressive craniectomy, when performed correctly, can reduce ICP and prevent cerebral herniation and death. Successful decompressive craniectomy allows the brain to swell, reducing the risk of neurologic injury from elevated ICP. In most instances, decompressive craniectomy also reduces the intensity of medical management in the intensive care unit.
Contraindications
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Decompressive craniectomy is most often performed in the setting of life-threatening, impending cerebral herniation. It is important that the surgical and critical care teams and the family members know the dire prognosis of many of these cases to avoid unrealistic expectations. Decompressive craniectomy is well established to treat elevated ICP, but it is less certain which patients are most likely to benefit from this procedure.
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Older patients and patients with limited brainstem reflexes and a low Glasgow Coma Scale score from the time of injury may be at greatest risk for a poor outcome.
Planning and positioning
Procedure
