Decompressive Craniectomy

Decompressive Craniectomy

15/12/10

SP Notes

Hitchings, L et al (2010) “Decompressive craniectomy for patients with severe non-traumatic brain injury: a retrospective cohort study” Critical Care and Resuscitation 12 (1), page 16-23

- can be prophylactic or theraputic

- 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

Jeremy Fernando (2011)