The essentials of decompressive craniectomy

2.  A neurosurgical procedure in which part of
the skull bone is removed to relieve pressure
in the cranial vault and to give room to the
swelling brain to expand without being
compressed (i.e allow brain tissue shifts)
 Allows brain to herniate upwards through the
defect rather than downwards leading to
brainstem herniation

7.  INTRACRANIAL PRESSURE: 5 – 15 mmHg
 CEREBRAL BLOOD FLOW: 55 ml/min/100 g
of brain tissue
 MEAN ARTERIAL PRESSURE: 90 – 110
mmHg

9.  PRIMARY (PROPHYLACTIC):
Performed in patients undergoing removal of IC
lesion with aim to avoid expected postsurgical
intracranial hypertension
 SECONDARY (THERAPEUTIC):
Performed with the intent to treat intracranial
hypertension intractable to maximal medical therapy.

10.  In Traumatic Brain Injury:
› PRIMARY: For acute interventions, specially for
existent or anticipated edema
 Intracranial hematoma or foreign body
› SECONDARY: To improve outcome in
 Documented ICH intractable to medical treatment
 Worsening midline shift or uncal herniation
 Acute massive stroke
› Malignant middle artery occlusion syndrome
› Large hemorrhagic strokes

11.  Uncontrollable brain swelling during
craniotomy
 Intracranial infection
 Acute disseminated encephalomyelitis
 Encephalopathy secondary to Reye’s
syndrome
 Toxoplasmosis
 Cerebral dural sinus thrombosis

12.  Age: >50 years in stroke; >65 years in TBI
 Absent brainstem reflexes
 Uncorrectable coagulopathy
 Prolonged severely low GCS
 Old injury or insult
 Imaging evidence of irreversible brain insult
 Lack of increased ICP on imaging studies
 Severe premorbid condition (unfit)

13. TECHNIQUES
Hemicraniectomy
Bifrontal
Craniectomy
Posterior
fossa
Craniectomy

14.  POSITION:
› Supine with a towel roll under the ipsilateral shoulder
and head turned to the contralateral side

19.  Dural onlay or duraplasty
 The galea should be closed with closely
spaced interrupted absorbable 2-0 sutures
 Skin is closed with running monofilament
nonabsorbable sutures

25. PRONE HEAD UP

26. Midline skin incision from above inion to ~ C2
spinous process

27.  Laterally till sigmoid sinus
 Superiorly till transverse sinus
 C1 Laminectomy is typically performed as
well

29.  Y-shaped incision

31.  Keep patient intubated
 Get a CT scan head
 Monitor and manage ICP/ brain oxygen
 Careful BP control
 Check coagulation status
 Remove subgaleal drain after 24 hours
 Remove staples/sutures at 7th-14th day
 Continue anticonvulsants till 1 week unless
seizures occur

32.  Discard it
 Place it in a subcutaneous pouch in the
patient’s abdomen
 Store for future implantation
In uncontaminated cases, reimplantation can
be considered after 6-12 weeks

33.  INTRAOPERATIVE:
› Entry into frontal sinus
› Venous Sinuses
› Bleeding
› Acute brain swelling

34.  POSTOPERATIVE:
› Bleeding
› Insufficient craniectomy leading to herniation
and laceration of the brain on bone edges
› Injury due to inadvertent external pressure
› Fluid collections : Hygromas or haematomas
› Enhancement of edema, new infarct

35. › Infection
› Alteration of CSF dynamics
› Post-traumatic Hydrocephalus
› Syndrome of the trephined
› Epilepsy and new-onset seizures
› Bone flap resorption