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JOURNAL OF NEUROSURGICAL SCIENCES

Rivista di Neurochirurgia


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Journal of Neurosurgical Sciences 2017 Nov 07

DOI: 10.23736/S0390-5616.17.04133-9

Copyright © 2017 EDIZIONI MINERVA MEDICA

lingua: Inglese

Efficacy of decompressive craniectomy in the management of intracranial pressure in severe traumatic brain injury

John K. YUE 1, Jonathan W. RICK 1, Hansen DENG 1, Michael J. FELDMAN 2, Ethan A. WINKLER 1

1 Department of Neurological Surgery, University of California, San Francisco, CA, USA; 2 Department of Neurological Surgery, Vanderbilt University, Nashville, TN, USA


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Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. Decompressive craniectomy (DC) involves removing a component of the bony skull to allow cerebral tissue expansion in order to reduce ICP. However, the impact of DC, which is performed in the setting of neurological instability, ongoing secondary injury, and patient resuscitation, has been challenging to study and outcomes are not well understood. This review summarizes historical and recent studies to elucidate indications for DC and the nuances, risks and complications in its application. The pathophysiology driving ICP elevation, and the corresponding medical interventions for their temporization and treatment, are thoroughly described. The current state of DC -- including appropriate injury classification, surgical techniques, concurrent medical therapies, mortality and functional outcomes - is presented. We also report on the recent updates from large randomized controlled trials in severe TBI (Decompressive Craniectomy (DECRA) and Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP (RESCUEicp)), and recommendations for early DC to treat refractory ICP elevations in malignant middle cerebral artery syndrome. Limitations for DC, such as the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes, are discussed in support of future investigations.


KEY WORDS: Decompressive craniectomy - Functional outcome - Intracranial pressure - Malignant middle cerebral artery syndrome - Mortality - Neurocritical care - Neuromonitoring - Secondary injury - Traumatic brain injury

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Publication History

Article first published online: November 07, 2017
Manuscript accepted: October 24, 2017
Manuscript received: June 23, 2017

Per citare questo articolo

Yue JK, Rick JW, Deng H, Feldman MJ, Winkler EA. Efficacy of decompressive craniectomy in the management of intracranial pressure in severe traumatic brain injury. J Neurosurg Sci 2017 Nov 07. DOI: 10.23736/S0390-5616.17.04133-9

Corresponding author e-mail

ethan.winkler@ucsf.edu