Neurosurgery notes/Trauma/Management of trauma/Surgery/Decompressive craniectomy

Decompressive craniectomy

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Surgery

General

  • An umbrella term for a group of procedures in which part of the skull is removed
  • Half of patients die due to ICP issues if no intervention done

Aim

  • Purpose of relieving elevated intracranial pressure
  • Primary treatment:
    • In the acute phase, leaving out the bone flap after evacuation of a mass lesion
  • Secondary treatment (protocol driven DC)
    • Second- or third- tier therapeutic measure for diffuse brain injury and oedema

Advantage

  • Physiological improvements
    • Improvement in brain tissue oxygenation,
    • Improvement in cerebral perfusion
    • Improvement in neurochemistry

Disadvantage

Early complications

  • Expansion of (contralateral) mass lesions
  • Wound infections
  • Healing problems
  • Subdural or subgaleal collections (hygromas)
      • The complications: acute phase
      • Significant hygroma with shift
      notion image
  • Hydrocephalus
      • Acute hydrocephalus in decompressed patients
      notion image

Delayed complications

  • Syndrome of the trephined
  • Complications related to the subsequent cranioplasty
  • Cosmesis and syndrome of trephine
    • Require cranioplasty
      • Complications
        • Infection
        • Seizure
        • Management of HCP

Options

Unilateral Frontotemporoparietal decompressive craniectomy

  • Aka
    • Hemi(spheric)- craniectomy
    • Unilateral DC
  • Indicated
    • Unilateral pathologies with midline shift and (potential) swelling
  • Technique
    • Unilateral craniectomy - tips
      • Positioning
      • Go big
      • Management of contusions
      • Preservation of bridging veins
      • Closure — Surgicel - non-suction drain
    • Bone flap should be large with a minimum anteroposterior diameter of 11– 12 cm
      • To achieve an adequate reduction of ICP
      • Reduce risk of transcalvarial herniation that is associated with parenchymal injuries
      • Reduce risk of cortical venous occlusion at the bone edge
    • Make sure the middle cranial fossa is exposed to allow decompress uncal herniation
Unilateral decompressive craniectomy. (A) The dotted line represents the usual skin incision made during unilateral decompressive craniectomy. To preserve adequate vascular supply, the length of the incision (distance B) should not exceed its width (distance A). (B) A myocutaneous flap is reflected. The dotted line represents the usual extent of the craniectomy. (C) The dotted line on the dura mater represents our preferred method for opening the dura. The dura is opened in a C-shaped fashion with its base along the sphenoid ridge. The dural incision is kept 5–10 mm away from the craniectomy edges to minimize the risk of injury to the protruding brain.
Unilateral decompressive craniectomy. (A) The dotted line represents the usual skin incision made during unilateral decompressive craniectomy. To preserve adequate vascular supply, the length of the incision (distance B) should not exceed its width (distance A). (B) A myocutaneous flap is reflected. The dotted line represents the usual extent of the craniectomy. (C) The dotted line on the dura mater represents our preferred method for opening the dura. The dura is opened in a C-shaped fashion with its base along the sphenoid ridge. The dural incision is kept 5–10 mm away from the craniectomy edges to minimize the risk of injury to the protruding brain.

Bifrontal DC

  • Indicated
    • Diffuse (bihemispheric) injuries with medically refractory intracranial hypertension
  • Bilateral craniectomy - tips
    • Relationship between scalp incision and craniotomy posteriorly
    • Consider anatomy of the frontal sinus on CT
    • Division of the falx at anterior extent
    • Closure — Surgicel — non-suction drain
  • Technique
    • Widely opened dura mater is required to allow the brain to sufficiently expand.
    • Different techniques have been described for the
      • Dura
        • Left open with onlay of haemostatic material, pericranium, or temporalis fascia, or closure with dural expansion grafts
      • SSS
        • Sectioning
        • Sparing
Cranialisation and occlusion of the frontal sinus
Cranialisation and occlusion of the frontal sinus
Bifrontal decompressive craniectomy. (A) The dotted line represents the usual skin incision for bifrontal decompressive craniectomy, which should be kept behind the hairline. (B) A bicoronal myocutaneous flap is reflected anteriorly. The dotted line on the skull represents the usual extent of the craniectomy. Subtemporal decompression is optional. (C) The bone flap has been removed. The dotted line on the dura mater represents our preferred method for opening the dura. The dura is opened on either side of the midline in a C-shaped fashion with its base along the superior sagittal sinus. Division of the superior sagittal sinus anteriorly and of the falx (red line) is optional.
Bifrontal decompressive craniectomy. (A) The dotted line represents the usual skin incision for bifrontal decompressive craniectomy, which should be kept behind the hairline. (B) A bicoronal myocutaneous flap is reflected anteriorly. The dotted line on the skull represents the usual extent of the craniectomy. Subtemporal decompression is optional. (C) The bone flap has been removed. The dotted line on the dura mater represents our preferred method for opening the dura. The dura is opened on either side of the midline in a C-shaped fashion with its base along the superior sagittal sinus. Division of the superior sagittal sinus anteriorly and of the falx (red line) is optional.
  • Get the craniotomy burr hole as low as possible to the middle cranial fossa will help decompress the brain stem

Bone flap storage

  • Abdo subcutaneous pocket
  • Certified tissue bank

Complications (Kurland 2016): Overall 13.4%

Types of complications
Patients affected
Subdural hygroma
27.4%
Haemorrhagic progression of contusion
12.6%
Hydrocephalus
14.8%
New ipsilateral hematoma
12.9%
Syndrome of the trephined
10%
New contralateral/remote hematoma
8.6%
Superficial complications (wound necrosis/poor healing, wound infection, subgaleal infection)
8.1%
CSF leak
6.7%
Meningitis/ventriculitis
6.1%
Deep complications in total (meningitis, ventriculitis, cerebral abscess, extradural/subdural empyema)
5.1%
  • Specific frequencies not available for
    • Paradoxical herniation
    • Falls onto unprotected cranium.

Evidence

General

DECRA
RESCUEicp
Surgery
73
20
Medical
82
196
Study duration
2002-2010
2004-2014
Follow up
6 months
6 then 24 months
Age
15-60
10-65
Stage of intervention
Stage 2
Stage 3 (when all medical therapy exhausted)
Craniectomy
bifrontal
Frontotemporoparietal and bifrontal
Time to decompression
Early <72 hrs
ICP threshold
>20mmHg for 15 mins in 1 hr
>25mmHg for 1hr
Pooled mortality
18.7%
37.5%
Poor outcome (medical group vs. surgical group)
51 vs 70% p<0.01
Similar mortality in both groups
65.4 vs. 57.2%, p = NS (6 months)
67.7 vs. 54.6%, p < 0.01 (12 months)
More of surgical survive but worse eGOS
  • If the same dichotomous cutoff used in the DECRA cohort was utilized in RESCUEicp, then 27.4% and 27.0% of the respective groups would have been considered to have had a favorable neurological outcome.
      ㅤ
      Taylor et al. (2)
      DECRA
      RESCUE-icp
      Recruitment up to 72 h post-TBI
      100%
      100% of patients
      56% of patients
      TBI type
      Diffuse injury and/or mass lesions
      Diffuse injury only
      Diffuse injury and/or mass lesions (including contusions and evacuated hematomas)
      ICP threshold
      ICP 20–24 mmHg for 30 min, 25–29 mmHg for 10 min, 30 mmHg or more for 1 min
      > 20 mmHg for 15 min in 1 h
      > 25 mmHg for at least 1 h
      ICP-lowering therapies before randomization
      Tier 1
      Tier 1
      Tiers 1 and 2
      Pooled mortality
      33.30%
      18.7%
      37.5%
      Mortality in DC vs. medical group
      11.1 vs. 22.2%
      19 vs. 18%
      26.9 vs. 48.9%
      Documented follow-up
      6 months
      6 months
      6 and 12 months
      Poor outcome (medical group vs. surgical group)
      86 vs. 46%, p = 0.046^
      51 vs. 70%, p < 0.01
      65.4 vs. 57.2%, p = NS (6 months)
      67.7 vs. 54.6%, p < 0.01 (12 months)

DC for TBI

  • Main randomized trials:
    • DECRA → role of neuroprotective, secondary, and bifrontal DC for moderate intracranial hypertension
    • RESCUEicp → role of last-tier secondary DC for severe and refractory intracranial hypertension
    • RESCUE-ASDH → role of primary DC for acute subdural hematoma
  • Primary DC
      • Leaving the bone flap out following initial surgery for a mass lesion typically acute subdural haematoma
      • RESCUE-ASDH
      notion image
  • Secondary DC
      • Removing a large bone flap to control raised intracranial pressure
      • DECRA, RESCUEicp
      notion image
  • Summary
      • notion image

RESCUE ICP

  • The Bottom Line
    • Decompressive craniectomy in patients with TBI and persistently raised intracranial pressure, after stage I and 2 management, was associated with lower mortality than medical management.
    • However, more survivors from in the surgical group than in the medical group were dependent on others
    • Lifesaving surgery may not predictably result in sufficiently good functional survival. But long term 24 month outcome show that surviving patient do improve over time
      • For every 100 patients treated with surgical rather than medical intent, there will be
        • 21 extra survivors
          • 1/3 will be dependent
          • 1/3 will be independent at home
          • 1/3 will be independent outside their home

DECRA trial

  • Bottom line:
    • Early decompressive craniectomy effective at reducing ICP and ICU length of stay but associated with more unfavorable outcomes for adult patients with severe TBI