World Library  
Flag as Inappropriate
Email this Article

Decompressive craniectomy

Article Id: WHEBN0005539379
Reproduction Date:

Title: Decompressive craniectomy  
Author: World Heritage Encyclopedia
Language: English
Subject: Ventriculostomy, Hypophysectomy, Craniotomy, Neurosurgery, Brain herniation
Collection: Neurosurgery, Neurotrauma, Surgical Removal Procedures
Publisher: World Heritage Encyclopedia

Decompressive craniectomy

Decompressive craniectomy
ICD-9-CM 01.2, 02.02

Decompressive craniectomy (crani- + -ectomy) is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury and stroke. Use of the surgery is controversial.[1]

The procedure evolved from a primitive form of surgery known as trephining or trepanning. The older procedure, while common in prehistoric times, was deprecated in favor of other, less invasive treatments as they were developed; although it was still performed with some frequency prior to the twentieth century, its resurgence in modern form became possible only upon the development of precision cutting tools and sophisticated post-operative care such as antibiotics.


  • Results of clinical trials 1
    • Reduction of intracranial pressure 1.1
      • DECRA trial 1.1.1
    • Other effects 1.2
    • Complications 1.3
    • Children 1.4
  • Follow-up treatment 2
  • Ongoing trials 3
  • References 4

Results of clinical trials

Reduction of intracranial pressure

Though the procedure is considered a last resort, some evidence suggests that it does improve outcomes by lowering intracranial pressure (ICP), the pressure within the skull.[1][2][3] Raised intracranial pressure is very often debilitating or fatal because it causes compression of the brain and restricts cerebral blood flow. The aim of decompressive craniectomy is to reduce this pressure. The part of the skull that is removed is called a bone flap. A study has shown that the larger the removed bone flap is, the more ICP is reduced.[4]

DECRA trial

In March 2011, investigators from Australia and several other countries published the results of the DECRA[5] trial in the New England Journal of Medicine. This was a randomized trial comparing decompressive craniectomy to best medical therapy run between 2002 and 2010 to assess the optimal management of patients with medically refractory ICP following diffuse non-penetrating head injury. The study investigators found that decompressive craniectomy was associated with worse functional outcomes, as measured by a standard metric, than best medical care. There were no differences in deaths between groups. However, the results of the DECRA trial have been rejected or at least questioned by many practicing neurosurgeons, and a concurrently published editorial raises several study weaknesses.[6] First, the threshold for defining increased ICP, and the time allowed before declaring ICP medically refractory, are not what many practicing physicians would consider increased or refractory. Second, out of almost 3500 potentially eligible patients, only 155 patients were enrolled, showing that the study cannot be generalized to all patients with severe non-penetrating brain injury. Lastly, despite being randomized, more patients in the craniectomy arm had unreactive pupils (after randomization but before surgery) than patients in the medical therapy arm, a potential confounding factor.

Other effects

In addition to reducing ICP, studies have found decompressive craniectomy to improve cerebral perfusion pressure[1][3] and cerebral blood flow in head injured patients.[1]

Decompressive craniectomy is also used to manage major strokes, associated with "malignant" edema and intracranial hypertension. The pooled evidence from three randomised controlled trials in Europe supports the retrospective observations that early (within 48 hours) application of decompressive craniectomy after "malignant" stroke may result in improved survival and functional outcome in patients under the age of 55, compared to conservative management alone.[7]

The procedure is recommended especially for young patients in whom ICP is not controllable by other methods.[1] Age of greater than 50 years is associated with a poorer outcome after the surgery.[3]


Infections such as meningitis or brain abscess can occur after decompressive craniectomy.[8]


In severely head injured children, a study has shown that decompressive craniectomy resulted in good recovery in all children in the study, suggesting the procedure has an advantage over non-surgical treatment in children.[9] In one of the largest studies on pediatric patients, Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients for accidental trauma after craniectomy when followed for more than five years. Only three patients were dependent on caregivers.[10] This is the only prospective randomised controlled study to date to support the potential benefit of decompressive craniectomy following traumatic brain injury.[11]

Follow-up treatment

After a craniectomy, the risk of brain injury is increased, particularly after the patient heals and becomes mobile again. Therefore, special measures must be taken to protect the brain, such as a helmet or a temporary implant in the skull.[12]

When the patient has healed sufficiently, the opening in the skull is usually closed with a cranioplasty. If possible, the original skull fragment is preserved after the craniectomy in anticipation of the cranioplasty.[13]

Ongoing trials

The RESCUEicp study [1] is an international multicentre trial that finished recruitement in March 2014. The aim of this study is to determine the effectiveness of decompressive craniectomy, compared to medical management alone, to treat brain swelling and improve outcome. This study is coordinated by the University of Cambridge Academic Neurosurgery Unit [2] and the European Brain Injury Consortium (EBIC)[3].

The RESCUE-ASDH study [4] is a multi-centre, pragmatic, parallel group randomised trial that aims to compare the clinical and cost-effectiveness of decompressive craniectomy versus craniotomy for the management of adult head-injured patients undergoing evacuation of an acute subdural haematoma (ASDH). The trial has started recruiting, and is expected to run until 2020. This study is coordinated by the University of Cambridge Academic Neurosurgery Unit [5].].


  1. ^ a b c d e Kunze, E; Meixensberger J; Janka M; Sorensen N; Roosen K (1998). "Decompressive craniectomy in patients with uncontrollable intracranial hypertension". Acta Neurochirurica (Supplement) 71: 16–18.  
  2. ^ Aarabi, B; Hesdorffer DC; Ahn ES; Aresco C; Scalea TM; Eisenberg HM (2006). "Outcome following decompressive craniectomy for malignant swelling due to severe head injury". Journal of Neurosurgery 104 (4): 469–479.  
  3. ^ a b c Schneider, GH; Bardt T; Lanksch WR; Unterberg A (2002). "Decompressive craniectomy following traumatic brain injury: ICP, CPP and neurological outcome.". Acta Neurochirurica (Supplement) 81: 77–79.  
  4. ^ Skoglund, TS; Eriksson-Ritzen C; Jensen C; Rydenhag B (2006). "Aspects on decompressive craniectomy in patients with traumatic head injuries". Journal of Neurotrauma 23 (10): 1502–1059.  
  5. ^ Cooper, DJ; et al. (25 March 2011). "Decompressive craniectomy in diffuse traumatic brain injury". New England J Medicine 364 (16): 1493–502.  
  6. ^ Servadei, F (2011). "Decompressive craniectomy in diffuse traumatic brain injury". New England J Medicine 364 (16): 1493–502.  
  7. ^ Vahedi K, Hofmeijer J, Juettler E, et al. (2007). "Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials". Lancet neurology 6 (3): 215–22.  
  8. ^ Albanese, J; Leone M; Alliez JR; Kaya JM; Antonini F; Alliez B; Martin C (2003). "Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year". Critical Care Medicine 31 (10): 2535–2538.  
  9. ^ Hejazi, N; Witzmann A; Fae P. "Unilateral decompressive craniectomy for children with severe brain injury. Report of seven cases and review of the relevant literature". European Journal of Pediatrics 161 (2): 99–104.  
  10. ^ Jagannathan, J; Okonkwo DO; Dumont, AS (April 2007). "Outcome following decompressive craniectomy in children with severe traumatic brain injury: a 10-year single-center experience with long-term follow up". Journal of Neurosurgery Pediatrics 106 (4): 268–275.  
  11. ^ Sahuquillo J, Arikan F (2006). Sahuquillo, Juan, ed. "Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury". Cochrane Database of Systematic Reviews (1): CD003983.  
  12. ^ S. Boström, L. Bobinski, P. Zsigmond, A. Theodorsson (2005). "Improved brain protection at decompressive craniectomy – a new method using Palacos R-40 (methylmethacrylate)". Acta Neurochirurgica 147 (3): 279–281.  
  13. ^ N. Grossman, H. S. Shemesh-Jan, V. Merkin, M. Gideon, A. Cohen (2007). "Deep-freeze preservation of cranial bones for future cranioplasty: nine years of experience in Soroka University Medical Center". Cell and Tissue Banking 8 (3): 243–246.  
This article was sourced from Creative Commons Attribution-ShareAlike License; additional terms may apply. World Heritage Encyclopedia content is assembled from numerous content providers, Open Access Publishing, and in compliance with The Fair Access to Science and Technology Research Act (FASTR), Wikimedia Foundation, Inc., Public Library of Science, The Encyclopedia of Life, Open Book Publishers (OBP), PubMed, U.S. National Library of Medicine, National Center for Biotechnology Information, U.S. National Library of Medicine, National Institutes of Health (NIH), U.S. Department of Health & Human Services, and, which sources content from all federal, state, local, tribal, and territorial government publication portals (.gov, .mil, .edu). Funding for and content contributors is made possible from the U.S. Congress, E-Government Act of 2002.
Crowd sourced content that is contributed to World Heritage Encyclopedia is peer reviewed and edited by our editorial staff to ensure quality scholarly research articles.
By using this site, you agree to the Terms of Use and Privacy Policy. World Heritage Encyclopedia™ is a registered trademark of the World Public Library Association, a non-profit organization.

Copyright © World Library Foundation. All rights reserved. eBooks from Project Gutenberg are sponsored by the World Library Foundation,
a 501c(4) Member's Support Non-Profit Organization, and is NOT affiliated with any governmental agency or department.