Decompressive Craniectomy (CD) . It consists of the resection of part of the cranial vault with the aim of giving more space to the brain and thus alleviating endocranial hypertension produced by various Pathologies | Pathology such as ischemic stroke, trauma, tumors , subarachnoid hemorrhage, etc.
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- 1 Decompressive craniectomy
- 1 Decompressive craniectomy in children
- 2 Historical Aspects
- 3 Features
- 4 Objectives of decompressive craniectomy
- 5 Risks
- 6 Sources
Decompressive craniectomy has been considered as one more tool in the treatment of elevated intracranial pressure (ICP) that has not responded to medical treatment. However, the selection of patients for this type of surgery must be quite careful, since it is a very invasive procedure. Furthermore, the performance of decompressive craniectomy has been difficult to evaluate, since there are no controlled studies and the casuistry is small. In the face of brain damage of any cause, an inflammatory brain response can be triggered that increases intracranial pressure.
Depending on the site of this inflammatory response and therefore the site of brain swelling, the brain will tend to move to areas of lower pressure , causing so-called brain herniations. The global increase in intracranial pressure will produce a descending transtentorial herniation. The increase in one of the hemispheres will displace the brain laterally producing subfalcin and / or uncal herniation. The increased pressure in the posterior fossa will produce a cerebellar herniation through the foramen magnum.
Brain herniations are serious, since compressing the trunk puts the patient at vital risk. The objective of decompressive craniectomy is to achieve a change in the direction of the cerebral displacement, in such a way that the brain stem is released. In addition, having an area without a cranial vault, a decrease in intracranial pressure is expected.
Decompressive craniectomy in children
Decompressive craniectromy continues to be a controversial therapy due to its indication criteria and its real efficacy in children who present with diffuse post-traumatic brain edema who develop severe endocranial hypertension and refractory to conventional therapy used in Pediatric Intensive Care Units. The morbidity and mortality associated with endocranial hypertension is high, despite advances in its diagnosis , neuromonitoring, and medical management . Trauma is the main cause of death in the age group between 1 and 14 years of age. Within this, encephalo-cranial trauma (ECT) represents the main cause of mortality in the group of schoolchildren.
According to some authors, 75% of all hospitalizations for trauma in children are due to traumatic brain injury (TBI), while 70% of deaths occur in the first 48 hours, with mortality ranging from 20 to 35%. Severe head injury represents the leading cause of death in children over one year of age in the first world , with 30% mortality in the United States of America and 15% in the United Kingdom . In Italy three out of 10 children are taken to an emergency medical department for this cause and one in 600 dies.
In a study of children conducted and performed at the Hospital “Roberto Rodríguez” in Morón, overall mortality from TBI was reported at 1.8%, but the behavior of mortality from severe traumatic brain injury in this population in the province is unknown . Increased intracranial pressure is closely related to a poor prognosis in patients with severe traumatic brain injury, which is why current management guidelines recommend continuous monitoring and, depending on their behavior, offer treatment. Decompressive craniectomy (CD) , is a recommended surgical procedure in children with severe traumatic brain injury, for the control of intracranial hypertension refractory to the best medical treatment.
Decompressive craniectomy has been performed for many years. In 1905 , Cushing reported a decompressive craniectomy as a treatment for a tumor.and later performed it in patients with traumatic brain injury. In the late 1960s, 3 cases of decompressive craniectomy were reported for trauma patients, but mortality was 100% in the early 1970s. Kjellberg and Prieto reported the first major series, with 73 patients operated, all of them for trauma, with very high mortality (82%). In the same decade, a series of authors published their experience in trauma patients, all of them with high mortality. Starting in the 1980s, better performance began to be shown, based mainly on decreased mortality. The idea that surgery done early and in patients with Glasgow over 5 has better results is beginning to be raised .
It is currently difficult to know the real performance of decompressive craniectomies, especially in patients who have suffered traumatic brain injury. There is no conclusive evidence, due among other things to the lack of controlled studies and there is no standardized surgical technique.
There are different modalities of decompressive craniectomy. They all have in common the resection of large portions of bone . Thus, there is the temporal-parieto-temporal craniectomy, the hemicraniectomy (resection of a large part of the half of the cranial vault, including the frontal , temporal, parietal and part of the occipital bones ), bifrontal and bifrontoparietal craniectomy. The durotomy can be performed in several ways: cross, starry or just a small opening in the fish’s mouth . The main goal is to perform a broad durotomy to allow the brain more displacement. At the end of the surgery, duroplasty can be performed with fascia, pericranium, artificial dura, substitutes for it or with sealing substances.
Goals of decompressive craniectomy
The objective of the intervention is to increase the capacity of the intracranial space to reduce intractable intracranial pressure by other means in case of massive cerebral infarctions or massive post-traumatic cerebral edema. In these cases it may be necessary to repair the bone defect late if the patient survives (cranioplasty It is also used to increase the capacity of the posterior fossa in the event of an Arnold – Chiari malformation associated or not with syringomyelia.
This intervention is extremely complex and delicate. There may be postoperative complications related to surgery ( hemorrhage , infection , cerebrospinal fluid), manipulation of the arteries (cerebral ischemia), of the brain (cerebral contusion, cerebral edema, epileptic seizures) or of the cranial nerves ( facial paralysis , paralysis of the cranial nerves) .Any of these complications can lead to a transient or permanent neurological worsening of the patient’s symptoms or the appearance of other new symptoms ( hemiplegia, aphasia, visual disturbances, disorders of superior functions, coma, etc.) More frequently, complications unrelated to the intervention (pulmonary infection, venous thrombosis, embolism, hyponatremia, anemia, gastrointestinal hemorrhage, etc.) appear. The final result and complications they depend on the patient’s condition and the aggressiveness of the surgery performed, and for one reason or another, postoperative mortality can be very high.