Decompressive craniectomy and decompressive hemicraniectomy are the similar termnologies which are used interchangeably to describe a wide frontotemporoparietal craniotomy on one side of the cranium to reduce the intranial pressure.
This procedure is commonly done in cases of traumatic brain injury and middle cerebral artery ( MCA) infarcts. About 10-15% patients with MCA infarct suffer from progressive clinical detrioration due to increased brain swelling, raised intracranial pressure (ICP) and subsequent herniation. Such space cupying infarct is commonly referred to as malignant MCA infarct. Edema associated with these infarcts is usually observed between the second and fifth day after the index event. Malignant MCA infarct is associated with poor prognosis.Its fatality rate is about 80% and most survivors are left with severe diability. Medical management of malignant MCA infarction is generally ineffective and requires a surgical intervention in the form of decompressive craniectomy for its relief. Surgical decompression reduces the risk of death or disability. An observation study conducted at AIIMS, Delhi had reported that patients who were operated within 48 hours from onset of smptoms and who were less than 60 years old showed better clinical improvement following decompressive craniectomy.
All patients with life threatening malignant MCA infarction indicated to undergo (DH) on the basis of clinical assessment basedon National Institute of Health Stroke Scale [ NIHSS], Glasgow oma scale (GCS) and neuroimaging.
Criteria for Surgery in cases of malignant MCA infarct are:
*NIHSS score more than 16
* GCS score less than 13
* Decrease in level of consciousness
* Clinical signs of herniation
*Presence of radiological evidence
A large Fronto temoporo pariental free bone craniotomy of about 12 centimeter to 15 centimeter is elevated with lax duraplasty. The free bone is placed in the subcutaneous fat pocket in the right iliac region of lower abdomen inferolateral to the umbilicus. When patient improves the cranioplasty is done with the same preserved bone.
DH in large MCA stroke patients leads to markedly improved survival and better functional outcome ( motor and language) and recovery in motor and ahasia recovery is progressive and sustained after 1 year.[1]
Decompressive craniectomy was originally decribed by Cushing. It is used in cases of refractomy intracranial hypertension where convenional therapies have failed. The technique involves removal of a large bone flap and opening the dura. The dura may be left open as it is or a graft may be used to enlarge the volume of the dural compartment. Once the period of intracranial hyertension has settled and patinet has improved, cranioplasty is done with the preserved free boen cranial flap. Study conducted at AIIMS by Sinha et al has reported that DC can ameliorate the secondary damage due raied ICP in cases of traumatic brain injury (TBI).
References
1. Long term outcome of decompressive hemicraniectomyin patients with malignat MCA infarcts: A prospective observational study. VK Rai et al , AIIMS, Delhi in Neurology India, 2014
2. Decompressive craniectomy in traumatic brain injury : a single center, multivariate analysis of 1,236 patients at a tertiary care hospital in India. Sumit Sinha et al, Neurology India
3. Ramamurthy and Tandons' Manual of Neurosurgery
This procedure is commonly done in cases of traumatic brain injury and middle cerebral artery ( MCA) infarcts. About 10-15% patients with MCA infarct suffer from progressive clinical detrioration due to increased brain swelling, raised intracranial pressure (ICP) and subsequent herniation. Such space cupying infarct is commonly referred to as malignant MCA infarct. Edema associated with these infarcts is usually observed between the second and fifth day after the index event. Malignant MCA infarct is associated with poor prognosis.Its fatality rate is about 80% and most survivors are left with severe diability. Medical management of malignant MCA infarction is generally ineffective and requires a surgical intervention in the form of decompressive craniectomy for its relief. Surgical decompression reduces the risk of death or disability. An observation study conducted at AIIMS, Delhi had reported that patients who were operated within 48 hours from onset of smptoms and who were less than 60 years old showed better clinical improvement following decompressive craniectomy.
All patients with life threatening malignant MCA infarction indicated to undergo (DH) on the basis of clinical assessment basedon National Institute of Health Stroke Scale [ NIHSS], Glasgow oma scale (GCS) and neuroimaging.
Criteria for Surgery in cases of malignant MCA infarct are:
*NIHSS score more than 16
* GCS score less than 13
* Decrease in level of consciousness
* Clinical signs of herniation
*Presence of radiological evidence
A large Fronto temoporo pariental free bone craniotomy of about 12 centimeter to 15 centimeter is elevated with lax duraplasty. The free bone is placed in the subcutaneous fat pocket in the right iliac region of lower abdomen inferolateral to the umbilicus. When patient improves the cranioplasty is done with the same preserved bone.
DH in large MCA stroke patients leads to markedly improved survival and better functional outcome ( motor and language) and recovery in motor and ahasia recovery is progressive and sustained after 1 year.[1]
Decompressive craniectomy was originally decribed by Cushing. It is used in cases of refractomy intracranial hypertension where convenional therapies have failed. The technique involves removal of a large bone flap and opening the dura. The dura may be left open as it is or a graft may be used to enlarge the volume of the dural compartment. Once the period of intracranial hyertension has settled and patinet has improved, cranioplasty is done with the preserved free boen cranial flap. Study conducted at AIIMS by Sinha et al has reported that DC can ameliorate the secondary damage due raied ICP in cases of traumatic brain injury (TBI).
References
1. Long term outcome of decompressive hemicraniectomyin patients with malignat MCA infarcts: A prospective observational study. VK Rai et al , AIIMS, Delhi in Neurology India, 2014
2. Decompressive craniectomy in traumatic brain injury : a single center, multivariate analysis of 1,236 patients at a tertiary care hospital in India. Sumit Sinha et al, Neurology India
3. Ramamurthy and Tandons' Manual of Neurosurgery
Non-contrast CT scan of head of the patient after 6 months of Middle cerebral infarction showing a large area of the infarct with large craniectomy defect. Now patients' CT scan does not suggest any midline shift so patient may undergo cranioplasty.
Craniotomy bone flap is preseved in the subcutaneous fat in the right iliac fossa region in abdomen.
