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Does size matter? Decompressive surgery under review

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Abstract

In patients with traumatic brain injury (TBI) and ischemic hemispheric stroke (IHS), supratentorial decompressive craniectomy (DC) is performed when intracranial pressure (ICP) is unresponsive to medical treatment. There are numerous publications about the indications of supratentorial DC, the selection of patients eligible for surgery, the complications of the procedure, and the neurological outcome of operated patients. Only few papers, however, describe comprehensively the technical aspects of this procedure. DC consists of a variety of steps that can be conducted in different manners. Based on the literature reviewed, this article gathers features that had been developed with the intent to improve the decompressive effect of this surgery and evaluates if there is a strong recommendation for clinical practice. The existing literature does not supply class I evidence of how an ideal DC should be designed to reduce peri- and postoperative complications and to provide the best functional outcome.

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The author declares that he has no conflict of interest or financial disclosure.

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  1. Service of Neurosurgery, Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano - Civico, Via Tesserete 46, 6900, Lugano, Switzerland

    Arthur R. Kurzbuch

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George M. Ghobrial, Jack Jallo, Philadelphia, USA

Decompressive hemicraniectomies remain in practice as an emergency, cost-effective, tried, and true measure in a neurosurgeon’s armamentarium for the life-sparing treatment of malignant intracranial hypertension in the setting of traumatic brain injury, extra-axial intracranial hemorrhage, and malignant infarction. Varying surgical techniques are encountered in prospective studies and operative atlases, while nuances and refinements are passed down over each generation through tradition and residency training. While the general goals of surgery remain the same—for the rapid relief of intracranial hypertension and the decompression of the brainstem and critical structures—considerable variation in technique is encountered. The authors set out to answer the question as to what specific technical specifications that contribute to the variation in this technique are supported in the medical literature by way of high-quality medical evidence through a review of the literature. The authors encounter numerous studies demonstrating the early benefits of emergency decompression through lowered mortality. Unsurprisingly, they encounter very few publications addressing various technical nuances, such as an ideal craniectomy flap size. In the question of the benefit of maximizing the craniectomy flap to the fullest extent possible, which for many is the overarching goal of decompression, support is encountered in retrospective studies that larger is better—particularly an improvement in mortality when the anteroposterior diameter exceeded 10 cm.1 While this question seems intuitive to many neurosurgeons, this study highlights the scarcity of high-quality literature in a procedure performed at a relatively high volume. Importantly, this manuscript highlights the fact that level I studies providing favorable2 and unfavorable3 evidence for intervention are performed with different techniques which are not well evaluated in the literature.

References

1. Sedney CL, Julien T, Manon J, et al. The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center. Journal of neurosciences in rural practice 2014;5:212–7.

2. Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke; a journal of cerebral circulation 2007;38:2506–17.

3. Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury. The New England journal of medicine 2011;364:1493–502.

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Kurzbuch, A.R. Does size matter? Decompressive surgery under review. Neurosurg Rev 38, 629–640 (2015). https://doi.org/10.1007/s10143-015-0626-2

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