Surgery for Brain Edema

Peter Hutchinson, F.R.C.S.(SN); Ivan Timofeev, M.R.C.S.; Peter Kirkpatrick, F.R.C.S.(SN)

Disclosures

Neurosurg Focus. 2007;22(5):E14 

In This Article

Decompressive Craniectomy

The concept of decompressive craniectomy is by no means novel; it can be defined as the removal of a large area of skull to increase the potential volume of the cranial cavity (Fig. 1). At the beginning of the last century, Kocher[42] asserted that "if there is no CSF pressure, but brain pressure exists, then pressure relief must be achieved by opening the skull." Since then, decompressive craniectomy has been in and out of vogue with the recognition that, although the procedure is theoretically attractive, a number of fundamental questions remain as to whether or not it should be performed. Such questions include the following. First, does decompressive craniectomy control raised ICP? Second, does decompressive craniectomy propagate brain herniation (and therefore edema at the bone margins)? Third, do the results justify the treatment? Fourth, what is the complication rate? Across a spectrum of pathological entities, there is concern that the operation is performed unnecessarily in patients who have a good prognosis with medical treatment alone and that decompressive craniectomy can save lives by controlling brain edema but could shift outcome to vegetative state and severe disability. What is different about this procedure now, compared with several years ago, however, is that it is being performed in the context of modern intensive care as part of protocol-driven therapy and is being evaluated in randomized controlled trials.

Figure 1.

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