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Refractory Intracranial Hypertension: The Role of Decompressive Craniectomy
Martin Smith1,2
1From the Neurocritical Care Unit, Department of Neuroanaesthesia and Neurocritical Care, the National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, United Kingdom.
Insights
Decompressive craniectomy lowers mortality for traumatic brain injury and stroke but increases severe disability. Patient preferences and quality of life are crucial for this intervention.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Raised intracranial pressure (ICP) is linked to poor outcomes in acute brain injury.
- Clinical guidelines recommend prompt management of intracranial hypertension.
- ICP-lowering therapies escalate from safer first-line options to higher-risk interventions for refractory cases.
Purpose of the Study:
- To review the management of intractable intracranial hypertension in adults.
- To focus on the role of decompressive craniectomy in traumatic brain injury (TBI) and acute ischemic stroke.
- To analyze the benefits and risks of decompressive craniectomy.
Main Methods:
- Narrative review of existing literature.
- Analysis of randomized controlled trials (RCTs) for decompressive craniectomy in TBI and stroke.
- Discussion of clinical indications and patient-specific factors.
Main Results:
- Decompressive craniectomy reduces mortality after TBI but increases severe disability.
- Hemicraniectomy improves mortality and functional outcomes in younger adults (<60) with malignant hemispheric infarction.
- In older adults (>60) with stroke, surgery reduces mortality but leads to more severe disability compared to medical management.
Conclusions:
- Decompressive craniectomy is a critical intervention for intractable intracranial hypertension in TBI and stroke.
- The decision to perform decompressive craniectomy requires careful consideration of clinical evidence, patient preferences, and quality of life expectations.
- While beneficial for mortality, the procedure's impact on long-term disability necessitates individualized treatment planning.
Abstract:
Raised intracranial pressure (ICP) is associated with worse outcomes after acute brain injury, and clinical guidelines advocate early treatment of intracranial hypertension. ICP-lowering therapies are usually administered in a stepwise manner, starting with safer first-line interventions, while reserving higher-risk options for patients with intractable intracranial hypertension. Decompressive craniectomy is a surgical procedure in which part of the skull is removed and the underlying dura opened to reduce brain swelling-related raised ICP; it can be performed as a primary or secondary procedure. After traumatic brain injury, secondary decompressive craniectomy is most commonly undertaken as a last-tier intervention in a patient with severe intracranial hypertension refractory to tiered escalation of ICP-lowering therapies. Although decompressive craniectomy has been used in a number of conditions, it has only been evaluated in randomized controlled trials after traumatic brain injury and acute ischemic stroke. After traumatic brain injury, decompressive craniectomy is associated with lower mortality compared to medical management but with higher rates of vegetative state or severe disability. In patients with stroke-related malignant hemispheric infarction, hemicraniectomy significantly decreases mortality and improves functional outcome in adults <60 years of age. Surgery also reduces mortality in those >60 years, but results in a higher proportion of severely disabled survivors compared to medical therapy in this age group. Decisions to recommend decompressive craniectomy must always be made not only in the context of its clinical indications but also after consideration of an individual patient's preferences and quality of life expectations. This narrative review discusses the management of intractable intracranial hypertension in adults, focusing on the role of decompressive craniectomy in patients with traumatic brain injury and acute ischemic stroke.
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