Expansive Craniotomy versus Standard Decompressive Craniectomy in Refractory Intracranial Hypertension: A Systematic...

Area of Science:

• Neurosurgery
• Critical Care Medicine
• Surgical Innovation

Background:

• Elevated intracranial pressure poses significant risks to mortality and outcomes following acute brain injury.
• Decompressive craniectomy (DC) is a standard procedure for refractory intracranial hypertension, but necessitates a subsequent cranioplasty.
• Expansive craniotomy (EC) aims to avoid cranioplasty by partially fixing the bone flap, yet its comparative safety and efficacy remain unclear.

Purpose of the Study:

• To systematically review and compare the safety and efficacy of expansive craniotomy (EC) versus decompressive craniectomy (DC).
• To evaluate key outcomes including mortality, reoperation rates, and neurological recovery (Glasgow Outcome Scale).

Main Methods:

• A systematic review adhering to PRISMA guidelines, including all study types except reviews.
• Meta-analysis conducted on data from randomized controlled trials and case-control studies.
• Outcomes assessed: mortality, acute reoperation rate, and Glasgow Outcome Scale (GOS).

Main Results:

• No significant difference in mortality was observed between EC and DC.
• Expansive craniotomy (EC) showed a trend towards improved GOS scores, potentially influenced by selection bias.
• A marginal increase in early reoperation rates was associated with EC (risk difference 0.08, p = 0.05).
• Risk of bias in the included studies was generally moderate to high.

Conclusions:

• Existing evidence is insufficient to definitively guide clinical decisions regarding EC versus DC.
• Expansive craniotomy (EC) shows promise as an alternative to DC in select patients, despite a potential for increased acute reoperation rates.
• A robust, adequately powered randomized controlled trial is strongly recommended to rigorously evaluate expansive craniotomy (EC).