Abstract
The fundamental idea behind decompressive craniectomy is a surgical solution to the conflict of an increasing intracranial content within an intracranial cavity of fixed volume. The expanding intracranial content is caused by brain edema brought about by a variety of pathologies.
In spite of a renaissance in decompressive craniectomy in recent years and some evidence of its effectiveness, its use is not yet generally accepted. By far the most frequent indication for decompressive craniectomy is traumatic brain injury.
However, evidence of its effectiveness is limited. Data on the role of secondary decompression in patients with refractory intracranial hypertension after the failure of conservative treatment are expected to be released in a short time.
Bifrontal early decompressive craniectomy is not superior to medical management in patients with diffuse traumatic injury. Primary decompression in patients with acute subdural haematoma has been investigated in randomized trial.
The most conclusive evidence is in patients with malignant middle cerebral artery infarction. In spite of this, the operation is still underutilized and does not correspond with the incidence of malignant infarction.
If decompression is performed within 48 hours of stroke onset in patients younger than 60 years it reduces mortality and improves functional outcome. Decompressive craniectomy is a lifesaving procedure even in patients over 60 years of age for whom it improves chances of survival without total dependency.
Decompression should be considered for patients with cerebral venous thrombosis that cause intractable intracranial hypertension. Decompressive craniectomy with or without hematoma evacuation might reduce mortality for patients with large supratentorial intracerebral hemorrhage, who are in coma or have refractory intracranial hypertension.
Decompressive craniectomy can be effective in selected subgroups of patients with subarachnoid hemorrhage.