Decompressive Craniectomy

• Before Surgery Evaluation:
  
  • Diagnosis:
    
    • CT scan identifies swelling, hematoma, or stroke-related mass effect (e.g., midline shift >5 mm, effaced ventricles).
    • ICP monitoring: A probe (e.g., intraventricular catheter) shows sustained ICP >20–25 mmHg despite medical therapy (e.g., mannitol, hyperventilation).
    • Symptoms: Deteriorating consciousness (Glasgow Coma Scale <8), pupil dilation (sign of herniation), or neurological deficits.
    • Blood tests: Coagulation profile to correct bleeding risk (e.g., with fresh frozen plasma if needed).
  • Stabilization: Mannitol or hypertonic saline to temporarily reduce ICP; antiseizure medications (e.g., levetiracetam) if seizures occur.
  • Consent: Risks, including infection and neurological deficits, are explained; family is informed of the procedure’s life-saving intent and potential disability.
• Surgical Techniques:
  
  • Hemicraniectomy (Most Common):
    
    • Performed under general anesthesia, lasting 2–4 hours.
    • A large scalp incision is made (e.g., question-mark shaped, 10–15 cm) over the affected side (unilateral) or both sides (bilateral, rare).
    • A large bone flap (e.g., 12–15 cm diameter) is removed, typically from the frontal to parietal region, to allow brain expansion.
    • The dura is opened widely (durotomy) to further relieve pressure; a dural patch (e.g., synthetic or pericranial) may be added to expand the space.
    • Any underlying hematoma (e.g., subdural, intracerebral) is evacuated if present.
    • The bone flap is not replaced; it is stored (e.g., in a sterile freezer or the patient’s abdomen) for later cranioplasty (replacement, 6–12 weeks later).
    • The scalp is closed over a drain to prevent fluid buildup.
  • Bifrontal Craniectomy:
    
    • Used for diffuse swelling (e.g., severe TBI), removing bone across both frontal regions.
  • Intraoperative Tools:
    
    • ICP monitoring: Continues post-surgery to guide ICU management.
    • Ultrasound: Assesses brain shift and hematoma evacuation.
    • Neuromonitoring: Tracks brain function to avoid further injury.
• After Surgery:
  
  • ICU monitoring for 3–7 days to manage ICP, swelling, and complications.
  • Hospital stay: 1–3 weeks, depending on recovery and complications.
  • Pain management: IV analgesics (e.g., morphine) for 1–2 days, then oral (e.g., ibuprofen).
  • Antibiotics (e.g., cefazolin) for 3–5 days to prevent infection.
  • Helmet or head protection: Required until cranioplasty to protect the brain.
  • Follow-up CT at 24–48 hours to assess brain expansion and check for rebleeding.

What causes the need for decompressive craniectomy?

Severe brain swelling from TBI, stroke, hemorrhage, or infections, leading to uncontrolled ICP.

Can brain swelling be treated without surgery?

Medical management (e.g., mannitol, hyperventilation) is tried first; surgery is a last resort for refractory ICP or herniation risk.

Will I regain full function?

Varies by condition: 40–60% achieve moderate disability; severe disability is common in large strokes or TBIs.

How soon can I resume activities?

Light activities in 2–4 weeks, normal routines in 3–6 months; full recovery may take 6–12 months.

Is decompressive craniectomy covered by insurance in India?

Yes, for life-threatening conditions; confirm with your provider.

Signs of complications?

Fever, severe headache, seizures, CSF leak, or new neurological deficits.

Why isn’t the bone flap replaced immediately?

To allow the brain to expand and reduce ICP; it’s replaced later via cranioplasty once swelling subsides.

Lifestyle changes post-surgery?

Wear a helmet until cranioplasty, avoid head trauma, attend rehabilitation, manage blood pressure, and follow up regularly.