Jae Hyun Kim 1, Yoon-Hee Choo 2, Heewon Jeong 3, Moinay Kim 1, Eun Jin Ha 4, Jiwoong Oh 5, Seungjoo Lee 1
Abstract
Decompressive craniectomy (DCE) and cranioplasty (CP) are surgical procedures used to manage elevated intracranial pressure (ICP) in various clinical scenarios, including ischemic stroke, hemorrhagic stroke, and traumatic brain injury. The physiological changes following DCE, such as cerebral blood flow, perfusion, brain tissue oxygenation, and autoregulation, are essential for understanding the benefits and limitations of these procedures. A comprehensive literature search was conducted to systematically review the recent updates in DCE and CP, focusing on the fundamentals of DCE for ICP reduction, indications for DCE, optimal sizes and timing for DCE and CP, the syndrome of trephined, and the debate on suboccipital CP. The review highlights the need for further research on hemodynamic and metabolic indicators following DCE, particularly in relation to the pressure reactivity index. It provides recommendations for early CP within three months of controlling increased ICP to facilitate neurological recovery. Additionally, the review emphasizes the importance of considering suboccipital CP in patients with persistent headaches, cerebrospinal fluid leakage, or cerebellar sag after suboccipital craniectomy. A better understanding of the physiological effects, indications, complications, and management strategies for DCE and CP to control elevated ICP will help optimize patient outcomes and improve the overall effectiveness of these procedures.
Keywords: Craniocerebral trauma; Craniotomy; Decompressive craniectomy; Intracranial pressure.
Copyright © 2023 Korean Neurotraumatology Society.
The Monro-Kellie Doctrine illustrating intracranial compensation mechanisms in response to an expanding mass.1) This doctrine demonstrates the complex interplay between brain tissue, CSF, and blood within the confined space of the skull. According to the Monro-Kellie Doctrine, when an expanding mass is introduced, compensatory mechanisms involving the reduction of one or both other components are employed to maintain constant intracranial pressure. These compensatory changes can reach a limit, after which further increases in mass may lead to rapid elevation of intracranial pressure and potential brain herniation.
ICP: intracranial pressure, CSF: cerebrospinal fluid.
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