Different Methods and Technical Considerations of Decompressive Craniectomy in the Treatment of Traumatic Brain Injury: A Review

The first decompressive craniectomy was presented by Kocher on 1901,1,2 followed by Cushing in 19053 and Horsley in 1906.2 However, because of unpleasant aesthetic results, the procedure lost its general acceptance.2 In traumatic brain injury (TBI), the benefit of this procedure has been agreed as well as disagreed. In 1940, Erlich suggested decompressive craniectomy for all head injuries with persistent coma for more than 24 hours.2 Rowbotham (1942) recommended decompressive craniectomy for all patients for whom medical treatment was ineffective for first 12 hours.2 During 1960 to 1970, Mayfield, Moody, Lewin presented papers noting high mortality with this procedure discouraging its use.2 After the introduction of computed tomographic (CT) scan on 1975, Ramshoff, Morantz presented decompressive craniectomy in series of comatose patients with traumatic acute subdural hematomas with 40% survival rate and 27% back to normal life.2 However, the method still did not get general approval. The credit of rediscovering the benefit of decompressive craniectomy goes to Guerra et al4 in 1999 who published their 20 years results of decompressive craniectomies using CT scan and intracranial pressure (ICP) monitoring in Journal of Neurosurgery. His evidence-based good results allowed this technique to be accepted as a recommended therapy for refractory ICP. At present, the European Brain Injury Consortium and Brain Trauma Foundation guidelines for severe TBIs recommend decompressive craniectomy as a treatment for refractory intracranial hypertension that does not respond to medical therapeutic measures.5,6 Concept of decompressive craniectomy is related to the Monro-Kellie doctrine. The brain is a soft organ housed in a stiff box (the skull). Apart from the brain substance, this box also houses arterial and venous blood and cerebrospinal fluid (CSF). Any increase in any one of these components will result in a shift of any other component from the box or increased pressure within the box (ICP). Decompressive craniectomy is performed to increase the size of the box so that the extra volume can be accommodated. Thus “a lifesaving procedure.”