Decompressive craniectomy: a lifeline to protect the balance of intracranial pressure

Author: Liu Baiyun, Chief Physician, Beijing Tiantan Hospital, Capital Medical University

Reviewer: Xiao Weizhong, Chief Physician, Peking University Third Hospital

In the vast medical field, neurosurgery has always been known for its complexity and precision. Among them, decompressive craniectomy, as an urgent and critical surgical method for treating intracranial hypertension, plays a vital role in the critical moment of increased intracranial pressure.

1. Principles and operation of decompressive craniectomy

Decompressive craniectomy, as the name suggests, is a surgical procedure that removes part of the skull (i.e., craniectomy) to free up space for swollen brain tissue and reduce intracranial pressure. This surgical procedure is usually performed on patients with increased intracranial pressure due to brain trauma, stroke, tumor, or infection.

Decompressive craniectomy is divided into internal decompression and external decompression. Internal decompression is aimed at brain lesions, such as tumor resection, to reduce the volume of brain tissue; external decompression is to expand the cranial cavity space, which is achieved by removing the skull flap. With the advancement of medicine, from the initial small bone flap to today's large bone flap surgery, the decompression effect has been significantly improved, providing better treatment options for patients with severe intracranial hypertension. Large bone flap craniotomy has become the preferred method for treating severe intracranial hypertension due to its significant decompression effect.

Figure 1 Original copyright image, no permission to reprint

At the beginning of the operation, the doctor will choose the appropriate surgical path according to the patient's specific situation, and use a step-by-step ladder-shaped approach, from the scalp and skull to the brain tissue layer by layer. This layer-by-layer approach not only helps to reduce the damage to surrounding tissues during surgery, but is also a specific application of the minimally invasive concept in neurosurgery.

Figure 2 Original copyright image, no permission to reprint

During the operation, the doctor will remove a large skull flap to fully expose the brain tissue and achieve the purpose of decompression. At the same time, the scalp flap will be expanded accordingly to ensure that the original physiological and anatomical structure can be restored when sutured.

When suturing, the doctor will proceed from the inside to the outside, first suturing the dura mater of the brain tissue, then dealing with the skull, and finally suturing the scalp. During this process, the doctor will pay special attention to maintaining the size relationship between the bone flap and the scalp, ensuring that the bone flap is larger than the brain tissue and the scalp is larger than the bone flap, in order to meet the requirements of human physiology and anatomy.

It is worth mentioning that after craniotomy and decompressive craniectomy, patients often need cranial repair surgery. When performing cranial repair, doctors will pay special attention to the size of the scalp flap to avoid increasing surgical risks and affecting the healing ability of the scalp due to a scalp flap that is too small.

2. Timing and indications for decompressive craniectomy

The timing and indications of decompressive craniectomy should be determined according to the patient's specific condition. In emergency situations, surgery should be performed every second to save lives. For patients with significantly increased intracranial pressure, who are ineffective with conservative treatment, or in cases where the risk of postoperative brain swelling is expected to be high, immediate surgery is necessary.

However, because decompressive craniectomy is often performed in emergency situations, the requirements for fasting and drinking may be different.

In elective surgery, patients are usually asked to abstain from water for 6 hours and fast for 12 hours before surgery to ensure the safety of the surgical procedure. However, in emergency situations, such as decompressive craniectomy, the requirement to abstain from water may be flexibly adjusted according to the patient's specific condition and surgical needs.

For patients undergoing emergency surgery, if waiting for fasting water may cause the condition to worsen or endanger life, doctors may decide to perform surgery without fasting water. Although there are certain risks in doing so, such as vomiting or aspiration, in an emergency, saving lives is the top priority.

Figure 3 Original copyright image, no permission to reprint

3. The role and effect of decompressive craniectomy

The main purpose of decompressive craniectomy is to reduce intracranial pressure, relieve symptoms and save patients' lives. When intracranial pressure increases, patients may experience symptoms such as headache, vomiting, and impaired consciousness, which may even be life-threatening in severe cases. Through decompressive craniectomy, doctors can provide additional space for swollen brain tissue and reduce intracranial pressure, thereby relieving patients' symptoms and improving their quality of life.

In addition, decompressive craniectomy can also create favorable conditions for subsequent treatment. For example, in the case of brain trauma or cerebral hemorrhage, by reducing intracranial pressure, the degree of brain tissue damage can be reduced, providing a better foundation for subsequent neurological rehabilitation treatment. In the case of tumors or infections, by removing diseased tissue and decompressing craniectomy, more space can be provided for subsequent chemotherapy, radiotherapy or anti-infection treatment, improving the treatment effect.