Decompressive craniectomy

Hi all,

I’m currently treating patients with TBI. I’ve seen many patients wearing a helmet to protect their head after craniectomy (removing part of the skull and opening the duramater), so I was wondering what other treatment options are, how it helps to manage increased intracranial pressure and what its outcome would be like.

ICP is the most frequent cause of death and disability after head injury and it’s important to maintain within normal range 15-20mmHg to prevent brain herniation and improve cerebral perfusion. General manoeuvres include head elevation, volume resuscitation, sedation, etc and more aggressive measures include CSF drainage, moderate hypocapnia and mannitol administration. When these therapeutic options are failed, second level therapies like decompressive craniectomy are considered.

This surgical decompression is divided into two types; primary and secondary. Primary decompressive craniectomy is performed to avoid expected postsurgical increases in ICP, whereas secondary decompressive craniectomy is to control high ICP for patients who have undergone surgery to evacuate tumour and who develop brain swelling.

There is no evidence of the routine use of this surgical procedure in adults population and the effectiveness of decompressive craniectomy are quite controversial in adults population as clinical trials have not confirmed although one study showed improved survival and neurological outcomes in pediatric patients with raised ICP. One study by C Woertgen et al stated that age and clinical signs of herniation were significantly associated with an unfavourable outcome regardless of the type of surgery (craniectomy or craniotomy).

I had an apportunity to observe one of the senior physiotherapist treating patient who had a craniectomy previously and now the piece of bone is back in. She told me that patient used to talk and walk around the ward, however now he doesn't have any voluntary movements in his limbs and hardly does visual tracking. She said the compressive force when the bone is put back in as well as dried and contracted dura mater while the bone was not there might be the reason for it and he should be able to regain his functions hopefully. It's very unfortunate that this guy lost what he has achieved in physio after craniectomy procedure and could be frustrating as a physiotherapist as we have to treat this guy from the start again.

Hope you all enjoying the placement
In Sun