CRITERIA AND PROCEDURES FOR DECOMPRESSIVE CRANIECTOMY IN CASES OF INTRACRANIAL PRESSURE IN ADULTS AND CHILDREN

Abstract

Decompressive craniotomy (DC) is a surgical procedure recommended for the immediate reduction of intracranial pressure (ICP), commonly used in cases of cerebral edema, acute subdural hematoma and some non-traumatic conditions. The technique involves performing a craniotomy and expanding the dura to accommodate the swollen brain. The work was carried out because various studies analyzing the indications for DC have presented varying results. Although there is no solid evidence to justify its routine use in adults with severe traumatic brain injury (TBI), it seems to be more effective in pediatric patients. The refractoriness of intracranial hypertension (ICH) to clinical interventions suggests a failure in cerebral autoregulation, characterizing the presence of brain swelling (BS) or cerebral edema. DC is indicated in cases of BS, whether bilateral (Marshall III) or unilateral (Marshall IV). The technique involves the removal of a more extensive bone fragment than that commonly used in cases of hematomas and contusions, with Kemp's “T” incision being preferred as it provides greater access to the frontotemporoparietal regions and allows for ample bone decompression. After the craniotomy, the dura mater is opened and then duroplasty is performed, ending with the replacement of the bone flap after the cerebral bulging has been reduced. Thus, DC is effective in immediately reducing ICP and preventing ICH, which is associated with an unfavorable prognosis. Its usefulness is particularly evident when performed early in TBI victims with ICH, compared to delayed intervention or the exclusive use of clinical measures to control ICP, such as barbiturate coma or hypothermia.