Decompressive Craniectomy

Decompressive craniectomy (from Latin de- — removal, compressio — compression and Greek kranion — skull, ektome — excision) is a radical, life-saving neurosurgical procedure.

Its essence lies in the removal of a large section of the skull bone and the incision of the dura mater to alleviate critical intracranial pressure.

Etiology and pathophysiology

The adult cranial cavity is a rigid, non-expandable bony structure of constant volume. In severe trauma, a massive brain tissue edema develops, or a large hematoma forms. According to the laws of physics, an increase in tissue volume in an enclosed space leads to a catastrophic rise in intracranial pressure.

When conservative methods (medication coma, edema-relieving drugs) stop working, the brain starts shifting into the natural openings of the skull, where the brainstem, controlling breathing and heartbeat, is located. To prevent this fatal compression, the surgeon artificially creates additional space. By removing a large bone flap (typically frontal-parietal-temporal), the doctor allows the edematous brain to shift into the area of the defect, beyond the contours of the skull, thus protecting brainstem structures from secondary trauma. Subsequent reduction in ICP leads to stabilization of perfusion pressure and the prevention of secondary ischemic changes in brain tissues.

Clinical significance

This procedure is an extreme measure and is performed solely on vital indications in the absence of effect from conservative treatment of ICP. The intervention quickly normalizes brain blood flow and reduces intracranial pressure.

The patient’s own bone flap, after removal, is temporarily preserved (placed in a special freezer bank or sutured under the fascia in the region of the abdomen). The brain remains protected only by a flap of soft tissue (scalp) post-surgery. Several months later, when the edema fully subsides and the patient recovers, a second stage of surgical treatment — cranioplasty (either repositioning the bone or placing a titanium implant) is mandatory to restore aesthetics and protect the organ.