Decompressive Hemicraniectomy

Evidence for DHC:

Capture

 

Mortality Reduction in Percentages:

Capture

 

Surgical Technique:

  • Place head in rigid 3-pin fixation
  • A large reverse question mark flap is turned to allow access to a large part of the hemicranium.
  • Large craniectomy of frontotemporoparietal region
  • Avoid frontal air sinus
  • Take the inferior bone cut as low as possible to the floor of the middle fossa and ronguer/drill additional bone to accomplish this
  • typical craniectomy flap measures at least 15 cm anteroposteriorly and 10 to 12 cm craniocaudal
  • dura is opened in a C-shaped or stellate manner
  • When the anterior temporal lobe is infarcted and tentorial herniation is present or impending, perform an anterior temporal lobectomy with resection of the uncus and visualization of the tentorial edge, third nerve, and midbrain
  • lax duraplasty with autologous pericranial graft, closure must be capacious; be able to pick up and freely slide the lax dural sac
  • Muscle reapproximated loosely or not at all
  • Scalp is closed in layers (drains optional but preferred)
  • parenchymal or subdural ICP monitor optional
  • bone flap typically discarded (prefer delayed cranioplasty with a custom implant) or store bone flap in abdominal wall or cryopreserve
  • transfer to NSICU without extubation.
Post-op Management:
  • standard ICU ICP management
  • attempt early extubation without gagging
  • early enteral nutrition by POD1
  • SQH after 24 hours unless with C/I
  • early trach / PEG if needed
  • if stable post-op CT, ASA after 24 h
  • aggressive PT, speech, rehab

 

Complications:

  • Hygroma / subdural fluid collection most common (50-58%), most clinically insignificant
  • delayed HCP in 7-12%
  • infection 2-7%
  • sinking flap syndrome (syndrome of trephined)

 

Reference:

Gupta, Aman et al. “Hemicraniectomy For Ischemic And Hemorrhagic Stroke”. Neurosurgery Clinics of North America 28.3 (2017): 349-360.

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