Abstract

Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions – both medical and surgical – exist to manage increased ICP. Medical management is used as first-line therapy; however it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.

INTRODUCTION

Increased intracranial pressure (ICP) secondary to cerebral edema is common in acute neurological disorders. Severe edema can be seen in malignant middle cerebral artery (MCA) ischemic stroke, traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH). Increased ICP can lead to life-threatening herniation syndromes and is a common cause of death when left untreated. Decompressive hemicraniectomy (DHC) is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. By removing the skull, the brain is allowed to expand, thereby normalizing ICP and reducing compression and/or midline shift. By reducing ICP, cerebral perfusion pressure and blood flow are restored. This article will summarize current medical literature regarding DHC in intracerebral hemorrhages, subarachnoid hemorrhage, malignant MCA stroke and traumatic brain injury.

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