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Decompressive craniectomy:rationale, indications and outcome Katsuji Shima 1 1Department of Neurosurgery, National Defense Medical College Keyword: 減圧開頭術 , 頭蓋内圧亢進 , 脳腫脹 , 静水圧性脳浮腫 pp.305-313
Published Date 2006/4/10
DOI https://doi.org/10.11477/mf.1431100138
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Decompressive craniectomy have been used as a final option in the management of refractory intracranial hypertension caused by severe head injury, cerebral infarction and various other causes including hypertensive intracerebral hemorrhage and subarachnoid hemorrhage. However, the beneficial effects of decompressive craniectomy remains controversial. There are large number of studies evaluating the effects of decompressive craniectomy on the outcome of those patients. Although decompression by large craniectomy with duraplasty would relieve the intracranial pressure from swollen brain tissue and prevent brain herniation, several early reports demonstrate a wide range of the outcome of patients after the decompression, with no clear consensus regarding the indications for the decompressive surgery. There are several limitation to compare the individual data published. Most studies are based on uncontrolled retrospective data, small number of patients and different surgical procedures and indications.

 Experimental studies on the effects of decompressive craniectomy in animals have not yielded clear results. Previous studies from our laboratory have shown that external decompression may have adverse effects on severe brain edema and swelling. After decompression, tissue pressure decreases, resulting in an increase in perfusion pressure. Then, the transluminal hydrostatic gradient of large magnitude will accelerate extravasation of edema fluid in the decompressive area. This hydrostatic edema enhances morphological and metabolic damage of the vascular wall and causes reopening of blood-brain barrier, which is similar to that in vasogenic edema.

 Decompressive craniectomy is considered to be one of several“second-tier therapies”for refractory intracranial hypertension by the American Association of Neurological Surgeons guidelines for the management of severe head injury, which is viewed as classⅢ(expert opinion)evidence. The need for multicenter, prospective, randomized controlled studies in head injury and cerebral infarction has recently been emphasized by several reports. In 2005, two prospected and randomized multicenter trails were reported from Chinese and European groups. The author reviewed these reports and analyzed to identify patients most likely to benefit from decompressive craniectomy.


Copyright © 2006, Igaku-Shoin Ltd. All rights reserved.

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電子版ISSN 1882-1243 印刷版ISSN 0001-8724 医学書院

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