Neurosurgery department, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, 83800, Cedex 9, Toulon, France.
Acta Neurochir (Wien). 2024 Sep 28;166(1):388. doi: 10.1007/s00701-024-06277-7.
Even though supratentorial unilateral decompressive craniectomy (DC) has become the gold standard neurosurgical procedure aiming to provide long term relief of intractable intracranial hypertension, its indication has only been validated by high-quality evidence for traumatic brain injury and malignant middle cerebral artery infarction. This scoping review aims to summarize the available evidence regarding DC for these two recognized indications, but also for less validated indications that we may encounter in our daily clinical practice.
A scoping review was conducted on Medline / Pubmed database from inception to present time looking for articles focused on 7 possible indications for DC indications. Studies' level of evidence was assessed using Oxford University level of evidence scale. Studies' quality was assessed using Newcastle-Ottawa scale for systematic reviews of cohort studies and Cochrane Risk of Bias Tool for randomized controlled trials.
Two randomized trials (level 1b) reported the possible efficacy of unilateral DC and the mitigated efficiency of bifrontal DC in the trauma setting. Five systematic reviews meta-analyses (level 2a) supported DC for severely injured young patients with acute subdural hematoma probably responsible for intraoperative brain swelling, while one randomized controlled trial (level 1b) showed comparable efficacy of DC and craniotomy for ASH with intraoperative neutral brain swelling. Three randomized controlled trials (level 1b) and two meta-analyses (level 1a and 3a) supported DC efficacy for malignant ischemic stroke. One systematic review (level 3a) supported DC efficacy for malignant meningoencephalitis. One systematic review meta-analysis (level 3a) supported DC efficacy for malignant cerebral venous thrombosis. The mitigated results of one randomized trial (level 1b) did not allow to conclude for DC efficacy for intracerebral hemorrhage. One systematic review (level 3a) reported the possible efficacy of primary DC and the mitigated efficacy of secondary DC for aneurysmal subarachnoid hemorrhage. Too weak evidence (level 4) precluded from drawing any conclusion for DC efficacy for intracranial tumors.
To date, there is some scientific background to support clinicians in the decision making for DC for selected cases of severe traumatic brain injury, acute subdural hematoma, malignant ischemic stroke, malignant meningoencephalitis, malignant cerebral venous thrombosis, and highly selected cases of aneurysmal subarachnoid hemorrhage.
尽管幕上单侧去骨瓣减压术（DC）已成为旨在长期缓解难治性颅内高压的金标准神经外科手术，但只有高质量证据才能验证其在创伤性脑损伤和恶性大脑中动脉梗死中的适应证。本范围综述旨在总结关于 DC 用于这两种公认适应证的现有证据，但也包括我们在日常临床实践中可能遇到的适应证。
在 Medline / Pubmed 数据库中进行了范围综述，从开始到现在都在寻找专注于 7 种可能的 DC 适应证的文章。使用牛津大学证据水平量表评估研究的证据水平。使用纽卡斯尔-渥太华量表评估队列研究的系统评价研究质量，使用 Cochrane 偏倚风险工具评估随机对照试验的质量。
两项随机试验（1b 级）报告了单侧 DC 和双侧额部 DC 在创伤环境中的可能疗效。五项系统评价荟萃分析（2a 级）支持 DC 用于可能因术中脑肿胀而导致急性硬膜下血肿的年轻严重受伤患者，而一项随机对照试验（1b 级）表明 DC 和开颅术治疗术中脑肿胀为中性的急性硬膜下血肿具有相当的疗效。三项随机对照试验（1b 级）和两项荟萃分析（1a 级和 3a 级）支持 DC 对恶性缺血性卒中的疗效。一项系统评价（3a 级）支持 DC 对恶性脑膜脑炎的疗效。一项系统评价荟萃分析（3a 级）支持 DC 对恶性脑静脉血栓形成的疗效。一项随机试验（1b 级）的缓解结果不允许得出 DC 对脑出血疗效的结论。一项系统评价（3a 级）报告了原发性 DC 和继发性 DC 对动脉瘤性蛛网膜下腔出血的可能疗效。证据太弱（4 级），无法得出 DC 对颅内肿瘤疗效的任何结论。
迄今为止，有一些科学依据支持临床医生在为选定的严重创伤性脑损伤、急性硬膜下血肿、恶性缺血性卒中、恶性脑膜脑炎、恶性脑静脉血栓形成和高度选择的动脉瘤性蛛网膜下腔出血病例做出 DC 决策。
