Craniectomia descompresiva en cirugía de aneurismas. ¿Cuando y cómo realizarla?

Abstract

Introduction: Decompressive craniectomy is a surgical technique known for more than a century, however its usefulness has been debated by different neurosurgeons over the years. After 1998, the technique was used in a significant way for a wide variety of pathologies in which intracranial hypertension has a refractory behavior. The Intracranial Decompression Technique increases compliance, decreases intracranial pressure, and increases cerebral perfusion pressure with tissue preservation. Objective: Our goal is to establish when and how to perform decompressive craniectomy in the presence of a complication of aneurysmal subarachnoid hemorrhage or surgery of unbroken aneurysms. Methods: A cross-sectional study was carried out by reviewing the medical records of patients submitted to decompressive craniectomy due to aneurysmal subarachnoid hemorrhage or unbroken aneurysms. The procedures were performed at the Neurosurgery Service of the Santa Casa de Misericórdia in Ribeirão Preto. Results: From 2010 to 2014, 144 craniectomies were performed, 37 of which were due to aneurysms (22 ruptures); Hunt-Hess classification: grade I: 7 cases (32%), grade II: 14 cases (64%), grade III: 1 case (4%); Fisher classification: Fisher 1: 6 cases (27%), Fisher 2: 3 cases (14%), Fisher 3: 5 cases (23%), Fisher 4: 8 cases (36%), 15 cases not broken. The mean age of the patients was 48 years. 22 cases (60%) survived (14 asymptomatic, 4 with deficits, 2 minor symptoms, 2 loss of follow-up); 15 cases (40%) died. There were 10 cases reoperated, 1 case on the same day, 4 cases
on day 2 and 5 cases on day 3. Of these, 4 (40%) survived and 6 (60%) died. Complications of reoperations: 1 hydrocephalus, 3 ischemias, 4 intraparenchymal hematomas, 2 refractory hypertension. Hunt-Hess and Fisher were those with the worst prognosis. Complications that resulted in craniectomy were hematomas, ischemia, edema or associations, asymmetry and mean line deviation greater than 0.5 cm. In relation to Bifrontal and Posterior Fossa we did not obtain cases of complicated aneurysms in these areas. Discussion: The purpose of decompressive craniectomy is to decrease intracranial pressure, regardless of causal factor, when PIC rises to alarming values. In 1940, Erlich suggested performing a Decompressive Craniectomy for all cranial lesions with persistent coma for more than 24-48 hours. Rowbotham in 1942 recommended the technique for all traumatic commas in which clinical treatment was ineffective for 12 hours. Patients with severe SAH often have poor prognosis, however, based on the encouraging results of Decompressive Craniectomy in the treatment of TBIs and CVA, there are increasing reports of successful decompression Craniectomy in the treatment of SAH. Conclusion: Decompressive craniectomy reduces intracranial hypertension with a decrease in morbidity and mortality. We did not indicate localized craniectomies due to the risk of border ischemia and clinical worsening. Early surgery evolves with better results, fewer deaths and
strengthens physician-patient relationship. Intracranial pressure monitoring (ICP) is essential, especially in borderline cases, in which the decision about performing the craniectomy is a challenge in the first moment.