The History of Decompressive Craniectomy in Traumatic Brain Injury

Abstract

Decompressive craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.

Keywords: bifrontal craniectomy; brain decompression; decompressive craniectomy; hemicraniectomy; history of head trauma; intracranial hypertension; traumatic brain injury.

Figure 1

(A) Frontispiece of De Fractura Calvae sive Cranei, original Italian translated copy (from Vittorio Putti, Berengario Da Carpi “De Fractura Calvae sive Cranei”, Bologna—L. Cappelli Editore, 1937, private collection. Figure is in public domain and no permission is required for reuse). (B–D) These pictures show some of the surgical instruments in use at that time to perform a trephination.

Figure 2

(A) Frontispice of De l'hémicrniectomie temporaire, by Charles Adrien Marcotte. (B) Sample of the surgical instruments used by Doyen. (C) Lines and burr holes showing the extension of the temporary craniectomy. (D) Intradural view after performing temporary hemicraniectomy: the dural flap is usually downward overturned [from Marcotte (16). Figure is in public domain and no permission is required for reuse].

Figure 3

Frontispiece of the manuscript by Dr. Theodor Kocher [from Kocher (18). Figure is in public domain and no permission is required for reuse].

Figure 4

(A) Decompressive measures described by Cushing for the management of cerebral hernia in inaccessible brain tumors [from Cushing (21). Figure is in public domain and no permission is required for reuse]. (B) Incision of the scalp for subtemporal craniectomy [from Cushing (20). Figure is in public domain and no permission is required for reuse].