Decompressive craniectomy technique in the RESCUEicp study.

To accommodate substantial variation in surgical practice and preferences between international neurosurgical centres participating in the study the protocol was designed with the following essential requirements in terms of the “standard surgical technique”

• Wide (≥12 cm in diameter) decompressive craniectomy (avoiding brain herniation, a. k .a. fungus cerebri).
  
  
• Opening the dura and leaving it open (with an option of duraplasty).

• Avoiding tight bandage or positioning patient head on the craniotomy side, after decompression.

• Documenting the size of the created bony window in the data collection proforma.

It is also recommended, although not absolutely essential:

• For diffuse brain swelling to use a  bifrontal decompressive craniectomy with bilateral U-shaped opening of the dura, based on the superior sagittal sinus and with ligation and division of the sinus and falx anteriorly for maximum decompression of the frontal regions. The frontal sinus, if inadvertently opened during craniectomy, should be cranialized (excision of posterior wall, stripping of mucosa and plugging of osteum with the pericranium and/or free muscle and/or tissue glue)

• For predominantly unilateral swelling with midline shift a–wide (≥12 cm in diameter) “trauma” craniectomy with temporal decompression on the side of the swelling.

• If it is not feasible to keep the existing ICP monitor in place during the operation, to replace the ICP monitor following craniectomy via separate burr hole / bolt, at least 3 cm away from the bony edge of craniectomy.

• Performing cranioplasty within 6 months following decompressive craniectomy.