What are the current management and recommendations for brain sagging post craniectomy (surgical removal of a portion of the skull)?

From the Guidelines

The current management and recommendation for brain sagging post craniectomy involves a stepwise approach, starting with conservative measures such as strict bed rest, hydration, and medication to stimulate CSF production and cause cerebral vasoconstriction, before considering surgical intervention like early cranioplasty. The management of brain sagging after craniectomy is crucial to prevent further complications and improve patient outcomes. Initial management includes:

• Strict bed rest with the head positioned flat or in Trendelenburg position to reduce gravitational effects on the brain
• Hydration is crucial, with intravenous fluids recommended to maintain euvolemia or mild hypervolemia, typically using normal saline at maintenance rates plus deficit replacement
• Caffeine administration (500 mg IV or 300-400 mg orally daily) can be effective by stimulating CSF production and causing cerebral vasoconstriction, as seen in general medical practice 1
• Theophylline (200-300 mg orally twice daily) offers similar benefits For patients not responding to these measures, an epidural blood patch may be considered, involving injection of 20-30 ml of autologous blood into the epidural space. Abdominal binders can help increase intracranial pressure by raising intra-abdominal and intrathoracic pressures. If conservative management fails, surgical options include early cranioplasty (skull reconstruction) to restore normal intracranial dynamics, typically performed within 1-3 months post-craniectomy rather than waiting the traditional 6 months, as recent guidelines suggest proceeding with surgery urgently, prior to significant decline in GCS or pupillary change 1. Brain sagging occurs because removing part of the skull disrupts normal intracranial pressure dynamics, allowing gravity to pull the brain downward without the usual bony containment, potentially causing headaches, altered consciousness, and cranial nerve dysfunction. Monitoring of neurological status, including assessments of level of consciousness, worsening symptom severity, and blood pressure, is crucial in the management of brain sagging post craniectomy, with recent recommendations suggesting close and frequent monitoring in an intensive care unit or neuro step-down unit 1.

From the Research

Current Management of Brain Sagging Post Craniectomy

• The current management of brain sagging post craniectomy involves a combination of medical and surgical interventions to reduce intracranial pressure (ICP) and prevent secondary brain damage 2, 3, 4.
• Decompressive craniectomy (DC) is a surgical procedure that involves removing a portion of the skull to allow the brain to expand and reduce ICP 2, 3, 4.
• The timing of DC is crucial, and early decompression may be beneficial in preventing secondary brain damage 2.
• Postoperative management, including intracranial pressure monitoring, is essential to prevent complications and improve outcomes 3.

Recommendations for Brain Sagging Post Craniectomy

• Patients who undergo craniectomy should be closely monitored for signs of intracranial hypotension, including postural headache, vertigo, nausea, vomiting, and cognitive changes 5.
• Aggressive management of intracranial hypotension, including hydration and empiric blood patch, may be necessary to prevent complications and improve rehabilitation outcomes 5.
• The use of hypertonic saline (HS) has been shown to be effective in reducing intraoperative brain edema and improving postoperative outcomes in patients undergoing craniotomy for low-grade gliomas 6.
• Decompressive craniectomy should be considered as a treatment option for patients with severe traumatic brain injury and refractory ICP elevations, particularly in cases of malignant middle cerebral artery syndrome 4.

Complications and Limitations

• Brain sagging post craniectomy can be associated with complications, including intracranial hypotension, brain edema, and cognitive changes 5, 6.
• The use of DC is not without risks, and limitations include the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes 4.
• Further studies are needed to elucidate the indications for DC, the nuances of its application, and the risks and complications associated with its use 4.