What is the most commonly known neuroplastic procedure among surgery of skull base, craniectomy, cisternal cervical puncture, and carpal tunnel?

Craniectomy is the Most Commonly Known Neuroplastic Procedure

Among the options provided, craniectomy is the most commonly known neuroplastic procedure due to its widespread use in managing traumatic brain injury and stroke-related brain swelling.

Understanding Craniectomy

Craniectomy is a surgical procedure where a section of the skull is removed to allow the brain to swell outward rather than compressing vital structures. This procedure is primarily performed in two clinical scenarios:

Indications for Craniectomy

1. Traumatic Brain Injury (TBI)

   • Used to control refractory intracranial hypertension when medical management fails 1
   • Performed as a rescue strategy in severe TBI with mass effect
   • The most commonly used technique is a large temporal craniectomy (>100 cm²) with enlarged dura mater plasty 1

2. Ischemic Stroke with Swelling

   • Recommended for patients <60 years with malignant middle cerebral artery (MCA) infarctions 1
   • Should be performed when patients deteriorate neurologically within 48 hours despite medical therapy 1
   • Suboccipital craniectomy is indicated for cerebellar infarctions with neurological deterioration 1

Technical Aspects

• Fronto-parieto-temporo-occipital craniectomy up to the midline with a diameter of at least 12 cm is the standard approach 1
• Durotomy and duroplasty are essential components of the procedure 1
• Removing ischemic brain tissue is generally not recommended 1

Comparing with Other Options

1. Surgery of Skull Base

   • More specialized and less frequently performed than craniectomy
   • Typically used for tumors and vascular abnormalities rather than emergency decompression

2. Cisternal Cervical Puncture

   • A diagnostic rather than therapeutic neuroplastic procedure
   • Less commonly performed than craniectomy

3. Carpal Tunnel

   • A peripheral nerve decompression procedure, not a neuroplastic procedure of the central nervous system

Clinical Outcomes of Craniectomy

• In TBI, decompressive craniectomy reduces mortality (26.9% vs 48.9% with medical management) 1
• In stroke patients <60 years, good outcomes (Glasgow Outcome Scale score 4-5) occur in 40-57% after unilateral craniectomy compared to 28-32% with medical management 1
• However, the procedure may increase survival at the expense of severe disability in some patients 1, 2

Important Considerations

• Timing is crucial - surgery should be performed before clinical signs of brainstem compression develop 1
• Age is an important factor, with better outcomes generally seen in patients <60 years 1
• Following craniectomy, cranioplasty is required to restore cranial integrity 3, 4
• Cranioplasty timing is important, with evidence suggesting avoiding early cranioplasty (within 10 weeks) due to higher complication rates 3

Potential Complications

• Wound dehiscence, particularly near the posterior aspect of the large craniectomy flap 1
• Many patients require tracheostomy and gastrostomy for management in the initial postoperative phase 1
• Delayed bone flap replacement can lead to communicating hydrocephalus 1, 3
• Surgical site infection is the most common complication of subsequent cranioplasty 5

Craniectomy remains the most recognized neuroplastic procedure due to its life-saving potential in acute neurological emergencies, despite its significant risks and the complex decision-making involved in its application.