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Static Station 5 - Neurosurgery OSCE Answers

Q1. What operative procedure is shown? (1 mark)

The photograph shows a decompressive craniectomy (specifically a frontoparietotemporal decompressive craniectomy with expansive duraplasty). The image displays an intraoperative view following removal of a large bone flap (typically 12-15 cm) with the dura opened/patched to allow the swollen brain to expand outward, relieving raised intracranial pressure (ICP).

Q2. For what purpose is it done in this case? (2 marks)

In this 44-year-old man with a head injury from a road traffic accident, the decompressive craniectomy was performed for two main purposes:
  1. To evacuate an intracranial hematoma - either an acute subdural hematoma (SDH), epidural hematoma (EDH), intracerebral hemorrhage (ICH), or brain contusion caused by the trauma. The large craniotomy allows surgical evacuation of the clot.
  2. To control raised intracranial pressure (ICP) and prevent cerebral herniation - Traumatic brain injury causes cerebral edema and swelling. By removing a section of skull and performing expansive duraplasty, the brain has room to swell outward rather than downward through the tentorium, thereby:
    • Maintaining cerebral perfusion pressure (CPP) at >60 mmHg
    • Preventing ischemia from reduced perfusion
    • Preventing fatal brainstem compression and herniation
    • Used when ICP >20-25 mmHg refractory to maximal medical therapy (sedation, osmotherapy, EVD drainage)
(Fischer's Mastery of Surgery, 8th ed. - the main indication of decompressive craniectomy when maximal medical management fails is to prevent low-perfusion pressure and prevent ischemia)

Q3. In which other conditions is it done? (2 marks)

Decompressive craniectomy is also performed in:
  1. Malignant middle cerebral artery (MCA) infarction ("malignant MCA syndrome") - large hemispheric ischemic stroke causing fatal brain swelling; hemicraniectomy is life-saving and improves functional outcomes (Schwartz's Surgery, 11th ed.)
  2. Diffuse axonal injury (DAI) with refractory ICP - in ~10% of severe TBI patients with DAI, medical management fails and craniectomy is needed to augment cerebral perfusion
  3. Hypertensive intracerebral hemorrhage - with mass effect and midline shift causing herniation
  4. Cerebral venous sinus thrombosis - with massive venous infarction and edema
  5. Subarachnoid hemorrhage - with refractory cerebral edema or infarction
  6. Posterior fossa decompression (suboccipital craniectomy) - for cerebellar infarction/hemorrhage compressing the brainstem
  7. Severe meningitis/encephalitis - with refractory brain swelling unresponsive to medical treatment
  8. Brain tumors - though technically a craniotomy for tumor resection follows similar principles; decompression may be needed with malignant cerebral edema
Key principle: Decompressive craniectomy is indicated whenever ICP cannot be controlled by maximal medical therapy and brain herniation is imminent - regardless of the underlying cause. The procedure replaces a bone flap with a dural patch graft (expansive duraplasty) to give the swollen brain room to expand without compressing critical structures. - Fischer's Mastery of Surgery, 8th ed.; Miller's Anesthesia, 10th ed.; Schwartz's Principles of Surgery, 11th ed.
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