Bilateral Decompressive Craniectomy
... Especially since we brought you back with one highly intense episode, huh?
In Episode 711, "Disarm," our doctors at Seattle Grace must confront their past trauma and treat victims from a local school shooting at Pacific College. The patients' injuries range from life-threatening gunshot wounds to horrible psychological shock, reminding our characters of their terrifying experience six months ago. However, this tragedy ends on a much more uplifting and healing note for our doctors. Ambulances deliver twenty-six victims to the hospital. And each patient survives.
So, what exactly happened to Professor Sturgeon?
John Sturgeon, Derek and Meredith's patient, fell four stories out the window while trying to help students escape from the building. And landed on his HEAD. When Sturgeon arrives at the hospital miraculously alive, he presents with an open skull fracture, blown pupil, and a sky-high intracranial pressure. Derek and Meredith rush Sturgeon to the OR because his brain is "herniating"—his brain tissue is being moved or pressed away from its usual position in the head.
The skull is usually very protective—helping us to save our brains when we hit our noggins. But in the case of increased pressure or a mass inside the brain, the brain needs to expand or swell, but there's no extra room to do it. The brain has to find somewhere to go, so sometimes, if the pressure becomes too much, it will "herniate"—which means it will find new places to go to try and cope with the pressure. There are a few holes it can find and try to squeeze through, but simply the squeezing itself can inflict damage to the delicate brain cells and brain tissue. And when the damage is coupled with potentially squeezing into a space that compresses the brain stem, POOF! There go your vital functions.
Derek and Meredith performed a cranie—what?
In order to let Sturgeon's brain swell (and thereby heal), Derek and Meredith perform a decompressive craniectomy—a procedure in which one part of the skull is removed to allow the brain space to swell and the pressure to decrease. But even after Derek and Meredith remove the left side of Sturgeon's skull, the brain continues to swell. So they remove the OTHER side of Sturgeon's skull, leaving a small strip of bone in the middle to protect the superior sagittal sinus (to prevent further complications with draining into the sinuses).
Along with removing the bone flaps, Derek also suctions out the damaged brain tissue. And rather than just leaving the brain out in the open, they sew the scalp and muscle over the exposed area. The patient then remains in a medically-induced coma in the ICU while the brain heals. Meanwhile, Derek and Meredith will place the removed pieces of skull into a medical freezer to prevent them from dying. And hopefully within a couple of weeks, Sturgeon's brain swelling will decrease enough that they can bring him back into the OR to perform a cranioplasty and surgically put his skull back together.
What kinds of patients need a decompressive craniectomy?
Neurosurgeons perform the surgery on patients who enter the hospital with a severe form of traumatic brain injury (TBI), typically from motor vehicle accidents or high falls. These patients usually present on the Glasgow Coma Scale (a scale used to assess the level of consciousness after head injury) with a score of eight or less out of fifteen and sometimes also display fixed and dilated pupils and an unresponsiveness to light. After a set of CT scans to see the level of contusions, these patients are immediately rushed to the operating room.
Is removing part of the skull okay?
Even though studies have shown that this type of surgery can significantly and rapidly reduce intracranial pressure and improve survival, decompressive craniectomy has actually always been considered controversial and only advised as a last resort. Without a cranial flap, patients are theoretically at increased risk for additional injury to an unprotected brain. Complications associated with the procedure include delayed intracranial hematomas, development of hydrocephalus, fistulas, infection, and traumatic epilepsy.
For more information on Traumatic Brain Injuries, please visit: