Management of Brain Bulge After Decompressive Craniectomy

Medical Management

The International Journal of Stroke recommends osmotherapy, including options such as mannitol 20% and hypertonic saline solutions, with a target serum osmolality of 300-310 mOsmol/kg, to manage brain bulge after decompressive craniectomy 1
Maintaining cerebral perfusion pressure (CPP) >60 mmHg using volume replacement and/or catecholamines is recommended, along with consideration of sedation, intubation, and controlled mechanical ventilation with a target PaCO₂ of 35 mmHg 1
Regular monitoring of intracranial pressure (ICP) and CPP is advised 1

Ensuring adequate craniectomy size (at least 12 cm diameter) and considering dural expansion with a large dural augmentation graft may be beneficial for persistent brain bulge not responding to medical management, according to Stroke 2
In severe cases with very large infarcts (>400 cm³), temporal lobectomy may be considered, and reoperation may be necessary if brainstem decompression is not adequately achieved 2
Early cranioplasty may be considered for persistent brain bulge, but the complication rate may be slightly higher in early cranioplasty (within 10 weeks of craniectomy) 2