Edited by: Stephen Honeybul, Sir Charles Gairdner Hospital, Australia
Reviewed by: Corrado Iaccarino, Azienda Ospedaliero-Universitaria di Parma, Italy; Rita Formisano, Fondazione Santa Lucia (IRCCS), Italy
This article was submitted to Neurotrauma, a section of the journal Frontiers in Neurology
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Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.
In medicine, there is increasing awareness that outcome must be evaluated in terms of quality of life and cost effectiveness, rather than merely extending the survival of a patient. Such considerations are especially important in decompressive craniectomy (DC), which is performed in certain cases of ischemic stroke, traumatic brain injury, and subarachnoid hemorrhage, to alleviate (ICP) and massive brain swelling (
Anticipating a possible rise in the frequency with which decompressive craniectomies are likely to be carried out, based on the strength of recent, strong, supportive, level-one evidence in both traumatic brain injury (
After DC, cranioplasty has to be done (
In this chapter, we classify and describe the complications of DC and suggest management techniques that can reduce the risks.
Decompressive craniectomy has many known complications. The overall complication rates range up to 53.9% (
We suggest that complications be classified as those that occur in the first 4 weeks (early) and those that manifest later (late or delayed). Early complications, which occur in the first 4 weeks, are likely to happen while the patients is still at the hospital. Specific complications tend to occur during particular time periods and awareness of that information helps anticipate and treat them efficiently. Kurland et al. classified them as (i) hemorrhagic, (ii) infectious/inflammatory, and (iii) disturbances of the CSF compartment (
Ban et al. reported, from their analysis of 89 patients, that specific complications occurred in a sequential fashion (
Patient-specific risk factors for developing complications include poor neurological status and age. A low preoperative GCS (below eight) has been shown to increase the possibility of all types of complications (
An overview of the complications is provided in Table
Overview of complications associated with decompressive craniectomy.
Early | •Hemorrhage (hematoma expansion) |
Late or delayed | •Subdural hygroma |
Types, causes, consequences, and measures to avoid or treat complications.
Expansion of conservatively managed contusions and appearance of new bleed | Loss of tamponade effect compounding the natural tendency of contusions to progress | Deterioration in sensorium, the need for evacuation | Early and more frequent scans after decompressive craniectomies at 24 and 48 h, especially in patients with contusions and contralateral calvarial fractures |
Extracranial cerebral herniation | Brain edema, inadequate size of the craniectomy | Venous compromise at the edge of the craniectomy leading to further bulge and damage | Adequate size of decompressive craniectomy, re-exploration to increase the size of the decompression (rescue decompression), inserting vascular cushion at draining veins |
Postoperative epilepsy | Reduced threshold for seizures but not known if the incidence is higher than if the patient has not undergone decompression. Possible effect of stretching of the scar due to sinking scalp flap | Increased metabolic demand, desaturation | Adequate dose of antiepileptic agents, early cranioplasty, as soon as possible (ASAP) |
CSF leakage | Brain bulge and inability to perform watertight dural closure | Meningitis | Early detection and resuturing, water tight duraplasty |
Subdural effusion | CSF flow abnormality | Usually resolves on its own | The superior and medial margin of the craniotomy should not be closer than 2.5 cm from the midline, early postoperative pressure dressing |
Post-traumatic hydrocephalus | CSF flow abnormality | Deterioration, need for CSF diversion | Superior and medial margin of the craniotomy should not be closer than 2.5 cm from the midline; CSF diversion required |
Postoperative neurological deterioration due to decompression | Distortion of the white matter tracts | Failure to achieve benefits of decompression | Excessively large decompression |
Syndrome of the trephined | Sinking scalp flap due to lack of support and sub-atmospheric pressure causes changes in blood flow and fluid shifts | Multiple new symptoms, delayed deterioration, and failure to hold the gains of initial improvement | Early cranioplasty (ASAP), pull up with external fixator if cranioplasty cannot be done |
Postoperative infection | Greater propensity for wound breakdown and CSF leaks | Greater mortality, increase in duration of hospital stay, delay in cranioplasty | Prophylactic antibiotics |
Paradoxical herniation | Subatmospheric negative intracranial pressure under the sinking flap and removal of CSF, typically by lumbar puncture. | Deterioration in sensorium and new neurological deficits | Intravenous hydration, Trendelenburg position, blood patch, and early (ASAP) cranioplasty |
A higher chance for injury with trivial trauma | Unprotected cranial contents when cranioplasty is delayed | Severe injuries or death | Hinge cranioplasty, early cranioplasty |
Expansion of conservatively managed contusions and other bleeds are major issues that occur early after the DC (Figure
Hematoma expansion.
A contralateral hematoma developed an average of 2.1 days after the primary decompression surgery (
We suggest mandatory CT scan(s) in the first 48 h after DC to help detect this complication quickly and limit the damage.
External cerebral herniation appears during the first week after surgery (Figure
Cerebral herniation.
Paradoxical herniation is an unusual complication that tends to occur when there is negative, sub-atmospheric intracranial pressure under the caved-in scalp flap causing the brain to herniate when procedures like lumbar puncture CSF removal (
Wound complications following DC or cranioplasty after DC have been classified as dehiscence, ulceration, or necrosis (
Meticulously preserving the superficial temporal artery and limiting the posterior extent of the flap to no more than 5 cm behind the ear could reduce chance of ischemic flap breakdown. A retrospective comparison of patients operated using an n-shaped incision with those who were operated using the conventional question mark flap showed that the former technique could accomplish greater bony decompression, allows more brain protrusion and is faster to perform (
The overall prevalence of CSF leak/fistulae due to DC has been shown to be up to 6.3% (
Superficial wound infections including wound breakdown, necrosis, surgical site infection, sub-galeal collections, and wound breakdown occurred in about 10% of patients and incidence of deeper infections like an epidural abscess, and subdural empyema was just under 4% (
Infections. Computed tomography depicting
The incidence of meningitis and ventriculitis is 4% probably due to the higher chances of CSF leaks. Early detection by looking for signs of meningeal irritation and guarded lumbar puncture CSF analysis is warranted.
Apart from the scalp wound complications, wound breakdown, and infection can occur when the bone flap is preserved in an abdominal pouch (Figure
Abdominal wound infection. A partially exposed bone flap is seen through the gaped abdominal storage site, predisposing to infections.
Postoperative epilepsy has been documented in a varying proportion of patients who have undergone DC (
In the case of TBI, Ban et al. reported that only about 3% developed seizures despite the use of anticonvulsants. Seizures disappeared in all the patients after increasing the dosage or after adding other antiepileptic drugs and that is a reasonable approach to follow in the first 2 weeks post injury (
Subdural hygroma formation is another widely encountered complication after DC occurring in 27.4% (723/2,643) of patients with TBI and 12.5% (42/336) of patients with malignant infarction treated with DC in the total frequency calculation done by Kurland et al. (
Early pressure dressing applied 7–10 days after DC has been shown to reduce this complication in a small randomized controlled trial (
Communicating hydrocephalus is another non-trivial complication of decompressive procedures because of the perturbation of CSF flow dynamics (Figure
Hydrocephalus. Computed tomography depicting a case of hydrocephalus after craniectomy.
Syndrome of trephined has an overall prevalence of 10% (
Sunken flap syndrome. Computed tomography depicting
Undue delay in cranioplasty and resorption of the bone flap after cranioplasty causes unsightly depression of the scalp. Temporal hollowing and chewing difficulty arises due to extensive dissection of the temporalis muscle to get good decompression at the temporal base. A technique of en bloc detachment and anteroinferiorly turning of the temporal muscle using a clover leaf scalp incision has been described by Missori et al., in 21 patients undergoing DC. They reported good aesthetic results and all eligible patients reported normal chewing ability (
Decompressive craniectomy for intractable intracranial hypertension due to stroke or traumatic brain injury is a proven treatment for reducing mortality and there is some evidence, albeit controversial (
MG, NS prepared, edited, structured, revised, and critically reviewed the manuscript. DS, SK, and DB critically reviewed and accepted the final draft. BD edited, critically reviewed, and accepted the final draft.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.