Complications Associated with Decompressive Craniectomy: A Systematic Review

Abstract

Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.

Fig. 1

Intraoperative images of a decompressive craniectomy. a A curvilinear incision (inset, red line) is used to raise a large scalp flap and mobilize the temporalis muscle and fascia, thereby gaining a wide frontoparieto-temporal exposure; the positions of planned burr holes are indicated by blue dots. b The bone flap that is removed should measure 12–14 cm. c After opening the dura, the swollen brain herniates outward, relieving compression on medial structures and on the brainstem. d An augmentation duroplasty is performed to accommodate and protect the swollen brain. The inset in (a) is reproduced from: Operative Techniques in Neurosurgery, 7(1):10–15, 2004, with permission