Complications of Decompressive Craniectomy

Abstract

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.

Keywords: cerebral herniation; decompressive craniectomy; hemorrhage expansion; hydrocephalus; infections; seizures; syndrome of the trephined.

Figure 1

Hematoma expansion. (A) A case of traumatic brain injury depicting subdural hematoma (B), hematoma expansion, and subdural collection post craniectomy.

Figure 2

Cerebral herniation. (A) A case of traumatic brain injury depicting cerebral herniation (B) from the craniectomy site.

Figure 3

Infections. Computed tomography depicting (A) a case of cerebral venous sinus thrombosis. (B) Post craniectomy showed a reduction in the midline shift. (C) However, this patient developed brain abscess (asterisk) 2 months later.

Figure 4

Abdominal wound infection. A partially exposed bone flap is seen through the gaped abdominal storage site, predisposing to infections.

Figure 5

Hydrocephalus. Computed tomography depicting a case of hydrocephalus after craniectomy.

Figure 6

Sunken flap syndrome. Computed tomography depicting (A) malignant hemispheric infarction, (B) sunken flap syndrome after 6 months, which improved (C) post cranioplasty. In a different patient (D), bilateral sunken flap syndrome was observed 25 months post DC, and (E) improved after cranioplasty. DC, decompressive craniectomy.