Neurosurg Rev (2015) 38:629–640
DOI 10.1007/s10143-015-0626-2
REVIEW
Does size matter? Decompressive surgery under review
Arthur R. Kurzbuch 1
Received: 30 May 2013 / Revised: 20 September 2014 / Accepted: 19 January 2015 / Published online: 12 April 2015
# Springer-Verlag Berlin Heidelberg 2015
Abstract In patients with traumatic brain injury (TBI)
and ischemic hemispheric stroke (IHS), supratentorial de-
compressive craniectomy (DC) is performed when intra-
cranial pressure (ICP) is unresponsive to medical treat-
ment. There are numerous publications about the indica-
tions of supratentorial DC, the selection of patients eli-
gible for surgery, the complications of the procedure, and
the neurological outcome of operated patients. Only few
papers, however, describe comprehensively the technical
aspects of this procedure. DC consists of a variety of
steps that can be conducted in different manners. Based
on the literature reviewed, this article gathers features
that had been developed with the intent to improve the
decompressive effect of this surgery and evaluates if
there is a strong recommendation for clinical practice.
The existing literature does not supply class I evidence
of how an ideal DC should be designed to reduce peri-
and postoperative complications and to provide the best
functional outcome.
Keywords Decompressive craniectomy . Durotomy .
Intracranial pressure . Technique . Traumatic brain injury
* Arthur R. Kurzbuch
kurzbuch@web.de
1
Service of Neurosurgery, Neurocenter of Southern Switzerland,
Ospedale Regionale di Lugano - Civico, Via Tesserete 46,
6900 Lugano, Switzerland
Introduction
Decompressive craniectomy (DC) per se describes a craniot-
omy aiming for the decompression of the supratentorial intra-
cranial space without reinserting the bone flap. The history of
decompressive surgery may go back to Ancient Egypt and
Ancient Greece. DC was practised since the beginning of the
twentieth century in different manners to treat elevated intra-
cranial pressure (ICP). In 1901, Kocher advertised decom-
pressive surgery in posttraumatic brain swelling [43]. Cushing
described in 1905 subtemporal craniectomy for patients with
inaccessible brain tumors [16], for brain edema and swelling
in bursting fractures of the skull [17]. Bauer in 1932 [8] and
Clark et al. in 1968 [12] reported on circular decompression
with dissatisfying outcome. Subtemporal and circular DC ex-
pose only a small surface of the underlying brain and have
very limited decompressive effect. Later hemispheric DC was
alternately favored and abandoned because of insufficient
results. Since the 1970s, large fronto-temporo-parietal,
fronto-temporo-parieto-occipital, bilateral, and bifrontal DC
are regularly performed for various indications. Infrequent
applications of DC are listed in Table 1. DC is nowadays
mainly performed on patients with traumatic brain injury
(TBI) and malignant edema from ischemic hemispheric stroke
(IHS) as the last resort to treat medically intractable elevated
ICP due to brain swelling. It is generally recognized that DC
can decrease ICP and raise the survival rate [13, 78].
Nevertheless, DC is not undoubted. Sahuquillo concludes that
the routine use of DC in TBI cannot be recommended in
patients older than 18 years of age; only as a rescue therapy
it would be acceptable [66]. In patients with TBI, the DECRA
study found that DC decreased ICP but was associated with
worse functional outcome of surgically treated patients [13].
The results of this study are still discussed [67]. The ongoing
prospective multicenter randomized controlled RESCUEicp
630 Neurosurg Rev (2015) 38:629–640

study compares the outcome of patients undergoing large DC Bdecompressive craniectomy technical^ 20 hits. The inquiry
to those patients with medical treatment [31]. For ischemic was repeated on April 10th, 2013 and provided ten more re-
stroke, three randomized controlled trials (DECIMAL, sults for the first search term and one further paper for the
DESTINY, and HAMLET) showed significant reduction in second. Papers were selected on the basis of the title, abstract,
mortality in operated patients over those with conservative and key words. Copies of the articles were printed or ordered
treatment and an increased number of patients aged between to verify whether they contain information of the aspects of
18 and 60 years with favorable functional outcome if DC is DC. The reference section of these articles was also checked
performed within 48 h of stroke onset [75]. for pertinent information and the papers obtained if they
Compared to the vast number of publications regarding proved to be relevant.
patient selection, there are only few papers outlining specifi-
cally the technical facets of the surgical procedure [27, 30, 33,
62, 63]. DC is composed of numerous steps that can be ac- Background of decompressive surgery
complished in varying ways and some of them may be vital
for the outcome by influencing the decompressive effect of the Compression—decompression
procedure. DC is considered as a technically straightforward
[28, 29, 74] but not a simple operation [48]. Stiver [71] high- According to the Monro-Kellie hypothesis, compression of
lights the complications of DC: blossoming of contusions, the rigid cranial compartment with elevation of ICP arises as
evolution of contralateral mass lesions, external cerebral her- soon as the capacity of compensation systems is exhausted.
niation, subdural effusions or hygromas, paradoxical hernia- Edema and ICP being part of a dynamic system can rise post-
tion, impaired wound healing and infection, hydrocephalus, operatively. Thus, solely eliminating preoperatively existing
syndrome of the trephined, bone resorption, and persistent compression may be insufficient. The aim is also to create a
vegetative state. Also epilepsy and CSF leakage through scalp novel reserve capacity to accommodate space claiming ele-
incisions are described [28, 82]. ments to develop. In this context, the term Bdecompressive
This review aims to provide a compilation of the technical craniectomy^ seems imprecise and the description Bspace
facets of DC performed for TBI by filtering those features that gaining surgery^ may be more accurate to clarify the two
enhance the decompressive effect and evaluates if there is a components of the procedure.
strong recommendation for clinical practice.
An online research for literature in PubMed was performed
on October 24th, 2012. The search term Bdecompressive Structures causing elevated ICP
c r a n i e c to m y te c h n i q u e ^ g e n e r a t e d 7 0 t i t l e s a n d
The head can be divided into extracranial, obligatory intracra-
Table 1 Infrequent indications for supratentorial decompressive
nial, and optional intracranial sections. Table 2 mentions the
surgery individual structures and their role in the context of compres-
sion and elevated ICP.
Pathology Reference The cephalic bone and the dura as restrictive factors as well
Herpes simplex encephalitis Bayram et al. [9] as optional intracranial space occupying elements are poten-
Yan [80] tially responsible for elevated ICP. These structures have to be
Encephalitis Aghakhani et al. [2] overcome when elevated ICP turns out to be recalcitrant to
Taferner et al. [73] medical treatment and indication for surgical treatment is
Schwab et al. [69] provided.
Empyema Aghakhani et al. [2] When opening the skull, the preoperative extra- and intra-
Methadone intoxication Aghakhani et al. [2] cranial compartments of the head merge and become a single
Meningoencephalitis Aghakhani et al. [2] unit. Consequently, the number of possible restrictive struc-
Reye’s syndrome Aghakhani et al. [2] tures postoperatively increases as the scalp with the galea and
Ausman et al. [7] the temporal muscle get in direct contact with the intracranial
Chi et al. [10] structures.
Aneurysmal subarachnoid hemorrhage Arikan et al. [6]
Güresir et al. [25]
Toxoplasmosis Agrawal and Hussain [3]
Surgical targets for space gaining maneuvers
Dural sinus thrombosis Stefini et al. [70]
Lanterna et al. [47] in supratentorial DC
Lead encephalopathy McLaurin and Nichols [51]
Greengard [22] All extra- and intracranial structures can be the target of sur-
gery (Table 3).
Neurosurg Rev (2015) 38:629–640 631

Table 2 Extra- and intracranial

structures contributing to Extracranial Intracranial
compression and elevated
intracranial pressure (ICP) Obligatory Optional

Scalp with galeaa Duraa, b Edemac, d

a
Temporal muscle Brain Hematoma Epiduralc, d
Cephalic bonea, b Intravascular blood volume Subduralc, d
Cerebrospinal fluid Intracerebralc, d
Contusionc, d
Hydrocephalusc, d
a
Potentially postoperatively restrictive
b
Potentially preoperatively restrictive
c
Potentially contributing to preoperatively elevated ICP
d
Potentially contributing to postoperatively elevated ICP

Skin incision
The shape of the cutaneous incision depends on the localiza-
tion of the DC that can be performed unilaterally, bilaterally,
stepwise bilaterally, and bifrontally. Incisions visualizing ana-
tomical landmarks as the sagittal suture, the upper point of the
zygoma, and the lambdoid suture reduce the risk of injury of
the superior sagittal sinus (SSS) and the transverse sinus and
to perform too small craniotomies.
For unilateral surgery, mainly three variants of incision
are used: the increased Btrauma flap^ or expanded
Breversed question mark incision,^ the BT-incision,^ and
the Binverse U-incision.^ The incision for the increased
Btrauma flap^ (Fig. 1a) begins no more than 1 cm anterior
to the tragus. It then curves in the form of a question mark
around the top of the pinna posteriorly to the occipital
region, passes the lambdoid suture, and runs up to and
then follows the midline to reach the hairline with a short
incision of about 1 cm directed to the contralateral side.
To reach more posteriorly, Johnson et al. propose to add a
short relieving incision in the occipital region [33]. The
superficial temporal artery (STA) with its frontal and pa-
rietal branches that supply the lateral territory of the scalp
is preserved. The posterior auricular artery (PAA) and the
occipital artery (OA) with its branches, however, may be
incised depending on the inferior and posterior extension
of the cutaneous incision. A small question mark incision
that runs too far from the midline and does not reach the
hairline may cause impaired wound healing due to insuf-
ficient blood supply as the width of the flap may be too
small at the ratio of its length. Furthermore, a small skin
incision limits the exposure of the bone and the size of the
craniectomy. The BT-incision^ (Fig. 1b) that exposes also
the aforementioned landmarks was described by Kempe
for hemispherectomy [39]. The BT^ consists of two
straight elements: a fronto-occipital midline incision and
a perpendicular incision going down from about 2 cm
posterior to the coronal suture just anterior to the tragus.
This incision sacrifices the parietal branch of the STA and
preserves the PAA and OA. The inverted BU-incision^
(Fig. 1c) runs from the frontal to the occipital region
reaching the midline [33]. This incision eliminates the risk

Table 3 Overview of surgical

targets for space gaining
maneuvers in supratentorial
decompressive surgery
Surgical target structure Procedure
Scalp with galea Galeotomy, scalp plasty
Temporal muscle Partial resection
Skull bone Craniectomy: unilateral, bilateral, bifrontal approach;
craniotomy with reinsertion of bone flap; osseous
decompression extending to the temporal floor;
osseous thinning, smoothen borders
Dura Durotomy, duraplasty
Vessels Vascular tunnel
Hematoma (epidural, subdural, intracerebral) Evacuation
Contused, infarcted, edematous brain Resection, partial lobectomy
Cerebrospinal fluid, hydrocephalus Cerebrospinal fluid drainage
Prophylactic procedure Subgaleal wound drainage
632
Fig. 1 Schematic drawings of the head illustrate the cutaneous incisions
(dashed lines) for decompressive craniectomy. Unilateral fronto-
temporo-parieto-occipital approach (a–c) in lateral view and bifrontal
approach (d) in anterior top-down view: increased Btrauma flap^ with
optional posteriorly directed incision (a), BT-incision^ (b), inverse BU-
incision^ (c), and bicoronal incision (d)
of a lesion of the STA and the PAA, whereas the OA may
be incised.
For the bifrontal approach (Fig. 1d), a bicoronal incision
begins no more than 1 cm anterior to the tragus. It follows a
line that lies about 1 cm posterior and parallel to the coronal
suture and reaches the corresponding starting point on the
contralateral side. There is no study that concludes a strong
recommendation of one specific skin incision.
Temporalis muscle
The skin flap and the temporal muscle can be elevated in two
layers with interfascial [84] or subfascial dissection of the
frontotemporal branch of the facial nerve and retrograde
subperiostal dissection [36, 58] of the temporal muscle. The
separation of the skin flap from the muscle allows to fold the
muscle inferiorly with sufficient exposure of the inferior part
of the squamous portion of the temporal bone. This is impor-
tant for the decompression of the temporal lobe.
Alternatively, the skin and the temporalis muscle can be
raised in one layer. The elevation of a myocutaneous flap is
less time consuming than the two layer technique but makes it
Neurosurg Rev (2015) 38:629–640
more difficult to fold the temporal muscle inferiorly. This may
limit the exposure of the temporal bone necessary for decom-
pression. Innervation and vascularization of the temporal mus-
cle and the integrity of the muscle fibers can be compromised.
The resulting edema of the muscle may further impede the
access to the floor of the middle cranial fossa and the decom-
pression of the temporal lobe. Postoperatively, muscle func-
tion may be affected.
An artificial dural substitute can be laid between the dura
and the internal surface of the temporal muscle to avoid the
formation of adhesions thereby facilitating cranioplasty with
less temporal muscle damage, operation time, and blood loss
[38].
With the removal of the cephalic bone, the elevated edem-
atous temporal muscle becomes part of the intracranial com-
partment and, thus, a space occupying intracranial element.
Park et al. [59] propose after surgery on 15 patients partial
resection of the temporal muscle and fascia down to the upper
part of the zygoma that corresponds to the floor of the middle
cranial fossa. When performing cranioplasty, they positioned
a prosthesis to fill the muscle defect with minor esthetic and
mechanical masticatory impairment.
Craniotomy—size
An important role is attributed to the size of craniotomy in
decompressive surgery. If the elevated bone flap is too small
the expanding brain can herniate already during the interven-
tion through the cranial defect, thus creating its strangulation
also known as external brain hernia, fungus cerebri [74],
mushrooming, or erectio cerebri [20]. Very large bone flaps
increase the risk of damaging structures (e.g., SSS, bridging
veins, transverse sinus) and may favor postoperative compli-
cations like hydrocephalus or the syndrome of the trephined.
Wirtz et al. [79] found in a geometric model the nonlinearity
of the diameter of craniectomy and the gained volume.
The dimensions of the craniotomy vary widely in the
reviewed literature between Bmore than 8 cm^ and Bat least
15 cm^ and result from case series (Table 4). The existing
literature does not provide class I evidence for the size of the
bone flap in space gaining surgery.
Craniotomy—unilateral approach
Craniotomy for a unilateral approach is performed in the
fronto-temporo-parieto-occipital or the fronto-temporo-
parietal area. The anterior-posterior and superior-inferior
extension determine the size of the craniotomy. The ana-
tomical landmarks of the craniotomy are anteriorly the
orbital rim and the frontal sinus, posteriorly the lambdoid
suture, superiorly the SSS, and inferiorly the upper point
of the zygoma that corresponds to the floor of the middle
cranial fossa. The dimension of the frontal sinus should be
Neurosurg Rev (2015) 38:629–640 633

Table 4 Size of supratentorial decompressive craniectomy for unilateral approach

Diameter Length×width Distance to midline

Equal or more than 8 cm Kunze et al. [46] 8×10 cm, 12×15 cm Yang et al. [82] 0 cm Kunze et al. [46]
10–11 cm Csókay et al. [14] 11×16 cm Güresir et al. [26] 1.0–1.5 cm Güresir et al. [26]
More than 11 cm Csókay et al. [15] 1.5 cm Güresir et al. [25] 2009
At least 12 cm Timofeev et al. [74] 2 cm Ragel et al. [63]
Michel et al. [54]
At least 15 cm Güresir et al. [25] >2.5 cm De Bonis et al. [18]
12–15 cm Valença et al. [76] 2.5–3 cm Timofeev et al. [74]

verified on the CT scan to avoid its opening. If the frontal
sinus is entered, it should be cranialized to reduce the risk
of postoperative CSF leak and infection.
For fronto-temporo-parieto-occipital craniotomy (Fig. 2a),
the bone flap reaches the occipital region by placing a burr
hole medially to the lambdoid suture [25, 26] (Fig. 2b). Re-
specting posteriorly, a line parallel and above the zygoma
minimizes the risk of lacerating the transverse or sigmoid
sinus. To avoid lesions of the SSS or the bridging veins, the
craniotomy should not be closer than 2 cm to the midline. De
Bonis et al. [19] propose in a retrospective review of 26 pa-
tients to place the superior border of the craniotomy at least
25 mm off the midline to reduce the risk of postoperative
hydrocephalus. Caudally, the craniotomy extends to the floor
of the middle cranial fossa to prevent brain stem compression
by the temporal lobe. The inferior part of the squamous por-
tion of the temporal bone is carefully removed with bone
rongeurs down to the temporal cranial base (Fig. 2a) [25, 26,
62]. In doing so, the creation of fractures or the expansion of
preexisting traumatic fractures that might cause bleeding may
be avoided. Münch et al. [57] state in a retrospective study of
49 patients the importance of the caudal extension down to the
temporal base over the size of the craniectomy. The reviewed
literature does not support strong recommendation for the po-
sitioning and local restriction of the craniotomy.
Craniotomy—bifrontal approach
The anterior border of the bifrontal craniectomy (Fig. 2c) rep-
resents the orbital rim; posteriorly, the craniectomy extends to
or 1 cm behind the coronal suture. Depending on the
pneumatization of the frontal bone, sparing of the frontal sinus
may not always be feasible. If it is entered, it should be
cranialized. A vascularized periostal flap can be elevated to

Fig. 2 Pictures of the skull reflect

the craniotomy line (dashed lines)
with temporal extension (solid
lines) of unilateral fronto-
temporo-parieto-occipital (a, b)
and bifrontal (c, d) decompressive
craniectomy. a Lateral view of a
craniotomy line for a large fronto-
temporo-parieto-occipital
craniectomy going down to the
temporal floor. b Posterior view
of a shows a burr hole (solid
circle) placed medially to the
lambdoid suture to include the
occipital region in the
craniectomy line. c Antero-lateral
top-down view of a bifrontal
craniectomy line reaching the
floor of the middle cerebral fossa.
d Antero-lateral top-down view
of a bifrontal craniectomy line to
lift two bone flaps that leave a
bone strip over the superior
sagittal sinus
634
place it over the cranialized frontal sinus. Caudally, the osse-
ous decompression goes down to the floor of the temporal
fossa. The bone flap is elevated in one piece. Alternatively,
it can be divided in a smaller and a larger part by adding a
unilateral parasagittal craniotomy line. After removal of the
smaller bone flap, the SSS can be exposed under vision what
may minimize its injury. Then the second and larger bone flap
is raised. Another technique is to lift one bone flap on each
side at which the SSS remains covered by bone (Fig. 2d).
Handling of the bone flap
At the end of the craniotomy, the raised bone flap can be left
out corresponding literally to the term craniectomy. Alterna-
tively, the bone is reinserted immediately.
Leaving the bone flap out
If the bone flap is not put back, it is either discarded or
preserved in different ways outside or in the patient’s
body to be available for later cranioplasty. External stor-
age comprises freezing, radiation, or sterilization in var-
ious manners. For internal preservation, the bone flap
can be placed in abdominal subcutaneous tissue. Alter-
natively, the bone flap is inserted in a subgaleal pouch
created by blunt or sharp dissection [45, 60]. As the
scalp covers the bone flap positioned under the galea,
there is less skin at disposal to accommodate brain ex-
ceeding the margin of the craniotomy. Hence, the decom-
pressive effect may be reduced.
Immediate reinsertion of the bone flap or substitutes
Different strategies were developed to combine in one opera-
tion the decompressive effect of craniectomy with the advan-
tages of cranioplasty that traditionally was performed at timely
distance. Khoo depicts in a technical note the Breplacement of
a self-adjusting^ bone flap [41]. Pieces of Raimondi catheter
tube are inserted and fixed in holes drilled on the cut surface of
the bone flap and the margin of the craniotomy. These con-
structs act like Bspring catheter connections^ that allow the
inward and outward movement of the bone flap according to
the protruding brain.
For the Bhinge^ technique [21, 35, 44, 68] (Fig. 3a),
the raised bone flap is reinserted and either fixed or
approximated with sutures or metal plates to the frontal
or upper border of the craniotomy. An additional plate
fixed only to the bone flap avoids its subsiding. The
creation of oblique cut surfaces by using a Gigli saw
also prevents the bone flap from sinking. Alternatively,
the craniotomy flap remains attached to the temporal
muscle and pericranium that act as a hinge [1, 56]. To
gain more space intracranially, the internal tabula of the
Neurosurg Rev (2015) 38:629–640
bone flap can be milled off. Valença et al. [76] modify
the raised craniotomy flap by cutting it vertically into
two approximate sized parts. The lateral borders of the
resulting pieces are fixed with two sutures to the margin
of the craniotomy (Fig. 3b). Thus, hinged to the skull,
the two bone flaps can open like window lids (Bin-win-
dow craniotomy^) in function of the underlying protrud-
ing brain. Inclining the craniotome prevents the bone
flap from subsiding later. Peethambaran and Valsalmony
[61] propose a similar procedure referred to as Bfour-
quadrant osteoplastic decompressive craniectomy^: They
cut the bone flap crosswise to obtain four similar pieces
they fix loosely among each other and to the margin of
the craniotomy. In a bifrontal craniotomy, Valença et al.
[77] reinsert immediately and hinge the bone flap to the
skull posteriorly with two sutures (Bcar hood decom-
pressive craniotomy^) (Fig. 3c).
In the area of the hinge, the decompression is less ef-
fective due to the reduced range of motion of the bone
flap. The hinge should therefore be placed far away from
the base of the temporal fossa. To avoid this disadvantage
of hinges, Ahn et al. perform the Bin situ floating resin
cranioplasty^ [4]. A 1-mm-thick resin flap that is about
5 mm larger than the original bone flap and that can ride
freely on the escaping brain is molded intraoperatively,
implanted, and fixed loosely with sutures. All hinge tech-
niques imply that the volume that is at disposal for the
protruding brain under the scalp is detracted from the
volume of the reinserted bone flap that may compromise
the decompressive effect.
Kenning et al. [40] compare in a retrospective review hinge
craniotomy (HC) to DC in 50 patients and find that HC seems
to be at least as good as DC concerning postoperative ICP
control and equivalent early clinical outcomes. Kano et al.
[37] found in a retrospective study of 58 patients HC with
ICP monitoring effective and safe without a significant differ-
ence in outcome.
Craniotomy margins
Flattening of the sharp surface of the craniotomy border re-
duces the risk of injury of exceeding brain [74, 76].
Durotomy—duraplasty
It is generally recognized that decompressive surgery re-
duces ICP in a double stage manner with removal of the
bone flap and subsequent durotomy [34, 65, 85]. Dura
opening is essential for the decompressive effect and as
a space gaining maneuver.
Numerous fashions of opening the dura are used when
performing unilateral decompressive surgery: stellate [15,
33, 44, 62], star-shape [15] or cruciate (Fig. 4a), fish
Neurosurg Rev (2015) 38:629–640
Fig. 3 Illustration of the hinge technique of supratentorial decompressive
surgery. Dashed line: craniotomy line. Solid line: Margin of the bone flap.
Curved arrows: indicate mobility. a The raised bone flap of a unilateral
fronto-temporo-parieto-occipital craniotomy is reinserted and anteriorly
attached with screws and plates to the skull, whereas the posterior plate is
mouth (Fig. 4b), horseshoe, dovetail [33], semicircular
[62], C-shaped fashion with spoke-wheel relief cuts
durotomy [27, 63] (Fig. 4c), and a U-shaped incision
based on the sphenoid wing [74] (Fig. 4d). Mracek
et al. [56] present a large curved incision with convexity
toward the skull base (Fig. 4e). For bifrontal decom-
pressive surgery, Kjellberg and Prieto [42] opened the
dura Bfish mouth^ like with incisions parallel to the an-
terior and caudal border of the craniotomy, directed to-
ward the SSS, and additional incisions close to the
pterion. Timofeev et al. [74] propose a BU-shaped^
durotomy pediculated to the SSS. Quinn et al. [62] illus-
trate a SSS-based shaped dural opening with an incision
going down to the floor of the temporal fossa (Fig. 4f).
To allow better distension of the swelling brain, two silk
ligatures can be applied to the most anterior part of the
SSS. The SSS between the ligatures as well as the falx
cerebri are then cut through with care to avoid parenchy-
mal and vessel injury [42, 62, 74] (Fig. 4g). Dural open-
ing for a bifrontal craniectomy at which the SSS remains
covered by bone is illustrated in Fig. 4h.
Yao et al. [83] present a gradual crosswise durotomy
and duroplasty performed in 12 patients. Likely that
gradual opening of the dura lowers the possible damage
of the underlying brain compared to the abrupt loss of
counterpressure due to instantaneous complete durotomy.
635
only fixed to the bone flap (lateral view). b The parts of the bisected bone
flap of an Bin-window craniotomy^ are only laterally attached to the skull
with sutures and can move outwards (lateral view). c A bifrontal bone flap
fixed posteriorly with sutures to the skull can move upwards, Bcar hood
decompressive craniotomy^ (antero-lateral top-down view)
Like the size of craniotomy, the size and fashion of
dural opening are important: If the durotomy is too
small, the brain can be compressed under the dural
edges, and if the opening is too large, postoperative hy-
drocephalus or the syndrome of the sinking flap may be
favored.
After the decompression, the dura is left open. Alter-
natively, duroplasty that furnishes additional space to en-
velop the swelling brain with autograft (vascularized
periostal flap) or allograft material may be performed.
Dura closure with a dural substitute may raise the risk
of infection [50]. Different sheets of artificial materials
are used as dural graft as well as anti-adhesion barrier.
These membranes may be sutured to the margins of the
durotomy or are laid sutureless on the cerebral cortex
under the dura or onto the dura. Mitchell et al. [55] per-
form a Blattice duroplasty^ without inserting additional
material (Fig. 4i) for the purpose of stepwise pressure
reduction and to limit the protrusion of the underlying
brain. They cover the exposed dura with a rectangular
lattice composed of parallel rows of straight 2-cm-long
staggered incisions. Duroplasty may decrease the inci-
dence of postoperative subdural effusion [81], CSF leak-
age, and wound breakdown with subsequent infection.
The necessity of dural closure, however, is still under
debate. Güresir et al. conclude that duraplasty is not
636
Fig. 4 Durotomy (dotted lines) of supratentorial decompressive surgery
(dashed lines: craniotomy lines). Stellate, star-shape, or cruciate (a); fish
mouth (b); C-shaped with spoke-wheel relief cuts (c); U-shaped based on
the sphenoid wing (d); and curved with convexity to the skull base (e)
durotomy for unilateral fronto-temporo-parieto-occipital surgery (lateral
view). f Dural incision for bifrontal decompressive craniectomy
extending to the temporal floor (antero-lateral top-down view). g In
necessary [26]. They open the dura in a stellate manner
and leave it unsutured. The dura and the underlying brain
Fig. 5 a Illustration of a cushion made of a folded rectangular piece of
hemostatic sponge and tightened with absorbable thread wound around
(anterior top-down view). The cushion acts as a spacer in the subdural
space. b Two-dimensional delineation of a subdural Bvascular tunnel^:
Neurosurg Rev (2015) 38:629–640
bifrontal craniectomy (antero-lateral top-down view), the superior
sagittal sinus (gray rectangle) is cut anteriorly with the falx (black solid
line) between two ligatures (black solid circles). h Durotomies in bifrontal
craniectomy with a bone strip left over the superior sagittal sinus (antero-
lateral top-down view). i Dural opening in the form of a mesh of straight
dural incisions (Blattice duroplasty^) for unilateral fronto-temporo-
parieto-occipital decompression (lateral view)
are then covered by hemostatic material. They found that
the Brapid closure technique^ saves operation time and
The cushions (k) depicted in a act as a protective spacer between the
vessels (h) and the overlying dura (b) when brain ( f ) protrudes because
of edema (g, arrows). Cephalic bone (a), subdural space (c), arachnoidea
(d), pia (e), protective space (double arrows)
Neurosurg Rev (2015) 38:629–640
does not create problems to find a dissection plane when
performing cranioplasty. There is no study that concludes
the superiority of one specific durotomy or duroplasty.
Vessels
After dura opening as well as postoperatively, brain swelling
may cause herniation of cerebral tissue with compression of
superficially running vessels under the border of the durotomy.
Csókay et al. [14, 15] describe the creation of a protective
vascular tunnel performed in 20 patients by placing cushions
parallel and on both sides of major vessels at the margins of the
durotomy. These pillars maintain the distance between the
swelling brain and the overlying dura, thus protecting the ves-
sels that run between the spacers from compression (Fig. 5a, b).
Hemorrhages in TBI
The removal of epidural and subdural hematomas is generally
accepted and performed. The beneficial effect of early evacu-
ation of traumatic intraparenchymal hematomas or contusions
is still under debate. International multicenter trials are con-
ducted [24, 52, 53].
Removal of contused or infarcted brain
The resection of brain tissue as a space gaining maneuver
during decompressive surgery is only exceptionally practiced.
Primarily, temporal [86] or anterior temporal lobectomy [11,
32] was described for patients with traumatic temporal lobe
contusions or hemispheric stroke [23].
CSF—hydrocephalus
According to the Monro-Kellie rule, external ventricular
drainage reduces ICP, and consequently, CSF drainage is prac-
ticed usually before DC [49]. As the correct positioning of an
external ventricular catheter may be technically difficult when
ventricles are displaced and narrow due to compression by
edematous brain, neuronavigation may be useful. The volume
of CSF that can be derived may be too little to lower ICP
sufficiently.
When external ventricular drain insertion has to be
performed at the same time as decompressive surgery,
the catheter should be placed before and on the contra-
lateral side of the craniectomy. Thus, ventricular drainage
with reduction of ICP can already start before decom-
pression, and neuronavigation can be used that might
otherwise lose its accuracy due to the displacement of
the brain after decompression. Another advantage of con-
tralateral placement of the EVD is that it is less prone to
displacement due to the expanding brain on the decom-
pressed side.
637
Scalp with galea—wound closure
Relaxing incisions of the rigid galea aponeurotica [64] enlarge
the inner surface of the cutaneous flap and the volume of the
underlying decompressed intracranial compartment. Wound
closure over massively swollen brain thus exerts less pressure.
Akutsu et al. [5] performed a plasty of the scalp with artificial
dermis in five patients with severe TBI to gain additional space.
Prophylactic procedures
Subgaleal wound drainage derives blood and wound fluid that
postoperatively compresses the dura and the underlying brain.
If duroplasty is not performed, a subgaleal drainage may favor
infection and CSF absorption problems. Sughrue et al., how-
ever, inserted in 127 patients who underwent DC without
dural closure two Jackson Pratt drains. They were left in place
for 3 to 8 days without complications [72].
Conclusion
The history of supratentorial space gaining surgery as part of
the armamentarium to treat elevated ICP is characterized by
the ingenuity to optimize the decompressive effect of the in-
tervention and to accommodate postoperatively swelling
brain. Various technical measures had been tried for all in-
volved intra- and extracranial structures. The published inno-
vations that might be intuitively plausible are often experi-
ences of a single institution with few patients treated. The
literature reviewed does not supply class I evidence that the
improvement of the decompressive effect of single features
reduces peri- and postoperative complications and furnishes
a better functional outcome of the operated patients. Conse-
quently, there is at present no undoubted design of an ideal
decompressive surgery.
For the efficacy of DC, it is indispensable to understand the
pathophysiological processes and time course of TBI and HIS
and the effect of the single decompressive maneuvers on these
processes. Therefore, studies are needed that elucidate the
nature and time course of brain edema formation and the effect
of shear forces on the brain tissue. This knowledge may help
to create a model of space gaining surgery that could serve as
subject to further studies.
Conflict of interest The author declares that he has no conflict of in-
terest or financial disclosure.
References
1. Adeleye AO, Azeez AL (2011) Decompressive craniectomy bone
flap hinged on the temporalis muscle: a new inexpensive use for an
old neurosurgical technique. Surg Neurol Int 2:150
638
2. Aghakhani N, Durand P, Chevret L et al (2009) Decompressive
craniectomy in children with nontraumatic refractory high intracra-
nial pressure. Clinical article. J Neurosurg Pediatr 3(1):66–69
3. Agrawal D, Hussain N (2005) Decompressive craniectomy in ce-
rebral toxoplasmosis. Eur J Clin Microbiol Infect Dis 24(11):772–
773
4. Ahn DH, Kim DW, Kang SD (2009) In situ floating resin
cranioplasty for cerebral decompression. J Korean Neurosurg Soc
46(4):417–420
5. Akutsu N, Aihara H, Sakurai A, Kusaka J, Yasuda M, Kohmura E
(2013) New technique of decompressive skinplasty with artificial
dermis for severe brain swelling: technical note. Neurol Med Chir
(Tokyo) 53(1):56–60
6. Arikan F, Vilalta J, Romero FJ et al (2010) Primary decompressive
craniectomy in patients with subarachnoid hemorrhage. Results of a
pilot study in 11 cases. Neurocirugia (Astur) 21(6):452–460
7. Ausman JI, Rogers C, Sharp HL (1976) Decompressive
craniectomy for the encephalopathy of Reye’s syndrome. Surg
Neurol 6(2):97–99
8. Bauer KH (1932) Die zirkuläre Kraniotomie als
Entlastungstrepanation bei drohender Turmschädelerblindung
und bei nicht lokalisierbaren Hirngeschwülsten. Dt Z Chirurgie
237:401–42
9. Bayram N, Ciftdogan DY, Karapinar B et al (2008) A case of herpes
simplex encephalitis revealed by decompressive craniectomy. Eur J
Pediatr 167(7):821–822
10. Chi CS, Law KL, Wong TT, Su GY, Lin N (1990) Continuous
monitoring of intracranial pressure in Reye’s syndrome—5 years
experience. Acta Paediatr Jpn 32(4):426–434
11. Cho DY, Chen TC, Lee HC (2003) Ultra-early decompressive
craniectomy for malignant middle cerebral artery infarction. Surg
Neurol 60(3):227–232
12. Clark K, Nash TM, Hutchison GC (1968) The failure of circumfer-
ential craniotomy in acute traumatic cerebral swelling. J Neurosurg
29(4):367–371
13. Cooper DJ, Rosenfeld JV, Murray L et al (2011) Decompressive
craniectomy in diffuse traumatic brain injury. N Engl J Med
364(16):1493–1502
14. Csókay A, Nagy L, Novoth B (2001) Avoidance of vascular com-
pression in decompressive surgery for brain edema caused by trau-
ma and tumor ablation. Neurosurg Rev 24(4):209–213
15. Csókay A, Együd L, Nagy L, Pataki G (2002) Vascular tunnel
creation to improve the efficacy of decompressive craniotomy in
post-traumatic cerebral edema and ischemic stroke. Surg Neurol
57(2):126–129
16. Cushing H (1905) The establishment of cerebral hernia as a decom-
pressive measure for inaccessible brain tumors; with the description
of intramuscular methods of making the bone defect in temporal
and occipital regions. Surg Gynecol Obstet I:297–314
17. Cushing H (1908) I. Subtemporal decompressive operations for the
intracranial complications associated with bursting fractures of the
skull. Ann Surg 47(5):641–644
18. De Bonis P, Pompucci A, Mangiola A, D’Alessandris QG, Rigante
L, Anile C (2010) Decompressive craniectomy for the treatment of
traumatic brain injury: does an age limit exist? J Neurosurg 112(5):
1150–115
19. De Bonis P, Pompucci A, Mangiola A, Rigante L, Anile C (2010)
Post-traumatic hydrocephalus after decompressive craniectomy: an
underestimated risk factor. J Neurotrauma 27(11):1965–1970
20. Gaab MR, Rittierodt M, Lorenz M, Heissler HE (1990) Traumatic
brain swelling and operative decompression: a prospective investi-
gation. Acta Neurochir Suppl (Wien) 51:326–328
21. Goettler CE, Tucci KA (2007) Decreasing the morbidity of decom-
pressive craniectomy: the Tucci flap. J Trauma 62(3):777–778
22. Greengard J, Voris DC, Hayden R (1962) The surgical therapy of
acute lead encephalopathy. JAMA 180:660–664
Neurosurg Rev (2015) 38:629–640
23. Greenwood J Jr (1968) Acute brain infarctions with high intracra-
nial pressure: surgical indications. Johns Hopkins Med J 122(5):
254–260
24. Gregson BA, Rowan EN, Mitchell PM et al (2012) Surgical trial in
traumatic intracerebral hemorrhage (STITCH(Trauma)): study pro-
tocol for a randomized controlled trial. Trials 13:193
25. Güresir E, Schuss P, Vatter H, Raabe A, Seifert V, Beck J (2009)
Decompressive craniectomy in subarachnoid hemorrhage.
Neurosurg Focus 26(6):4
26. Güresir E, Vatter H, Schuss P, Oszvald A, Raabe A, Seifert V et al
(2011) Rapid closure technique in decompressive craniectomy. J
Neurosurg 114(4):954–960
27. Holland M, Nakaji P (2004) Craniectomy: surgical indications and
technique. Oper Tech Neurosurg 7(1):10–15
28. Honeybul S, Ho KM (2011) Long-term complications of decom-
pressive craniectomy for head injury. J Neurotrauma 28(6):929–
935
29. Honeybul S, Ho KM, Lind CR, Gillett GR (2010) Decompressive
craniectomy for neurotrauma: the limitations of applying an out-
come prediction model. Acta Neurochir (Wien) 152(6):959–964
30. Huang X, Wen L (2010) Technical considerations in decompressive
craniectomy in the treatment of traumatic brain injury. Int J Med Sci
7(6):385–390
31. Hutchinson PJ, Corteen E, Czosnyka M et al (2006) Decompressive
craniectomy in traumatic brain injury: the randomized multicenter
RESCUEicp study (www.RESCUEicp.com). Acta Neurochir
Suppl 96:17–20
32. Ivamoto HS, Numoto M, Donaghy RM (1974) Surgical decom-
pression for cerebral and cerebellar infarcts. Stroke 5(3):365–370
33. Johnson RD, Maartens NF, Teddy PJ (2011) Technical aspects of
decompressive craniectomy for malignant middle cerebral artery
infarction. J Clin Neurosci 18(8):1023–1027
34. Jourdan C, Convert J, Mottolese C, Bachour E, Gharbi S, Artru F
D1993] EEvaluation of the clinical benefit of decompression
hemicraniectomy in intracranial hypertension not controlled by
medical treatment^. Neurochirurgie 39D5]:304–310, French
35. Jung SM, Kim SW, Lee SM (2004) Modified decompressive cra-
niotomy for control of intracranial pressure. J Korean Neurosurg
Soc 36:260–263
36. Kadri PA, Al-Mefty O (2004) The anatomical basis for surgical
preservation of temporal muscle. J Neurosurg 100(3):517–522
37. Kano T, Kurosaki S, Wada H (2012) Retrospective analysis of
hinge technique for head trauma or stroke. Neurol Med Chir
(Tokyo) 52(11):816–821
38. Kawaguchi T, Hosoda K, Shibata Y, Koyama J (2003) Expanded
polytetrafluoroethylene membrane for prevention of adhesions in
patients undergoing external decompression and subsequent
cranioplasty. Neurol Med Chir (Tokyo) 43(6):320–323
39. Kempe LK (2004) Hemispherectomy. In: Kempe’s operative neu-
rosurgery, 2nd ed, vol 1. New York: Springer, 170−176
40. Kenning TJ, Gandhi RH, German JW (2009) A comparison of
hinge craniotomy and decompressive craniectomy for the treatment
of malignant intracranial hypertension: early clinical and radio-
graphic analysis. Neurosurg Focus 26(6):E6
41. Khoo JC (1976) Replacement of a self-adjusting bone flap.
Technical note. J Neurosurg 45(5):589–591
42. Kjellberg RN, Prieto A Jr (1971) Bifrontal decompressive craniot-
omy for massive cerebral edema. J Neurosurg 34(4):488–493
43. Kocher T (1901) Die Therapie des Hirndrucks. In: Hölder A (ed)
Hirnerschütterung, Hirndruck und chirurgische Eingriffe bei
Hirnkrankheiten. Hölder, Wien, pp 262–266
44. Ko K, Segan S (2007) In situ hinge craniectomy. Neurosurgery
60(4 Suppl 2):255–258
45. Krishnan P, Bhattacharyya AK, Sil K, De R (2006) Bone flap pres-
ervation after decompressive craniectomy—experience with 55
cases. Neurol India 54(3):291–292
Neurosurg Rev (2015) 38:629–640
46. Kunze E, Meixensberger J, Janka M, Sörensen N, Roosen K (1998)
Decompressive craniectomy in patients with uncontrollable intra-
cranial hypertension. Acta Neurochir Suppl 71:16–18
47. Lanterna LA, Gritti P, Manara O et al (2009) Decompressive sur-
gery in malignant dural sinus thrombosis: report of 3 cases and
review of the literature. Neurosurg Focus 26(6):E5
48. Li CH, Yang SH, Wang HS, Tu YK, Kuo MF (2010) Use of the
Bmortise and tenon^ principle in the augmentation of autologous
cranioplasty using bone cement in a child. Childs Nerv Syst 26(12):
1807–1811
49. Li LM, Timofeev I, Czosnyka M, Hutchinson PJ (2010) Review
article: the surgical approach to the management of increased intra-
cranial pressure after traumatic brain injury. Anesth Analg 111(3):
736–748
50. Malliti M, Page P, Gury C, Chomette E, Nataf F, Roux FX (2004)
Comparison of deep wound infection rates using a synthetic dural
substitute (neuro-patch) or pericranium graft for dural closure: a
clinical review of 1 year. Neurosurgery 54(3):599–603
51. McLaurin RL, Jr Nichols JB (1957) Extensive cranial decompres-
sion in the treatment of severe lead encephalopathy. Pediatrics
20(4):653–667
52. Mendelow AD, Gregson BA, Fernandes HM et al (2005) Early
surgery versus initial conservative treatment in patients with spon-
taneous supratentorial intracerebral haematomas in the International
Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised
trial. Lancet 365(9457):387–397
53. Mendelow AD, Gregson BA, Mitchell PM, Murray GD, Rowan
EN, Gholkar AR (2011) Surgical trial in lobar intracerebral haem-
orrhage (STICH II) protocol. Trials 2:124
54. Michel P, Arnold M, Hungerbühler HJ et al (2009) Decompressive
craniectomy for space occupying hemispheric and cerebellar ische-
mic strokes: Swiss recommendations. Int J Stroke 4(3):218–223
55. Mitchell P, Tseng M, Mendelow AD (2004) Decompressive
craniectomy with lattice duraplasty. Acta Neurochir (Wien)
146(2):159–160
56. Mracek J, Choc M, Mork J, Vacek P, Mracek Z (2011) Osteoplastic
decompressive craniotomy—an alternative to decompressive
craniectomy. Acta Neurochir (Wien) 153(11):2259–2263
57. Münch E, Horn P, Schürer L, Piepgras A, Paul T, Schmiedek P
(2000) Management of severe traumatic brain injury by decom-
pressive craniectomy. Neurosurgery 47(2):315–322
58. Oikawa S, Mizuno M, Muraoka S, Kobayashi S (1996) Retrograde
dissection of the temporal muscle preventing muscle atrophy for
pterional craniotomy. Technical note. J Neurosurg 84(2):297–299
59. Park J, Kim E, Kim GJ, Hur YK, Guthikonda M (2009) External
decompressive craniectomy including resection of temporal muscle
and fascia in malignant hemispheric infarction. J Neurosurg 110(1):
101–105
60. Paşaoğlu A, Kurtsoy A, Koc RK et al (1996) Cranioplasty with
bone flaps preserved under the scalp. Neurosurg Rev 19(3):153–
156
61. Peethambaran AK, Valsalmony J (2012) Four-quadrant osteoplastic
decompressive craniotomy: a novel technique for decompressive
craniectomy avoiding revision cranioplasty after surgery. Neurol
India 60(6):672–674
62. Quinn TM, Taylor JJ, Magarik JA, Vought E, Kindy MS, Ellegala
DB (2011) Decompressive craniectomy: technical note. Acta
Neurol Scand 123(4):239–244
63. Ragel BT, Klimo P Jr, Martin JE, Teff RJ, Bakken HE, Armonda
RA (2010) Wartime decompressive craniectomy: technique and
lessons learned. Neurosurg Focus 28(5):E2
64. Raposio E, Santi P, Nordström RE (1998) Effects of galeotomies on
scalp flaps. Ann Plast Surg 41(1):17–21
65. Reithmeier T, Löhr M, Pakos P, Ketter G, Ernestus RI (2005)
Relevance of ICP and ptiO2 for indication and timing of
639
decompressive craniectomy in patients with malignant brain ede-
ma. Acta Neurochir (Wien) 147(9):947–951
66. Sahuquillo J (2006) Decompressive craniectomy for the treatment
of refractory high intracranial pressure in traumatic brain injury.
Cochrane Database Syst Re, issue 1. Art. No.: CD003983. doi:10.
1002/14651858.CD003983.pub2
67. Sahuquillo J, Martínez-Ricarte F, Poca MA (2013) Decompressive
craniectomy in traumatic brain injury after the DECRA trial. Where
do we stand? Curr Opin Crit Care 19(2):101–106
68. Schmidt JH 3rd, Reyes BJ, Fischer R, Flaherty SK (2007) Use of
hinge craniotomy for cerebral decompression. Technical note. J
Neurosurg 107(3):678–682
69. Schwab S, Jünger E, Spranger M et al (1997) Craniectomy: an
aggressive treatment approach in severe encephalitis. Neurology
48(2):412–417
70. Stefini R, Latronico N, Cornali C, Rasulo F, Bollati A (1999)
Emergent decompressive craniectomy in patients with fixed dilated
pupils due to cerebral venous and dural sinus thrombosis: report of
three cases. Neurosurgery 45(3):626–629
71. Stiver SI (2009) Complications of decompressive craniectomy for
traumatic brain injury. Neurosurg Focus 26(6):E7
72. Sughrue ME, Bloch OG, Manley GT, Stiver SI (2011) Marked
reduction in wound complication rates following decompressive
hemicraniectomy with an improved operative closure technique. J
Clin Neurosci 18(9):1201–1205
73. Taferner E, Pfausler B, Kofler A et al (2001) Craniectomy in severe,
life-threatening encephalitis: a report on outcome and long-term
prognosis of four cases. Intensive Care Med 27(8):1426–1428
74. Timofeev I, Santarius T, Kolias AG, Hutchinson P (2012)
Decompressive craniectomy—operative technique and periopera-
tive care. Adv Tech Stand Neurosurg 38:11–36
75. Vahedi K, Hofmeijer J, Juettler E et al (2007) Early decompressive
surgery in malignant infarction of the middle cerebral artery: a
pooled analysis of three randomized controlled trials. Lancet
Neurol 6(3):215–222
76. Valença MM, Martins C, da Silva JC (2010) BIn-window^ craniot-
omy and Bbridgelike^ duraplasty: an alternative to decompressive
hemicraniectomy. J Neurosurg 113(5):982–989
77. Valença MM, Martins C, da Silva JC, Mendonça CMF, Ambrosi
PB, Andrade-Valença LPA (2012) An innovative technique of de-
compressive craniectomy for acute ischemic stroke. In: Balestrino
M (ed) Advances in the treatment of ischemic stroke. http://www.
intechopen.com/books/advances-in-the-treatment-of-ischemic-
stroke/decompressive-craniectomy-for-cerebral-ischemia.
Accessed 12 Apr 2013
78. Whitfield PC, Patel H, Hutchinson PJ, Czosnyka M, Parry D,
Menon D (2001) Bifrontal decompressive craniectomy in the man-
agement of posttraumatic intracranial hypertension. Br J Neurosurg
15(6):500–507
79. Wirtz CR, Steiner T, Aschoff A et al (1997) Hemicraniectomy with
dural augmentation in medically uncontrollable hemispheric infarc-
tion. Neurosurg Focus 2(5):E3
80. Yan HJ (2002) Herpes simplex encephalitis: the role of surgical
decompression. Surg Neurol 57(1):20–24
81. Yang XJ, Hong GL, Su SB, Yang SY (2003) Complications in-
duced by decompressive craniectomies after traumatic brain injury.
Chin J Traumatol 6(2):99–103
82. Yang XF, Wen L, Shen F et al (2008) Surgical complications sec-
ondary to decompressive craniectomy in patients with a head inju-
ry: a series of 108 consecutive cases. Acta Neurochir (Wien)
150(12):1241–1247
83. Yao Y, Mao Y, Zhou L (2007) Decompressive craniectomy for
massive cerebral infarction with enlarged cruciate duraplasty. Acta
Neurochir (Wien) 149(12):1219–1221
84. Yaşargil MG, Reichman MV, Kubik S (1987) Preservation of the
frontotemporal branch of the facial nerve using the interfascial
640
temporalis flap for pterional craniotomy. Technical article. J
Neurosurg 67(3):463–466
85. Yoo DS, Kim DS, Cho KS, Huh PW, Park CK, Kang JK (1999)
Ventricular pressure monitoring during bilateral decompression
with dural expansion. J Neurosurg 91(6):953–959
86. Young PH, Smith KR Jr, Dunn RC (1982) Surgical decompression
after cerebral hemispheric stroke: indications and patient selection.
South Med J 75(4):473–475
Comments
George M. Ghobrial, Jack Jallo, Philadelphia, USA
Decompressive hemicraniectomies remain in practice as an emergen-
cy, cost-effective, tried, and true measure in a neurosurgeon’s armamen-
tarium for the life-sparing treatment of malignant intracranial hyperten-
sion in the setting of traumatic brain injury, extra-axial intracranial hem-
orrhage, and malignant infarction. Varying surgical techniques are en-
countered in prospective studies and operative atlases, while nuances
and refinements are passed down over each generation through tradition
and residency training. While the general goals of surgery remain the
same—for the rapid relief of intracranial hypertension and the decom-
pression of the brainstem and critical structures—considerable variation
in technique is encountered. The authors set out to answer the question as
to what specific technical specifications that contribute to the variation in
this technique are supported in the medical literature by way of high-
quality medical evidence through a review of the literature. The authors
Neurosurg Rev (2015) 38:629–640
encounter numerous studies demonstrating the early benefits of emergen-
cy decompression through lowered mortality. Unsurprisingly, they en-
counter very few publications addressing various technical nuances, such
as an ideal craniectomy flap size. In the question of the benefit of maxi-
mizing the craniectomy flap to the fullest extent possible, which for many
is the overarching goal of decompression, support is encountered in ret-
rospective studies that larger is better—particularly an improvement in
mortality when the anteroposterior diameter exceeded 10 cm.1 While this
question seems intuitive to many neurosurgeons, this study highlights the
scarcity of high-quality literature in a procedure performed at a relatively
high volume. Importantly, this manuscript highlights the fact that level I
studies providing favorable2 and unfavorable3 evidence for intervention
are performed with different techniques which are not well evaluated in
the literature.
References
1. Sedney CL, Julien T, Manon J, et al. The effect of craniectomy size
on mortality, outcome, and complications after decompressive
craniectomy at a rural trauma center. Journal of neurosciences in rural
practice 2014;5:212–7.
2. Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter,
randomized, controlled trial of early decompressive craniectomy in ma-
lignant middle cerebral artery infarction (DECIMAL Trial). Stroke; a
journal of cerebral circulation 2007;38:2506–17.
3. Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive
craniectomy in diffuse traumatic brain injury. The New England journal
of medicine 2011;364:1493–502.