Question 9

What are the indications for decompressive craniectomy?  Briefly outline the complications of decompressive craniectomy. Comment  briefly on the outcome from decompressive craniectomy.

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College Answer

Recognised indications

  • Malignant MCA infarction

Indications for which there is anecdotal  evidence:

  • Refractory intracranial hypertension following TBI
  • Cerebral swelling from vasospasm and SAH
  • Hypertensive bleeds
  • Encephalitis
  • Cerebral venous thrombosis


  • Infection
  • Collections –subgaleal and subdural collections usually on the ipsilateral side.
  • Bleeding
  • Brain herniation through the craniotomy
  • Venous thrombosis secondary to herniation through the defect and occlusion of venous circulation.
  • Sinking flap syndrome
  • Paradoxical subtentorial herniation with LP or CSF drainage – due to atmospheric pressure – intracranial pressure gradient
  • Hydrocephalus
  • Bone flap resorption
  • Worsening of brain injury


 Long term data are lacking. Although hospital survival is improved in patients with refractory ICP in head injury and malignant infarction, quality of survival needs further evaluation. Age is important in patient selection and current recommendation for DCI in malignant MCA infarcts is <50 and considered on a case by case basis over 50. Paediatric data suggest better outcome in paediatric head injuries.


Decompressive craniectomy in general, and within the specific context of a malignant MCA infarction, is discussed in great detail elsewhere:

Additionally, LITFL have a nice summary page on this topic.

To simplify revision, a summary table is lazily pasted here.

Decompressive Craniectomy In Brief Summary




  • Herniation though the defect
  • Delayed paradoxical herniation
  • Subdural hygroma
  • Infection
  • Bleeding
  • Post-traumatic hydrocephalus
  • "Sinking Flap Syndrome"
  • Bone resorption


Traumatic brain injury


  • Unchanged mortality
  • Worse disability outcome

Malignant MCA infarction syndrome


  • Improved mortality
  • Unchanged disability outcome
  • Only 14% of survivors "could look after their own affairs without assistance"

Subarachnoid haemorrhage

  • Unchanged mortality
  • For the majority, unchanged disability
  • Good long-term outcome in 25%
  • Careful patient selection is key:
    • Progressive brain oedema
    • No radiological signs of infarction
    • Obvious haematoma

Intraparenchymal intracranial haemorrhage

  • Probably improved mortality
  • Unchanged disability outcome

Dural sinus thrombosis

  • Probably improved mortality
  • Probably improved disability


  • Improved survival
  • Improved disability

Subdural haematoma

  • Unchanged mortality
  • Unchanged disability outcome

In a nontabulated form, one might answer thus:

Indications for a decompressive craniectomy:

  • Raised intracranial pressure due to
    • Traumatic brain injury
    • Severe intracranial haemorrhage with midline shift
    • Malignant MCA infarction syndrome
    • Subarachnoid haemorrhage
    • Intraparenchymal intracranial haemorrhage
    • Dural sinus thrombosis
    • Encephalitis
    • Subdural haematoma

Why is malignant MCA infarction a "recognised indication"? Well. Three European trials confirmed that mortality from massive MCA infarction is halved with craniectomy, and that is hard to argue with.

Complications of decompressive craniectomy:

  • Brain hernation though the opening
  • Delayed paradoxical herneation
  • Subdural hygroma
  • Infection
  • Bleeding
  • Post-traumatic hydrocephalus
  • Syndrome of the Trephined, or "Sinking Flap Syndrome"
  • Bone resorption

Outcome of decompressive craniectomy:

  • MCA infarct patients: mortality improved by 50%
  • Traumatic brain injury patients: mortality unchanged, but neurological outcome was worse in the craniectomized patients.


Cooper, D. James, et al. "Decompressive craniectomy in diffuse traumatic brain injury." New England Journal of Medicine 364.16 (2011): 1493-1502.

Vahedi, Katayoun, et al. "Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial)." Stroke 38.9 (2007): 2506-2517.

Hofmeijer, Jeannette, et al. "Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial." The Lancet Neurology 8.4 (2009): 326-333.

Jüttler, Eric, et al. "Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY) a randomized, controlled trial." Stroke 38.9 (2007): 2518-2525.

Lee, Kyeong Woo, et al. "Functional Outcomes of Patients with Severe MCA Infarction after Decompressive Craniectomy." Brain & Neurorehabilitation 7.1 (2014): 48-53.

Tuzgen, Saffet, et al. "Decompressive craniectomy in patients with cerebral infarction due to malignant vasospasm after aneurysmal subarachnoid hemorrhage." Journal of neurosciences in rural practice 3.3 (2012): 251.

Murthy, J. M. K., et al. "Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage." Neurocritical care 2.3 (2005): 258-262.

Güresir, Erdem, et al. "Decompressive craniectomy in subarachnoid hemorrhage." Neurosurgical focus 26.6 (2009): E4.

Keller, E., et al. "Decompressive craniectomy in severe cerebral venous and dural sinus thrombosis." New Trends of Surgery for Stroke and its Perioperative Management. Springer Vienna, 2005. 177-183.

Schirmer, Clemens M., Daniel A. Hoit, and Adel M. Malek. "Decompressive hemicraniectomy for the treatment of intractable intracranial hypertension after aneurysmal subarachnoid hemorrhage." Stroke 38.3 (2007): 987-992.

Adamo, Matthew A., and Eric M. Deshaies. "Emergency decompressive craniectomy for fulminating infectious encephalitis." (2008). Journal of Neurosurgery January 2008 / Vol. 108 / No. 1 / Pages 174-176

Hutchinson, Peter, Ivan Timofeev, and Peter Kirkpatrick. "Surgery for brain edema." Neurosurgical focus 22.5 (2007): 1-9.

Margules, Andrew, and Jack Jallo. "Complications of decompressive craniectomy." JHN Journal 5.1 (2010): 4.