Decompressive craniectomy is described as a surgical technique to treat malignant cerebral edema and refractory intracranial hypertension. It involves removing part of the skull bone and dura to allow the brain room to swell externally rather than being compressed. The key steps include identifying anatomical landmarks, making burr holes connected by bone removal to create a bone flap, opening and closing the dura, and standard scalp closure. Post-operative care focuses on managing complications like hydrocephalus or seizures. While early decompressive craniectomy can improve outcomes for conditions like severe traumatic brain injury, further research is still needed to fully understand its long-term costs and benefits.

1. FTP Decompressive Craniotomy:
How I do it?
Dr Amit Agrawal, MCh
Professor of Neurosurgery
Narayana Medical College and Hospital
Nellore (AP)

2. Conflict of interest
• None

3. • Background
• Introduction
• Indications
• Contraindications
• Surgical technique
• Post-operative care
• Complications
• Cranioplasty
• Follow up

4. • Decompressive craniectomy helps to prevent
secondary brain injury due to uncontrolled
brain edema*
• Malignant cerebral edema-mortality is nearly
100 %**
Background
*Grindlingerv et al. Decompressive craniectomy for severe traumatic brain
injury: clinical study, literature review and meta-analysis
*Brain Trauma Foundation (2007) Guidelines for the management of severe
traumatic brain injury. J Neurotrauma 24:1-106
**Miller et al. Significance of intracranial hypertension in severe head injury. J
Neurosurg 47:503-516

5. Decompressive hemicraniectomy
• Removal of bone flap followed by duroplasty
and thus allows edematous brain to herniate
externally rather than downwards
• Prevents brainstem compression and its
sequel

6. Neurosurg Clin N Am 24 (2013) 375-391; Tarek Y. El Ahmadieh et al
Indications
• Severe TBI
– Focal (contusions/hematoma) and diffuse
– Coma or semicoma (GCS < 9)
– Refractory ICP despite best conventional therapy
– Pupillary abnormalities, but responding to mannitol
• Malignant MCA infarction
• Cerebral venous thrombosis
• Deep seated intracerebral hematoma

8. Contraindications
• Signs of fatal brain stem damage
• GCS < 4 or fixed and dilated bilateral pupils
• Poor general condition with abnormal
parameters particularly coagulation profile

9. How I do it?
• Being taught to us
• Being described in the literature
• With regular updates with contemporary
literature
• Customized to the circumstances

10. Essentials
• Detail clinical evaluation
• Detail radiological interpretation
• A proper informed consent
• Verify the correct indication
• Identify the correct patient/site
• Cervical spine precautions
• Detail counseling to the relatives including
discussions regarding expectations

11. Decompressive hemicraniectomy
• Supine
• Foam/rubber horseshoe
• No pins
• Rolled towel beneath ipsilateral shoulder
• Head towards contralateral side
• Make sure the jugulars are not compressed
and endotracheal tube is in position

12. Identification of anatomical landmarks
• Mark midline
• Mark coronal sutures
• Mark the incision outline
• Mark the bone flap outline

13. DHC
Surgical technique
• Incision - Reverse question mark
• Posterior extent -15 cm behind key hole
• Deepened down to cranium
• Myocutaneous flap
• Five burr holes
– Temporal squamous bone superior to the zygomatic
process inferiorly
– Keyhole area behind the zygomatic arch anteriorly
– Along the superior temporal line posteroinferiorly
– Parietal and Frontal parasagittal areas

14. Beez T, Munoz-Bendix C, Steiger H-J, Beseoglu K. Decompressive craniectomy for
acute ischemic stroke. Critical Care 2019;23:209.

15. Timofeev I, Santarius T, Kolias AG, Hutchinson PJ. Decompressive craniectomy -
operative technique and perioperative care. Adv Tech Stand Neurosurg.
2012;38:115-36

16. Surgical technique
• Dural dissection from beneath the bone
• Burr-holes connected
• Bone flap removed (try not to cause dural
tears)
• Wax the bone edges
• Dural tack-up stitches
• Dural opening (controlled manner)

17. Handling brain
• Do not touch (irritate) the angry brain
• Try to remove the clots by irrigation or just
gentle traction and irrigation
• Do not pull the clots
– Particularly those are near to the midline and
venous sinuses

18. Dural closure
• Closure of the dura with dural substitute
(pericranium)
• Dural closure
– Place the thin piece of gel foam under the dural along
the length of the dural incision
– Move needle from free graft to dura
• Start early dural closure
– It takes approximately 10-15 minutes to close the dura
– Sufficient time to achieve hemostasis

19. Surgical technique
• Subgaleal suction drain (maintain low
pressure)
• Standard scalp closure

20. Additional steps
• Removal of any intracranial hematomas
• Subtemporal decompression
• Temporal lobectomy

21. Please remember
• Opening the dura has been shown to improve the
reduction in ICP from 30% (dura left intact) to
85% (dura opened)
• Smaller craniectomy can lead to the damage to
cortical veins and parenchyma
• Avoid burr holes near to the midline and venous
sinuses
• Opened frontal air sinus will need exteriorization
• Be careful of mastoid air cells

22. Post-operative care
• Standard post-operative care
• Early tracheostomy
• Aggressive physiotherapy

23. Complications
• Refractory ICP elevation
• Hydrocephalus
• Ventriculitis/meningitis
• Seizures
• CSF leak
• Coagulopathy
• DVT/PE
• Decubitus ulcer

24. • Subcutaneous pocket in the abdomen
• Or in a bone bank facility (at a temperature <
70°C)*
Bone flap
*Sinha et al. Decompressive craniectomy in traumatic brain
injury: A single-center, multivariate analysis of 1,236 patients
at a tertiary care hospital in India. Neurol India 2015;63:175-
83.

25. Results
• Early decompressive craniectomy improves
both functional and mortality outcomes*
• An overall favorable outcome with an
acceptable morbidity and mortality**
*Juttler et al. Decompressive surgery for the treatment of
malignant infarction of the middle cerebral artery (DESTINY)
a randomized, controlled trial. Stroke 38:2518-2525
**Sinha et al. Decompressive craniectomy in traumatic brain
injury: A single-center, multivariate analysis of 1,236 patients
at a tertiary care hospital in India. Neurol India 2015;63:175-
83.

26. • Financial constraints
• Difficult follow up
Challenges
*Sinha et al. Decompressive craniectomy in traumatic brain
injury: A single-center, multivariate analysis of 1,236 patients
at a tertiary care hospital in India. Neurol India 2015;63:175-
83.

27. Customizing the procedure
• Decompressive craniectomy(DC) has been
used as a final option in the management of
refractory intracranial hypertension
• Aggressive home based physiotherapy
(training the relatives)

28. Conclusions
• Decompressive craniectomy (DC) is an effective
treatment to manage malignant cerebral edema
and thus help to reduce
mortality
• Improve neurological outcome in patients with
massive brain swelling
• We need to further understand the cost involved
and long term functional outcomes
• There is a need for randomized trials showing the
effects of DC