Decompressive craniectomy is a surgical technique used to relieve increased intracranial pressure by removing a portion of the skull bone and opening the dura mater. It allows swollen brain tissue room to expand and reduces pressure. The document discusses the history of the procedure, indications such as severe traumatic brain injury and malignant stroke, types including decompressive hemicraniectomy and bifrontal craniectomy, potential complications like subdural fluid collections, and the role of later cranioplasty. While controversies remain, decompressive craniectomy can be life-saving for carefully selected patients with medically refractory elevated intracranial pressure.

1. Decompressive craniectomy for
TBI
Dr. Joe M Das
Senior Resident
Dept. of Neurosurgery

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History
ICP and methods to reduce it
Definition
Craniectomy vs craniotomy
Current evidence
Indications
Types
Procedure
Complications & their management
Cranioplasty

3. History
• Ancient Egypt and Greece – TBI, epilepsy,
headache, mental illness
• First described by Annandale (1894)
• Surgical decompression to treat elevated ICP –
Kocher (1901) and Cushing (1905) –
subtemporal and suboccipital
Cushing H. The establishment of cerebral hernia as a decompressive measure for inaccessible brain tumors; with the description of
intermuscular methods of making the bone defect in temporal and occipital regions. Surg Gynecol Obstet.1905;1:297–314

5. Harvey Cushing spent several months in the lab of Kocher in 1900,
performing cerebral surgery and first encountering the Cushing reflex .

6. • Erlich (1940) – For all head injuries with
persistent coma for more than 24-48 hrs
• Rowbotham (1942) – All traumatic comas
which improved at first and when medical
treatment was ineffective for 12 hrs
• Munro (1952) – If intra-op, the brain was
contused and swollen
• Guerra (1999) – personal results of 20 years –
2nd tier therapy in refractory ICP
Guerra WK, Gaab MR, Dietz H. et al: Surgical decompression for traumatic brain swelling: indications and results. J
Neurosurg 90:187-196, 1999

7. ICP
• In a normal adult, the cranial vault can
accommodate an average volume of
approximately 1500 mL.
• V Intracranial space = V Brain + V Blood + V CSF
• The normal ICP ranges between 10 and 15 mm
Hg in an adult.
• CPP = MAP – ICP
• Systemic hypertension is required to maintain
cerebral perfusion
Monro A (1783). Observations on the structure and function of the nervous system. Edinburgh: Creech & Johnson.
Kelly G (1824). "Appearances observed in the dissection of two individuals; death from cold and congestion of the
brain". Trans Med Chir Sci Edinb 1: 84–169.

9. Methods to reduce ICP
ACSSurgery Principles & Practice - Section 7 / Chapter 2 Injuries to the Central Nervous System

10. • The limits of welltolerated ICP together
with lowering of CPP:
– SAH – 18-20 mm Hg
– Malignant Sylvian stroke
– 20-22 mm Hg
– Trauma – 25 mm Hg
– Slow growing tumors
and HCP – 30-40 mm Hg
Aschoff A., Schwab S., Spranger M, et al - The value of intracranial pressure monitoring in acute hemispheric stroke,
Neurology 47 (1996): 393-398

11. • A craniectomy of 8 cm  23 ml additional
volume (1.5% of total cerebral volume).
• For real decompression, 12 cm or more (86 ml
additional volume)
• Superior to the one realised by
hyperventilation (2 mm Hg lowering of pCO2),
ventricular tap of 20-30 ml and without the
risk of loop diuretics.

12. Brain facts

13. Definition
• Decompressive hemicraniectomy and durotomy
is a surgical technique used to relieve the
increased intracranial pressure and brain tissue
shifts that occur in the setting of large cerebral
hemisphere mass, or space-occupying lesions.
• In general, the technique involves removal of
bone tissue (skull) and incision of the restrictive
dura mater covering the brain, allowing swollen
brain tissue to herniate upwards through the
surgical defect rather than downwards to
compress the brainstem.

14. Craniotomy vs craniectomy
• Craniotomy – the bone flap is returned to its
previous location
• Craniectomy – the bone flap is not returned

15. Current evidence
• Evidence supporting emergent Decompressive
Craniectomy in Trauma remains controversial
• In animal studies, craniectomy has been a/w
increased cerebral edema,hemorrhagic
infarcts and cortical necrosis 1
• Decreased ICP2
• Improved Oxygen tension2
• Improved cerebral perfusion2
1.Forsting M, Reith W(1995) ; Wagener S et al(J Neurosurg 94:693-696, 2001)
2. Burket W. Zentralbl Neurochir 50:318-323, 1988; Gaab M et al Childs brain 5:484-498, 1979
Hatashita S, J Neurosurg 67:573-578, 1987

16. “The role of decompressive craniectomy in TBI
and in the control of intracranial
hypertension remains a matter of debate.”
Youmans Neurological Surgery - Volume 4, Section XI, page 3442

19. Brain facts
• Brain generates 10-23 Watts of electricity
• You have an average of 70,000 thoughts per
day

20. Indications
• Severe TBI
– Heterogeneous lesions in cerebral parenchyma
– Focal (contusions/hematoma) and diffuse
• Malignant MCA infarction
• Aneurysmal SAH
• Others
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Central venous thrombosis
Encephalitis
Metabolic encephalopathies
Intracerebral hematoma
Neurosurg Clin N Am 24 (2013) 375–391; Tarek Y. El Ahmadieh et al

21. Indications & Contraindications in TBI
• Indications:
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Coma or semicoma (GCS < 9)
Pupillary abnormalities, but respond to mannitol
Supratentorial lesion with midline shift on CT
Refractory ICP despite best conventional therapy
Age: initially < 80 years , now 70 years
(Of patients who were > 70 years, 75% were dead)
• Contraindications:
– Fatal brain stem damage
– GCS < 4 or fixed and dilated bilateral pupils

22. When to perform?
• Bifrontal decompressive craniectomy is indicated
within 48 hours of injury for patients with diffuse,
post-traumatic cerebral edema and medically
refractory elevated ICP.
• Subtemporal decompression, temporal
lobectomy, and hemispheric decompressive
craniectomy can be considered as treatment
options for patients who present with diffuse
parenchymal injury and refractory elevated ICP
who also have clinical and radiographic evidence
for impending transtentorial brain herniation.
Bullock MR, Chesnut R, Ghajar J, et al. Neurosurgery 2006;58(Suppl 3) Surgical management of traumatic
parenchymal lesions. :S25–46 [discus-sion: Si-iv]. - BTF Guidelines

23. Guidelines
• Up to date there are no specific guidelines or protocols
stating exactly when or in what circumstances DC is
appropriate, but there are some recommendations:
1. The North American Brain Trauma Foundation suggests
DC may be the procedure of choice in the appropriate
clinical context and also considering the use of DC in the
first tier of TBI management. (Bullock et al, 2006)
2. European Brain Injury Consortium recommend DC as an
option for refractory intracranial hypertension in all ages.
(Maas et al,1997)
3. A Cochrane review (2006) recommended DC may be
justified in some children with medically intractable ICP
after head injury but concluded there was no evidence to
support its routine use in adults. (Sahuquillo & Arikan,
2006)

24. Types

25. Brain facts
• Stress alters brain cells and function
• Music increases brain organisation

26. Decompressive hemicraniectomy
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Foam / rubber donut
No pins
Cervical spine precautions
Don’t compress the jugulars

27. DHC
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Supine
Rolled towel beneath ipsilateral shoulder
Head towards contralateral side
Mark midline
Incision – Reverse question mark
Posterior extent – 15 cm behind key hole
Deepened down to cranium
Myocutaneous flap reflected
Five burr holes are made in the following locations: (1)
temporal squamous bone superior to the zygomatic
process inferiorly, (2) keyhole area behind the zygomatic
arch anteriorly, (3) along the superior temporal line
posteroinferiorly, and in the (4) parietal and (5) frontal
parasagittal areas

28. • Smaller craniectomy  Damage to cortical veins and
parenchyma
• Dura dissected off from beneath the bone
• Bur-holes connected
• Bone flap removed
• Temporal decompression
• Wax bone edges
• Dural tack-up stitches
• Dural opening (controlled manner) with radial incisions
in stellate fashion
• Closure with dural substitute and after keeping suction
drain

35. Brain facts
• 2,50,000 neurons are produced per minute in
early pregnancy
• Brain stops growing at around 18 years

36. Bifrontal craniectomy
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Bifrontal contusions / diffuse cerebral edema
Mark midline and coronal suture
Bicoronal incision (2-3 cm behind coronal)
Myocutaneous flap brought over the orbital rim (Preserve
supra-orbital nerves)
Bur-holes – b/l keys, b/l squamous temporal, straddling the
SSS just posterior to coronal suture
Bone flap
Temporal decompression
Bone wax, dural tack-up stitches
Divide the anterior portion of SSS and falx
Dural opening wide
Kjellberg RN, Prieto A Jr: Bifrontal decompressive craniotomy for massive cerebral edema. J Neurosurg 34:488-493,
1971

51. What is the percentage reduction in
ICP attained by DC?
• Opening the dura has been shown to improve
the reduction in ICP from 30% (dura left
intact) to 85% (dura opened)

52. Brain facts
• Dreaming requires more activity than any
waking function
• Oxytocin makes you feel love

53. Complications
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50-55 %
Abnormalities in CSF absorption
Expansion of hematomas after decompression
Syndrome of the trephined
Infection

54. CSF absorption disorders
• Subdural hygromas & hydrocephalus
• Causes:
– Ruptured arachnoid  One-way valve
– Pressure gradients between hemispheres
– Alteration in brain’s shape
• Treatment
– Ventriculostomy & oversewing if CSF leak
– VP shunt (programmable)
– Cranioplasty

55. Expanding hematomas
• New or existing mass lesions can
develop postoperatively, especially
given the high incidence of
coagulopathy and platelet dysfunction
• Evolution of both contusions and extra-axial
hematomas can occur after the tamponading
effects of cerebral edema, and elevated ICP has
been relieved by decompressive craniectomy.
• Postoperative imaging is recommended
especially in the setting of no ICP monitoring

56. SYNDROME OF THE TREPHINED
• Variety of symptoms that can develop following
craniectomy, including fatigue, headache, mood
disturbances, and even motor weakness.
• Mechanisms:
– CSF flow abnormalities
– Direct atmospheric pressure on the brain
– Disturbances in cerebral blood flow.
• Often resolves with replacement of the bone flap
• There is no evidence that it is harmful or that delay of
cranioplasty can result in long-term consequences

57. Cranioplasty
• Usually carried out 6 to 8 weeks after the DC,
assuming that the patient has recovered from the
initial injury and hydrocephalus or brain swelling is not
present.
• In the interim - “hockey helmet”
• Autologous bone flap, (frozen after the initial
surgery / kept in abdominal subcutaneous tissue) is
used and provides good cosmetic results.
• The bone flap remains sterile in a −70°C freezer for
many months.
• Autoclaving of the bone (e.g., if contaminated by a
compound scalp wound before cranioplasty) 
reduce the viability of the graft.

58. Cranioplasty
• Complication associated with abdominal
preservation of bone flap - bone resorption (510%) due to hypovascular bone necrosis and
sepsis of the flap.
• Other materials - methyl methacrylate and
titanium mesh when the bone is heavily
comminuted or contaminated.
• For large, cosmetically important defects, the
use of casts, stereolithographic models, and
CT-based “computer-assisted design”
reconstruction technology

60. Conclusion
• IC-HTN results from many disease processes.
• Decompressive craniectomy can be life
preserving procedure.
• Selection criteria remains in involution.
• Best outcomes are achieved in young patients
treated early in course of disease.