Suboccipital decompressive craniectomy due to space-occupying cerebellar infarction

All patients treated with suboccipital decompressive craniectomy (SDC) due to space-occupying cerebellar infarction between January 2009 and October 2015 in the Rigshospitalet, were included in the study. Data was retrospectively collected from patient records, CT/MRI scans and surgical protocols. Long-term functional outcome was determined by the modified Rankin Scale (mRS) and mRS ≥ 4 was defined as unfavorable outcome.

Twenty-two patients (16 male, 6 female) were included in the study. Median age was 53 years. Nine patients were treated with external ventricular drainage as an initial treatment attempt prior to SDC. Median time from symptom onset (stroke ictus) to initiation of the SDC surgery was 48 h (IQR 28-99 hours) and median GCS before SDC was 8 (IQR 5-10). At follow up, median mRS was 3 (IQR 2-6). Outcome was favorable (mRS 0-3) in 12 patients and unfavorable in 10 (3 with major disability, 7 dead). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome.

In this small study, functional long-term outcome in patients with space-occupying cerebellar infarction treated by SDC was acceptable and comparable to previously published results (favorable outcome in 54% of patients). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome 1).1) Lindeskog D, Lilja-Cyron A, Kelsen J, Juhler M. Long-term functional outcome after decompressive suboccipital craniectomy for space-occupying cerebellar infarction. Clin Neurol Neurosurg. 2018 Dec 1;176:47-52. doi: 10.1016/j.clineuro.2018.11.023. [Epub ahead of print] PubMed PMID: 30522035.

UpToDate: Decompressive craniectomy for intracerebral hemorrhage

Decompressive craniectomy for intracerebral hemorrhage

Systematic review

Yao et al. conducted a systematic review to verify the effects of decompressive craniectomy (DC) on improving outcome in spontaneous intracerebral hemorrhage.

Through searching several electronic databases, they screened eligible publications. Respective risk ratio (RR) and its 95% confidence interval (CI) were calculated, data were synthesized with a fixed-effect model, and sensitivity analyses and subgroup analyses were performed. Publication bias was measured with Begg and Egger tests.

Overall effect showed that DC significantly reduced the poor outcome compared with the control group (RR, 0.91; 95% CI, 0.84-0.99; P = 0.03). But in the subgroup analyses, only studies published after 2010, studies using hematoma evacuation as control, and studies measuring outcome with Glasgow outcome score showed better outcomes in the DC group than in the control group. The other subgroup analyses and sensitivity analyses achieved inconsistent results. Compared with the control group, DC effectively decreased mortality (RR, 0.67; 95% CI, 0.53-0.85; P = 0.0008). The sensitivity analyses and subgroup analyses achieved consistent results.

The application of DC effectively reduced mortality in patients with sICH. DC might improve functional outcomes in certain populations and needs further verification. DC is not associated with increased incidences of postoperative rebleeding and hydrocephalus 1).

Experimental work

Marinkovic et al. from Helsinki, Finland, used the model of autologous blood injection into the basal ganglia in rats. After induction of ICH and then magnetic resonance imaging, animals were randomly allocated to groups representing no craniectomy (n = 10) or to craniectomy at 1, 6, or 24 hours. A fifth group without ICH underwent craniectomy only. Neurological and behavioral outcomes were assessed on days 1, 3, and 7 after ICH induction. Furthermore, terminal deoxynucleotidyl transferase dUTP nick-end labeling-positive cells were counted.

After 7 days, compared with the ICH + no craniectomy group, all craniectomy groups had strikingly lower mortality (P < 0.01), much better neurological outcome (P < 0.001), and more favorable behavioral outcome. A trend occurred in the ICH + no craniectomy group toward more robust apoptosis.

Decompressive craniectomy performed up to 24 hours improved outcome after experimental ICH, with earlier intervention of greater benefit 2).

Case series

Rasras et al. from the Department of Neurosurgery, Ahvaz Jundishapur University of Medical Sciences, AhvazIran, sought to assess the preliminary utility of decompressive hemicraniectomy (DHC) without clot evacuation in patients with deep-seated supratentorial ICH.

Patients with deep seated spontaneous intracerebral hemorrhage who were admitted to the Golestan Hospital, of Ahvaz, from November 2014 to February 2016, were prospectively enrolled in a study. A prospective clinical trial where 30 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B using permuted-block randomization. These patients (n = 30), who all had large deep seated supratentorial ICH with surgery indications, were randomly divided to two groups. ultimately, in one group (n = 13), large DHC was performed without clot evacuation, while in the other (n = 17), craniotomy with clot evacuation was done. Data pertaining to the patients characteristics and treatment outcomes were prospectively collected.

There was no statistically significant difference between two treatment groups (P > 0.05). No significant difference was observed between the two groups in terms of mortality and GOS at 6 months (P > 0.05); nevertheless, the good outcome (Glasgow Outcome Scale = 4-5) for patients with hematoma evacuation was slightly higher (35.3%) as compared to the DHC patients without clot evacuation (30.7%).

Decompresive craniectomy without clot evacuation in deep seated ICH can be accomplished with identical mortality and outcome in comparison to patient that undergone clot evacuation 3).


A total of 54 eligible patients with spontaneous supratentorial hemorrhage (median age, 55 years; interquartile range, 47-64 years) who underwent decompressive craniectomy were retrospectively matched to 72 patients managed with best medical treatment (median age, 58 years; interquartile range, 32-74 years). Glasgow Outcome Scale (GOS) scores were dichotomized into favorable and unfavorable outcomes. Survival and functional outcomes were analyzed at discharge, 3, 6, and 12 months.

Survival in the craniectomy group was significantly higher compared with the medical treatment group at 30 days, 6, and 12 months (76%, 70%, and 70% vs. 60%, 57%, and 52% respectively; all P ≤ 0.05). There was no difference in functional outcomes at discharge, 3, 6, or 12 months after hemorrhage (all P > 0.05). Decompressive craniectomy was associated with longer hospital stay (median of 30 days vs. 7 days in the control group; P < 0.001). Hospital adverse events were more frequent in the craniectomy group than in the control group (76% vs. 33%; P < 0.001), the commonest adverse events being pneumonia and urinary tract infections.

They showed that decompressive craniectomy significantly improved survival compared with medical treatment with lasting benefits. This improvement came at a cost of increased length of hospital stay and related adverse events. There was no improvement in functional outcome 4).


Decompressive craniectomy is associated with a significant increase in perihematomal edema compared to patients who have been treated conservatively. Perihematomal edema itself lasts about 60 days if it is not treated, but decompressive craniectomy ameliorates the mass effect exerted by the intracerebral hemorrhage plus the perihematomal edema, as reflected by the reduced midline shift 5).


Of 21 patients who underwent DC for hemispheric hypertensive ICH in the Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan, eleven of the patients were male and 10 were female, with an age range of 22-75 years (mean, 56.6 years). Their preoperative Glasgow Coma Scale scores ranged from 3 to 13 (mean, 6.9). The hematoma volumes ranged from 33.4 to 98.1 mL (mean, 74.2 mL), and the hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. Intraventricular extensions were observed in 11 patients. With regard to the complications after DC, postoperative hydrocephalus developed in ten patients, and meningitis was observed in three patients. Six patients had favorable outcomes and 15 had poor outcomes. The mortality rate was 10 %. A statistical analysis showed that the GCS score at admission was significantly higher in the favorable outcome group than that in the poor outcome group (P = 0.029). Our results suggest that DC with hematoma evacuation might be a useful surgical procedure for selected patients with large hemispheric hypertensive ICH 6).


Fung et al. compared consecutive patients (November 2010-January 2012) with supratentorial ICH treated with DC without hematoma evacuation and matched controls treated by best medical treatment. DC measured at least 150 mm and included opening of the dura. We analyzed clinical (age, sex, pathogenesis, Glasgow Coma Scale, National Institutes of Health Stroke Scale), radiological (signs of herniation, side and size of hematoma, midline shift, hematoma expansion, distance to surface), and surgical (time to and indication for surgery) characteristics. Outcome at 6 months was dichotomized into good (modified Rankin Scale 0-4) and poor (modified Rankin Scale 5-6).

Twelve patients (median age 48 years; interquartile range 35-58) with ICH were treated by DC. Median hematoma volume was 61.3 mL (interquartile range 37-83.5 mL) and median preoperative Glasgow Coma Scale was 8 (interquartile range 4.3-10). Four patients showed signs of herniation. Nine patients had good and 3 had poor outcomes. Three patients (25%) of the treatment group died versus 8 of 15 (53%) of the control group. There were 3 manageable complications related to DC.

DC is feasible in patients with ICH. Based on this small cohort, DC may reduce mortality. Larger prospective cohorts are warranted to assess safety and efficacy 7).


Records of 12 consecutive patients with hypertensive ICH treated with decompressive hemicraniectomy were reviewed. The data collected included Glasgow Coma Scale (GCS) score at admission and before surgery, ICH volume, ICH score, and a clinical grading scale for ICH that accurately risk-stratifies patients regarding 30-day mortality. Outcome was assessed as immediate mortality and modified Rankin Score (mRS) at the last follow-up.

Of the 12 patients with decompressive hemicraniectomy, 11 (92%) survived to discharge; of those 11, 6 (54.5%) had good functional outcome, defined as a mRS of 0 to 3 (mean follow-up: 17.13 months; range: 2-39 months). The mean age was 49.8 years (range: 19-76 years). Three of the 7 patients with pupillary abnormalities made a good recovery; of the 11 patients with intraventricular extensions (IVEs), 7 made a good recovery. The clinical finding (which was present in all 3 patients with mRS equal to 5 and which was not present in patients with mRS less than 5) was abnormal occulocephalic reflex. Of the 10 patients with an ICH score of 3, 9 (90%) survived to discharge, 4 (44%) had good functional outcome (mRS: 1-3). Hematoma volume was 60 cm3 or greater in eight patients, four (50%) of whom had good functional outcome (mRS: 0-3).

Decompressive hemicraniectomy with hematoma evacuation is life-saving and improves unfavorable outcomes in a select group of young patients with large right hemispherical ICH 8).

References

1)

Yao Z, Ma L, You C, He M. Decompressive Craniectomy for Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis. World Neurosurg. 2018 Feb;110:121-128. doi: 10.1016/j.wneu.2017.10.167. Epub 2017 Nov 10. Review. PubMed PMID: 29129764.
2)

Marinkovic I, Strbian D, Pedrono E, Vekovischeva OY, Shekhar S, Durukan A, Korpi ER, Abo-Ramadan U, Tatlisumak T. Decompressive craniectomy for intracerebral hemorrhage. Neurosurgery. 2009 Oct;65(4):780-6, 1 p following 786; discussion 786. doi: 10.1227/01.NEU.0000351775.30702.A9. PubMed PMID: 19834384.
3)

Rasras S, Safari H, Zeinali M, Jahangiri M. Decompressive hemicraniectomy without clot evacuation in supratentorial deep-seated intracerebral hemorrhage. Clin Neurol Neurosurg. 2018 Aug 23;174:1-6. doi: 10.1016/j.clineuro.2018.08.017. [Epub ahead of print] PubMed PMID: 30172088.
4)

Lo YT, See AAQ, King NKK. Decompressive Craniectomy in Spontaneous Intracerebral Hemorrhage: A Case-Control Study. World Neurosurg. 2017 Jul;103:815-820.e2. doi: 10.1016/j.wneu.2017.04.025. Epub 2017 Apr 17. PubMed PMID: 28427977.
5)

Fung C, Murek M, Klinger-Gratz PP, Fiechter M, Z’Graggen WJ, Gautschi OP, El-Koussy M, Gralla J, Schaller K, Zbinden M, Arnold M, Fischer U, Mattle HP, Raabe A, Beck J. Effect of Decompressive Craniectomy on Perihematomal Edema in Patients with Intracerebral Hemorrhage. PLoS One. 2016 Feb 12;11(2):e0149169. doi: 10.1371/journal.pone.0149169. eCollection 2016. PubMed PMID: 26872068; PubMed Central PMCID: PMC4752325.
6)

Takeuchi S, Takasato Y, Masaoka H, Hayakawa T, Yatsushige H, Shigeta K, Nagatani K, Otani N, Nawashiro H, Shima K. Decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage. Acta Neurochir Suppl. 2013;118:277-9. doi: 10.1007/978-3-7091-1434-6_53. PubMed PMID: 23564148.
7)

Fung C, Murek M, Z’Graggen WJ, Krähenbühl AK, Gautschi OP, Schucht P, Gralla J, Schaller K, Arnold M, Fischer U, Mattle HP, Raabe A, Beck J. Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage. Stroke. 2012 Dec;43(12):3207-11. doi: 10.1161/STROKEAHA.112.666537. Epub 2012 Oct 30. PubMed PMID: 23111437.
8)

Murthy JM, Chowdary GV, Murthy TV, Bhasha PS, Naryanan TJ. Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage. Neurocrit Care. 2005;2(3):258-62. PubMed PMID: 16159072.

Update: Decompressive craniectomy for traumatic brain injury

Decompressive craniectomy for traumatic brain injury

Intracranial hypertension is the largest cause of death in young patients with severe traumatic brain injury 1).
The management of traumatic brain injury progressed significantly in the 1980s and 1990s due to advances in neuroimaging (widespread introduction of CT scanning), prehospital management, neurointensive care (widespread adoption of ICP monitoring and tiered therapeutic protocols) and rehabilitation. This led to a renaissance of interest in decompressive craniectomy (DC) with many uncontrolled studies reporting a survival benefit with DC 2) 3).
Since that time, DC has been increasingly studied in the setting of different conditions, including subarachnoid hemorrhage, and malignant middle cerebral artery infarction.
Furthermore, dural opening, usually followed by insertion of a dural graft (duraplasty), has meanwhile become an integral part of the decompressive surgery technique 4).
The 21st century, so far, has seen consistent efforts to improve the evidence base for DC following TBI with the conduct of randomized clinical trials5).
In severely head injured children, a study has shown that decompressive craniectomy resulted in good recovery in all children in the study, suggesting the procedure has an advantage over non-surgical treatment in children.
In one of the largest studies on pediatric patients, Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients for accidental trauma after craniectomy when followed for more than five years. Only three patients were dependent on caregivers.
This is the only prospective randomised controlled study to date to support the potential benefit of decompressive craniectomy following traumatic brain injury.

Outcome

Early decompressive craniectomy (DC) has been used as the first stage treatment to prevent secondary injuries in cases of severe traumatic brain injury (TBI). Postoperative management is the major factor that influences outcome.
Intracranial pressure monitoring in conjunction with postoperative treatment, after early DC, is associated with a significantly reduced risk of death6).
Patients surviving from DC need a second operation to repair the bone defect.
In the 2010s the use of decompressive craniectomy (DC) in everyday neurosurgical practice has largely increased, even though the effectiveness of this procedure is still uncertain 7).

Complications

The conversion of the cranium from a “closed box” to an “open box” alters the barometric pressure, cerebrospinal fluid (CSF), and cerebral blood flow (CBF) and may or may not lead to syndrome of the trephined (sinking skin flap syndrome) 8).

Trials

The claim that decompressive craniectomy increases unfavourable outcome is overstated and not supported by the data presented in DECRA trial.
Sahuquillo et al. believe it premature to change clinical practice. Given the dismal outcome in these patients, it is reasonable to include this technique as a last resort in any type of protocol-driven management when conventional therapeutic measures have failed to control ICP, the presence of operable masses has been ruled out and the patient may still have a chance of a functional outcome. The main lesson to be learned from this study is that an upper threshold for ICP must be used as a cut-off for selecting decompressive craniectomy candidates 9).
see RescueICP Study.

Systematic review and meta-analysis

Although many studies have been conducted in this topic, there is still much uncertainty about the effectiveness of surgical treatment in TBI 10).
Zhang et al. aimed to perform a systematic review and metaanalysis to examine the prognostic value of decompressive craniectomy (DC) in patients with traumatic intracranial hypertension. PubMed, EMBASE, Cochrane Controlled Trials Register, Web of Science, http://clinicaltrials.gov/ were searched for eligible studies. Ten studies were included in the systematic review, with four randomized controlled trials involved in the meta-analysis, where compared with medical therapies, DC could significantly reduce mortality rate [risk ratio (RR), 0.59; 95% confidence interval (CI), 0.47-0.74, P < 0.001], lower intracranial pressure (ICP) [mean difference (MD), -2.12 mmHg; 95% CI, -2.81 to -1.43, P < 0.001], decrease the length of ICU stay (MD, -4.63 days; 95% CI, -6.62 to -2.65, P < 0.001) and hospital stay (MD, -14.39 days; 95% CI, -26.00 to -2.78, P = 0.02), but increase complications rate (RR, 1.94; 95% CI, 1.31-2.87, P < 0.001). No significant difference was detected for Glasgow Outcome Scale at six months (RR, 0.85; 95% CI, 0.61-1.18, P = 0.33), while in subgroup analysis, early DC would possibly result in improved prognosis (P = 0.04). Results from observational studies supported pooled results except prolonged length of ICU and hospital stay. Conclusively, DC seemed to effectively lower ICP, reduce mortality rate but increase complications rate, while its benefit on functional outcomes was not statistically significant 11).

Case series

2016

31 patients aged 16-72 of either sex who sustained a severe, non-penetrating TBI and underwent a unilateral DC for evacuation of parenchymal or extra-axial hematoma or for failure of medical therapy to control intracranial pressure (ICP).
Review of the electronic medical record of patients undergoing DC for severe TBI and assessment of extended Glasgow Outcome Score (e-GOS) at 6-months following DC.
The mean age was 39.3y ± 14.5. The initial GCS was 5.8 ± 3.2, and the ISS was 29.7 ± 6.3. Twenty-two patients underwent DC within the first 24 h, two within the next 24 h and seven between the 3rd and 7th day post injury. The pre-DC ICP was 30.7 ± 10.3 and the ICP was 12.1 ± 6.2 post-DC. Cranioplasty was performed in all surviving patients 1-4 months post-DC. Of the 29 survivors following DC, the e-GOS was 8 in seven patients, and 7 in ten patients. The e-GOS was 5-6 in 6 others. Of the 6 survivors with poor outcomes (e-GOS = 2-4), five were the initial patients in the series.
In patients with intractable cerebral hypertension following TBI, unilateral DC in concert with practice guideline directed brain resuscitation is associated with good functional outcome and acceptable-mortality 12).

2009

A case control study comparing a group of patients (n: 16) operated for severe TBI between January 2002 and July 2004 according to an institutional management protocol characterized by an early decompressive craniectomy (DC) approach versus a historical control group (n: 20) managed before the implementation of such protocol. Mortality and Glasgow Outcome Score (GOS) at 6 months were used as the main outcome variables.
An early DC protocol implemented within 12 hours from injury in 16 patients with severe isolated TBI and a Marshall score between III or IV was associated with a lesser mortality than the conventional approach with ventriculostomy and Intensive Care Unit (ICU) management alone. The GOS was significantly better in the DC group (p=0.0002) than in the control group.
The use of an early DC protocol for severe TBI patients (Glasgow Coma Scale <9) had a significantly improved outcome compared with the conventional approach with ventriculostomy and ICU management in Simòn Bolivar Hospital in Bogotá, Colombia 13).
1)

Alvis-Miranda H, Castellar-Leones SM, Moscote-Salazar LR. Decompressive Craniectomy and Traumatic Brain Injury: A Review. Bull Emerg Trauma. 2013 Apr;1(2):60-8. Review. PubMed PMID: 27162826; PubMed Central PMCID: PMC4771225.
2)

Polin RS, Shaffrey ME, Bogaev CA. et al.Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 19974184–92.92
3)

Whitfield PC, Patel H, Hutchinson PJ. et al.Bifrontal decompressive craniectomy in the management of posttraumatic intracranial hypertension. Br J Neurosurg 200115500–7.7
4)

Hutchinson P, Timofeev I, Kirkpatrick P. Surgery for brain edema. Neurosurg Focus.2007;22:E14
5)

Kolias AG, Adams H, Timofeev I, Czosnyka M, Corteen EA, Pickard JD, Turner C, Gregson BA, Kirkpatrick PJ, Murray GD, Menon DK, Hutchinson PJ. Decompressive craniectomy following traumatic brain injury: developing the evidence base. Br J Neurosurg. 2016 Apr;30(2):246-50. doi: 10.3109/02688697.2016.1159655. Epub 2016 Mar 14. PubMed PMID: 26972805; PubMed Central PMCID: PMC4841020.
6)

Kim DR, Yang SH, Sung JH, Lee SW, Son BC. Significance of intracranial pressure monitoring after early decompressive craniectomy in patients with severe traumatic brain injury. J Korean Neurosurg Soc. 2014 Jan;55(1):26-31. doi:10.3340/jkns.2014.55.1.26. Epub 2014 Jan 31. PubMed PMID: 24570814.
7)

Aarabi B, Hesdoffer DC, Ahn ES, Aresco C, Scalea TM, Eisenbergh HM: Outcome following decompres- sive craniectomy for malignant swelling due to se- vere head injury. J Neurosurg 104: 469–479, 2006
8)

Gadde J, Dross P, Spina M. Syndrome of the trephined (sinking skin flap syndrome) with and without paradoxical herniation: a series of case reports and review. Del Med J. 2012 Jul;84(7):213-8. PubMed PMID: 23252092.
9)

Sahuquillo J, Martínez-Ricarte F, Poca MA. Decompressive craniectomy in traumatic brain injury after the DECRA trial. Where do we stand? Curr Opin Crit Care. 2013 Apr;19(2):101-6. doi: 10.1097/MCC.0b013e32835eba1a. Review. PubMed PMID: 23422159.
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Moon JW, Hyun DK. Decompressive Craniectomy in Traumatic Brain Injury: A Review Article. Korean J Neurotrauma. 2017 Apr;13(1):1-8. doi: 10.13004/kjnt.2017.13.1.1. Epub 2017 Apr 30. Review. PubMed PMID: 28512611; PubMed Central PMCID: PMC5432443.
11)

Zhang D, Xue Q, Chen J, Dong Y, Hou L, Jiang Y, Wang J. Decompressive craniectomy in the management of intracranial hypertension after traumatic brain injury: a systematic review and meta-analysis. Sci Rep. 2017 Aug 18;7(1):8800. doi: 10.1038/s41598-017-08959-y. PubMed PMID: 28821777.
12)

Grindlinger GA, Skavdahl DH, Ecker RD, Sanborn MR. Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis. Springerplus. 2016 Sep 20;5(1):1605. doi: 10.1186/s40064-016-3251-9. eCollection 2016. PubMed PMID: 27652178; PubMed Central PMCID: PMC5028365.
13)

Rubiano AM, Villarreal W, Hakim EJ, Aristizabal J, Hakim F, Dìez JC, Peña G, Puyana JC. Early decompressive craniectomy for neurotrauma: an institutional experience. Ulus Travma Acil Cerrahi Derg. 2009 Jan;15(1):28-38. PubMed PMID: 19130336; PubMed Central PMCID: PMC3413286.
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