Decompressive Hemicraniectomy in Acute Neurological Diseases
Decompressive Hemicraniectomy in Acute Neurological Diseases
Angela Crudele 0 1
Syed Omar Shah 0 1
Barak Bar 0 1
0 Decompressive Hemicraniectomy, Intracerebral Hemorrhage, Malignant MCA Stroke, Traumatic Brain Injury, Aneurysmal Subarachnoid Hemorrhage , Intracranial Pressure, Herniation
1 Department of Neurology, Thomas Jefferson University , Philadelphia, PA , Department of Neurological Surgery, Thomas Jefferson University , Philadelphia, PA , USA
Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions - both medical and surgical - exist to manage increased ICP. Medical management is used as first-line therapy; however it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.
Increased intracranial pressure (ICP) secondary to cerebral edema is common in acute
neurological disorders. Severe edema can be seen in malignant middle cerebral artery
(MCA) ischemic stroke, traumatic brain injury (TBI), subarachnoid hemorrhage (SAH),
and intracerebral hemorrhage (ICH). Increased ICP can lead to life-threatening
herniation syndromes and is a common cause of death when left untreated.
Decompressive hemicraniectomy (DHC) is a surgical option to reduce ICP, increase
cerebral compliance, and increase cerebral blood perfusion when medical
management becomes insufficient. By removing the skull, the brain is allowed to expand,
thereby normalizing ICP and reducing compression and/or midline shift. By reducing
ICP, cerebral perfusion pressure and blood flow are restored.
This article will summarize current medical literature regarding DHC in intracerebral
hemorrhages, subarachnoid hemorrhage, malignant MCA stroke and traumatic
DHC IN THE SETTING OF INTRACEREBRAL HEMORRHAGE
Current guidelines for the management of spontaneous ICH developed from the
American Heart Association and American Stroke Association (AHA/ASA)
recommend initial medical therapy for elevated ICP (external ventricular drainage [EVD]).1
The guidelines also address surgical management, but not for treatment of refractory
There are currently no large randomized controlled trials regarding the use of DHC
in ICH. There have only been a few case/control and case series regarding DHC for
management of refractory ICP in ICH,
and these studies are divided between
DHC alone versus a hematoma
evacuation alongside with DHC.2-9 Table 1
provides a summary of the key studies
that have been published thus far.
DHC WITHOUT HEMATOMA
We were able to find two relevant studies
in which DHC was done without
evacuation of the hematoma. The largest study
conducted by Ramnarayan et al.4
evaluated 23 patients with primary putaminal
hemorrhage. Only seven patients had a
Glasgow Comas Scale (GCS) less than
8, while more than half had a GCS of
9-12. Seven patients had an ICH volume
of greater than 60 cc, while 13 had a
volume between 30-60 cc. The majority
of patients had surgery performed within
6 hours of presentation, but no details
regarding exact timing were provided.
Mortality rate was low in this case series
(13%), but this finding may be partly
explained by the low severity of illness
with a relatively high GCS and small
hematoma volumes. ICH score was not
reported which would have allowed for
better comparison with other studies.
Fung et al.8 performed a case-control
study of 12 patients. These patients had
a larger median hematoma volume of
61 cc compared to Ramnarayan et al.4
Median time to DHC was within 12 hours
with a mortality rate of 25% in the DHC
group while the controls had a 53%
mortality rate. Mortality was higher in
the control group with hemorrhages
greater than 60cc as compared to the
DHC WITH HEMATOMA
The oldest and largest reported series
of patients with hematoma evacuation
along with DHC is a 73 patient
casecontrol series by Dierssen et al.9 in 1983.
Design No. of Cases Decompressive Craniectomy WITH clot evacuation
with IVH Score
Decompressive Craniectomy WITHOUT clot evacuation
GCS was not directly reported on
admission, but 43 (59%) patients presented
with a neurological exam of stupor to
deep coma. Despite having a poor initial
presentation, the long-term functional
outcome was good in nearly half of the
survivors and a statistically significant
improvement in mortality was found in
the DHC group. Murthy et al.5 published
a 12 patient cases series in which the
majority of the patients (92%) survived
to follow-up at 17 months, and good
functional outcome was achieved in 55%
of patients (mRS 0-3). Good functional
outcome would have increased to 67%
if it was defined as a mRS of 0-4. One
methodological weakness in this study
is possible selection bias as 92% of the
patients had right hemisphere pathology.
A larger case series was published by
Kim et al.7 including 24 patients, 19
(79%) of whom had a GCS less than 8.
Good functional outcome was defined
as a GOS of 4-5 and was present in half
the patients at 6 months. Most of the
patients had poor neurological exams,
but the authors did not provide enough
information to determine the utility of
DHC. Also, indications for surgery in this
study (GCS <8) may have caused delays
for patients that would have benefited
from earlier decompression.
Ma et al.6 performed a case-control study
of 38 patients. Controls were patients
who received a hematoma evacuation
alone. In unadjusted analysis, there was
a 32% mortality rate in the DHC group
compared to 43% in the control group
(p=0.26). There were significantly more
patients with herniation, patients with
intraventricular hemorrhage (IVH), and
patients with a higher ICH score in the
DHC group than the control group.
The patients’ ICH score, hematoma
volumes, and admission GCS may have
played a role in the higher mortality rates
than other studies in our review. When
adjusted for these variables, the odds
ratio for 30-day mortality was 0.12 (95%
CI 0.02-0.64, p=0.01), and an adjusted
odds ratio for good outcome (GOS 3-5)
of 23.23 (95% CI 2.13-252.86, p=0.01).
The most recent study was conducted by
Takeuchi et al.2 The median ICH score
was 3, and all patients were taken for
surgery within 24 hours of presentation.
Patients had lower GCS scores, higher
ICH volumes, and longer delay prior to
surgery in comparison to other studies
reviewed, which may explain the worse
Bearing in mind the differences in
methodology between all 7 studies, there was
an overall combined mortality of 26%.
It is fair to conclude that DHC done
alone or combined with hematoma
evacuation appears to be safe. Patients
in both populations demonstrated that
this surgical technique may reduce
mortality, as well as improve functional
outcome, especially in those who have
large hematoma volume, low GCS score,
and high ICH score.
We recommend that patients with
refractory ICP elevation in the setting of ICH
(i.e., primary DHC). Group 2 consisted
of patients undergoing DHC who had
endovascular treatment of their ruptured
aneurysm and developed intractable
intracranial hypertension immediately or
in a delayed fashion. Group 3 consisted
of patients who had DHC done after
initial clipping of aneurysm but in a
delayed fashion. Group 4 consisted of
patients in group 1 who required repeat
surgery to enlarge the primary DHC. The
authors found no significant difference
in neurological outcome based on the
group the patient was assigned.
Interestingly, the authors did not find that
timing of DHC influenced functional
outcome. The main finding of their
study was that etiology of intractable ICP
influenced functional outcome. Patients
undergoing DHC due to intractable ICP
elevation secondary to a hematoma had
improved functional outcome (p=0.038)
compared to patients undergoing DHC
due to cerebral edema secondary to
ischemic infarction. The weakness of the
study is the lack of a comparison group
and its retrospective design.
In contrast, Buschmann et al.11 also
grouped patients based on indication
for DHC and showed that timing of
DHC could potentially be a factor
affecting long-term functional outcome.
Patients in group 1 had primary DHC;
group 2 were patients who developed
intractable ICP (>20 mmHg) and space
occupying epidural, subdural, or
intracerebral hematoma after aneurysm
surgery (secondary DHC due to
hematoma); group 3 consisted of patients
who developed cerebral edema and
intractable ICP without infarctions
(secondary DHC without infarctions);
and group 4 had elevated ICP and
infarctions (secondary DHC with infarctions).
Notably the majority of the patients
in their study were in group 1 (55%).
Patients who recovered with good
functional outcome (GOS 4 and 5) were
treated earlier by secondary DHC (within
3.6 ± 1.6 days after SAH) than those who
died or survived with severe or moderate
disability (GOS 1-3) who were treated
later (within 5.9 ± 5.5 days [p=0.12]). Also
in this study, the outcome of the patients
differed according to the indication for
DHC with 83.3% of patients in group 3
(secondary DHC without infarctions)
having a good functional outcome.
Subgroup of patients with DHC due to hematoma formation had
improved outcome (P=0.038) compared to patients with DHC due
to cerebral edema secondary to ischemic infarction
Subgroup of patients with DHC for treatment of cerebral edema
without infarction had 83.3% good functional outcome
Poor-grade aSAH patients with associated ICH and evidence of
focal mass effect treated with DHC did not have improved quality
of life compared to a similar group of patients treated
Early DHC was associated with better outcome: 6/8 patients (75%)
had good mRS outcomes compared with 1/8 patients in whom the
decompression was performed after 48 hours (p<0.01).
The outcome was comparable regardless of the underlying etiology leading to DHC being performed. Only included patients with MCA aneurysm associated with hematoma volume greater than 25 mL.
However, there were only 6 patients in
this group. Overall, 53% of the patients
had a good functional outcome (GOS
4-5) at 1 year which is impressive given
that 82% of the patients presented with a
Hunt and Hess grade IV-V SAH.
Nonetheless, the study by D’Ambrosio
et al.12 came to a different conclusion.
In this study of poor-grade SAH patients
presenting with focal ICH necessitating
DHC, quality of life (QoL) was assessed
in addition to functional outcome.
Notably the patients all had Hunt and
Hess grade IV-V SAH and clinical signs
of brainstem compression. Patients who
underwent DHC did not have improved
QoL or functional outcome compared
to a similar group of patients treated
conservatively. A methodological
weakness is that the control group used had
smaller hematoma volume, less midline
shift, and higher GCS. Furthermore,
although the average time to
hemicraniectomy for the group as a whole was only
11.4 (±4.3) hours, half the patients had
DHC performed greater than 24 hours
after onset of clinical signs of brainstem
compression. However, the authors
did not find a statistically significant
difference comparing the early
hemicraniectomy group to the control group.
Given the small sample size, the subgroup
analysis is not powered to detect a
statistically significant difference. Despite the
negative findings of this study, 33% of
patients in the DHC group had a good
functional outcome at one year.
A similar study was conducted by Smith
et al.,13 also in a population of
poorgrade SAH patients presenting with a
focal ICH (sylvian fissure hematoma
greater than 25 mL ipsilateral to an MCA
aneurysm). However, unlike the study
done by D’Ambrosio et al.,12 the patients
in this study all had a prophylactic DHC
which was planned from the outset of
the aneurysm clipping operation. This
earlier time frame for the performance
of the DHC may explain the significantly
different results which showed that 62%
of the patients had good functional
outcome at one year. Unfortunately
the authors do not report on the actual
timing of the DHC in relation to onset of
SAH. In this study, DHC led to significant
and sustained decrease in elevated ICP
and the procedure added only 20-25
minutes to the original operation.
In contrast to the two previous studies,
Schirmer et al.14 evaluated patients
presenting with SAH with small to no
ICH. Notably, in this small study half of
the patients had their aneurysm treated
via endovascular coiling. This study also
lends support to the idea that early DHC
may be more beneficial than delayed
DHC. The authors noted that DHC
performed within the first 48 hours after
SAH had a beneficial effect on outcome:
75% of the patients who underwent early
DHC fared better at long-term
followup (mRS 0-3) compared to 12.5% of
patients in whom DHC was performed
after 48 hours (p<0.01). The strength of
this study is that herniated brain volume
was assessed, however the authors do
not describe in detail what is meant by
maximal medical management which
was an inclusion criteria.
Lastly, Guresir et al.15 evaluated the
outcome of patients undergoing primary
or secondary DHC for management of
refractory elevated ICH stratified according
to the different underlying pathologies in
order to determine predictors to help
guide treatment. Patients were stratified
as follows: group 1 (primary DHC) had
Vahedi, et al. 2007 DECIMAL
Jüttler, et al. 2007 DESTINY
et al. 2006
Zhao, et al. 2012 38 132
Jüttler, et al. 20 112
DESTINY II *This was time to randomization; time to surgery is not reported.
Criteria: <55 Range: 22-55 Mean: 43.4
Criteria: 18-60 Range: 29-60 Mean: 44.6
Criteria: 18-60 Range: 51-60 Mean: 48.7
Criteria: <24 Range: 7-43 Mean: 20.5
Criteria: 12-36 At 12 months:
Range and mean 18 vs. 53%
not reported p=0.03
At 12 months:
25 vs. 78%
ARR 52.8% in
Criteria: <96 Range: 29-50* Mean: 41*
At 12 months:
22 vs. 59%
ARR 38% in
Criteria: <48 At 12 months:
Range and mean 16.7 vs. 69.6%
not reported p<0.001
At 12 months:
43 vs 76%
At 12 months:
<3: 50 vs. 22%
craniectomy enlarged after aneurysm
clipping in the presence of massive
brain swelling, group 2 had craniectomy
enlarged after aneurysm clipping in
the presence of massive brain swelling
with additional ICH, group 3 had
intractable ICP without radiological signs of
rebleeding or infarction, group 4 had
intractable ICP with signs of
infarction, and group 5 had intractable ICP
with rebleeding. They found that the
outcome was comparable regardless of
the underlying etiology leading to DHC.
The weakness of the study is the small
number of patients in groups 1, 3, and 5.
One of the challenges particular to the
management of patients with SAH is
the development of delayed cerebral
ischemia. In a patient afflicted by ICH
associated with SAH, the timing of
peak perihematomal edema formation
coincides with the beginning of the
development of vasospasm. Therefore a
dilemma may occur in which
deterioration in a patient’s neurological exam is
difficult to distinguish whether it is due
to delayed cerebral ischemia, elevated
ICP, or both. It is clear that DHC leads to
effective and sustained ICP control thus
helping to address this clinical dilemma.
If a patient has significant improvement
after DHC is performed, it can be inferred
that the underlying pathophysiology was
elevated ICP and not delayed cerebral
ischemia. More importantly perhaps is
that the treatment of elevated ICP and
vasospasm use conflicting strategies.
The use of hyperventilation and
hyperosmolar therapy, for instance, could
lead to increased vasoconstriction and
dehydration respectively, both
potentially worsening vasospasm. DHC in
SAH patients allows the clinician to treat
vasospasm effectively without concern
for exacerbating elevated ICP from
induced hypertension or hypervolemia.
Furthermore, patients with SAH may have
various underlying etiologies leading to
elevated ICP including ICH, infarction,
rebleeding, and cerebral edema. Several
studies10,11,13 suggest that the underlying
etiology leading to elevated ICP could
play a role in determining the
effectiveness of DHC. These studies suggest that
performing DHC for intractable ICP in
the setting of an ICH associated with
SAH is beneficial. However, Guresir et al.
15 came to a different conclusion, that
the underlying etiology is not relevant
in determining the usefulness of DHC.
Regardless of the etiology leading to
intractable ICP, there is a final common
pathway of decreased cerebral perfusion
which can lead to ischemia and further
cerebral edema. This vicious cycle
can perhaps be halted by the timely
performance of DHC. Therefore, these
conflicting findings could possibly be
accounted for by the differences in the
timing of DHC depending on the
indication and underlying pathology. Early
DHC versus delayed DHC was associated
with improved functional outcome in
several of these studies.11,13,14
All of the studies reviewed found that
DHC can be done safely in a population
of poor-grade SAH patients. Most of
the studies suffer from the weaknesses
inherent to a retrospective observational
study and a very small sample size.
Clearly, there is a need for prospective
studies with standardized treatment
protocols and clear indications for DHC
DHC IN THE SETTING
OF MALIGNANT MIDDLE
CEREBRAL ARTERY INFARCT
Malignant middle cerebral artery (MCA)
infarct is described as a total or near
total infarction of the MCA territory.16
Due to the large area of ischemia, this
injury is followed by massive amounts of
cerebral edema,17 peaking between days
two and five.18 This progressive edema
leads to herniation, resulting in death in
approximately 80% of patients, even with
the use of maximum medical therapy.16,19
Patients that survive are typically left
The guidelines by the American Heart
Association acknowledge the lack of
evidence for conservative medical
management in the treatment of patients
with elevated ICP following stroke.18
There is poor evidence for the benefit
of hyperventilation, corticosteroids, or
osmotic diuretics in improving
functional outcome. It is currently a Class I
recommendation that patients should
be monitored closely for increased ICP.
Currently American Heart and American
Stroke Associations’ guidelines state
osmotic therapy for patients with
deterioration concerning for swelling is
reasonable, but do not recommend
hypothermia, barbiturates, or steroids given
insufficient data. They also state a Class
I recommendation for DHC in patients
under the age of 60 within 48 hours.20
The Neurocritical Care Society (NCS) has
similar recommendations against steroids
and barbiturates, but states hypothermia
may be considered in patients who are
not eligible for surgery. They share the
recommendation for osmotic therapy.
In regards to surgery, the NCS also
recommends DHC within 24-48 hours,
regardless of age. However, an additional
recommendation is made that families
of patients over 60 should consider the
higher likelihood of severe disability.21
Though these guidelines acknowledge
the use of DHC to acutely decrease ICP
and reduce secondary injury as
potentially lifesaving, the resulting functional
outcome remains unclear.
In recent years, there have been a
number of randomized controlled trials
comparing mortality and functional
outcome between patients
undergoing DHC and patients managed
with maximum medical therapy. These
studies have attempted to prove not
just a mortality benefit of
decompression, but also improvement in functional
outcome. Table 3 provides a summary of
the key studies that have been published
HAMLET, DECIMAL, and DESTINY are
three European trials that were published
within two years of each other, and
represented the first set of randomized
controlled trials to compare DHC with
standard medical therapy.
Jüttler et al.22 (DESTINY) published a
trial evaluating 32 patients ranging in
ages from 18 to 60 with symptom onset
less than 36 hours prior to
randomization and used a primary outcome of a
modified Rankin Scale (mRS) score 0 to
3 versus 4 to 6. The study was based on a
sequential design, first evaluating 30-day
mortality, and the study discontinued
enrollment after 32 patients had
undergone randomization and the mortality
endpoint was reached. The
conservative therapy group had a higher median
National Institutes of Heath Stroke Scale
(NIHSS) of 24 when compared to the
DHC group whose median NIHSS was
21. Survival was significantly higher
in the surgical group compared to
the conservative therapy group at 12
months. DESTINY was limited by its
small patient size, in part because the
trial was terminated early given the
immense survival benefit of the
procedure, and in light of the simultaneously
conducted trials that will be discussed
below. Though the article failed to reach
its primary outcome, survival benefit was
Vahedi et al.23 (DECIMAL) studied 38
patients aged 18-55 years who were
randomized within 24 hours of symptom
onset. Patients randomized to DCH were
required to undergo the procedure
within 6 hours of randomization, at most
30 hours after symptom onset. Similar
to DESTINY, the primary outcome was
a favorable functional outcome (mRS
≤3) at 6 months. Under the guidance of
the data safety monitoring committee,
enrollment was suspended early at 38
patients (18 medical, 20 surgical) due to
slow patient enrollment and the
intention of DECIMAL, DESTINY, and HAMLET
to pool data and publish together. Again,
the primary outcome of mRS ≤3 did not
reach statistical significance.
The third European randomized
controlled trial (HAMLET) was conducted
by Hofmeijer et al.24 This study reported
on 64 patients randomized equally
between surgical and medical
management. One notable difference about
HAMLET is that this study randomized
patients up to 4 days after initial symptom
onset. The primary outcome was mRS at
1 year, with a good outcome defined as
0-3 and poor outcome of 4-6.
Recruitment was stopped under the advisement
of the data monitoring committee after
64 patients were enrolled because it
was thought to be very unlikely that
the primary outcome measure would
produce a statistically significant
difference. Like DECIMAL and DESTINY,
HAMLET did not show a statistically
significant difference between an mRS
of 0 to 3 versus 4 to 6. HAMLET, unlike
DESTINY and DECIMAL did not show a
significant difference when outcome
was dichotomized for mRS ≤ 4 (p=0.13).
With DESTINY, DECIMAL, and HAMLET
recruiting patients simultaneously,
authors from each of these studies
contributed data to an article by Vahedi
et al.25 This article pooled the data of
the first three European trials to include
patients randomized within 48 hours of
symptoms onset. The article reported
the data of 93 patients 18 to 60 years
old. All of the patients from DESTINY
and DECIMAL were included; 23
HAMLET patients were included. Overall,
51 patients received decompressive
surgery, while 42 received
conservative therapy. Like each of the individual
studies, there was a significant benefit
for mRS >4 cutoff and mortality at 1 year.
Additionally, with the pooled data, there
was a statistically significant difference
between the groups for an mRS >3 at 12
months (medical patients 79%, surgical
patients 57%, p=0.014). This study also
reported that the likelihood of ending up
with an mRS of 4 was 10 times greater
after surgery than after standard medical
therapy, but the risk of ending up with an
mRS of 5 was not increased.
Studies then began to consider the
benefits of this procedure in an older
population. Zhao et al.26 had a similar
study design to the European trials, but
allowed patients to enroll up to 80 years
of age. In patients older than 60, risk of
death was also significantly lower at 1
year. There was no statistical difference
between the groups for an mRS >3.
However, in the older subgroup, there
was still a statistically significant
difference when dichotomizing the groups to
an mRS >4, similar to the results with a
younger patient population.
The DESTINY group conducted a second
randomized controlled trial further
evaluating the effect of DCH on older
patients.27,28 Unlike the pooled analysis
of the European trials, the older patient
population was not able to achieve
statistical significance when the data was
dichotomized to an mRS of 0 to 3 versus
4 to 6. DESTINY II showed a survival
benefit and functional benefit with data
dichotomized to an mRS of ≤ 4, though
the treatment effect was diminished in
the older population.
Frank et al. published HEADDFIRST,29
which randomized 26 patients within 96
hours after symptom onset. At 6 months,
the DHC group had a mortality rate of
36% and 40% in the medical group which
was not consistent with the previous
trials. However, the randomization for
HeADDFIRST required more mass effect
and allowed greater delay to
randomization, which the authors speculated
could have led to worse outcomes. Small
enrollment numbers were another
methodological limitation in this study.
This discussion focuses on the major
randomized controlled trials evaluating
DHC in the management of malignant
MCA infarction. Mortality benefit is
significant in all studies but HeADDFIRST.
However, the question of benefit in terms
of functional outcome is less clear.
Though the pooled European trials were
able to show a benefit of surgery with
an mRS of 0-3 compared to 4-6, it also
showed the increased risk of having
an mRS of 4. Whether this represents
an acceptable outcome is a matter of
debate and must be individualized for
the patient. Even physicians have not
come to a consensus as to the definition
of an acceptable outcome (Neugebauer
et al.), though Kiphuth et al. did find that
most patients or their families would
still retrospectively consent following
decompression.30,31 These benefits
were not reproducible using an older
population, though mortality benefit
and benefit with data dichotomized with
an mRS ≤ 4 remained significant. More
data regarding quality of life and
depression following DHC for malignant MCA
stroke would be helpful in determining
the utility of this life-saving procedure.
DHC IN THE SETTING OF
TRAUMATIC BRAIN INJURY
Traumatic brain injury (TBI) is an
extremely prevalent problem in the
United States. Approximately 2 million
people each year sustain TBI, many of
whom can be treated and released from
emergency departments. However, for
the nearly 300,000 patients hospitalized
each year, those with severe disease can
have devastating outcomes, leading to
thousands of deaths and patients with
permanent disability.32 The reported
overall mortality with medical
management varies widely throughout the
literature, but ranges approximately
Evaluation of hemicraniectomy in
nonpenetrating diffuse TBI represents
a more difficult analysis than surgery
following malignant MCA infarct. The
initial injury prompting evaluation for
surgery has more variability. The
decompressions themselves can be pursued for
different purposes, aiming to treat primary
damage caused by lesions causing mass
effect or secondary damage caused by
elevated intracranial pressure.34,35
Additionally, the preferred surgical
approach and timing35 of the surgery is
still unclear. The pivotal study DECRA
used a bifrontal approach to their
craniectomy.36,37 Other studies used a
bilateral hemicraniectomy approach.38
Both of these approaches fall outside of
the scope of this review. The literature
available is therefore limited due to the
variability of the initial injury as well as the
surgical approach employed.
To our knowledge, there have only been
two published randomized controlled
trials evaluating decompressive
craniectomy in traumatic brain injury compared
to maximum medical management:
DECRA evaluated a bifrontal approach
and yielded disappointing results,36
and a small study evaluating
decompression in children showed a possible
benefit.39 A third randomized controlled
trial, RescueICP, has yet to be published
and will evaluate bifrontal and
unilateral hemicraniectomies.40 With so few
randomized controlled trials, the optimal
surgical approach remains controversial
Current guidelines for controlling ICP
in TBI remain focused on conservative
management as first line therapies:
elevation of the head of the bed, pain control,
sedation, ventriculostomy. When this
fails to acutely manage ICP, barbiturate,
hypothermia and hyperosmolar therapies
have been used.41 Outcomes of patients
with severe TBI managed with maximum
medical therapy vary in the literature,
but frequently show a mortality rate of
around 40%, and rates of good outcome
(Glasgow Outcome Score 4-5) of 40%.42
DHC is considered when these therapies
fail and ICP remains elevated. DHC can
rapidly decrease ICP, however, the
clinical significance and outcome benefit
Wen et al.35 compared early versus late
DHC, defining early DHC as within 24
hours of injury in 44 TBI patients. Both
groups had a 6 month mortality rate of
approximately 20%. However, 52% in
the early DHC group achieved a GOS of
4-5, compared to 63% in the late group,
which did not reach statistical
significance. Though the groups were similar,
the early group had more significant
midline shift. It is possible that the
treatment effect is too small to be detected
with such a small sample size.
Aside from the study of early versus
late DHC in patients with TBI, there is
controversy regarding whether
decompression with or without evacuation of a
mass lesion is more efficacious. Yuan et
al.43 studied this question by examining
164 patients, 93 of whom underwent
decompression with evacuation of a
mass lesion at least 25mL and 71 who
were decompressed without
evacuation of a mass lesion. About 15% more
patients from the mass lesion group
underwent surgery within 24 hours (72%
mass lesion, 58% diffuse edema). The
mortality rate was 22% at 60 days and
favored the mass lesion group (14% mass
lesion, 32% diffuse edema, p=0.014).
Overall rate of good outcome was about
42% without a statistically significance
difference between the two groups.
Aarabi et al.44 performed a similar
retrospective cohort study to evaluate
50 patients with severe closed TBI, but
excluded patients who had DHC with
evacuation of a mass lesion. Ten patients
went to surgery within the first 24 hours
(9 immediately, 1 secondary to clinical
worsening). The remaining 40 patients
underwent DHC after 24 hours. Overall
mortality was 28%, and 51% of the
patients had a good outcome with GOS
4-5 at 30 days. The remaining patients
were left vegetative or severely disabled.
Qiu et al.45 evaluated 74 patients with
brain swelling after severe TBI and
randomized patients to undergo a
traditional DHC (bone window diameter
15cm) compared to the control group
which underwent a unilateral
temporoparietal craniectomy (bone window
diameter 8cm). Thirty-seven patients
underwent a DHC, and 57% of these
patients had a GOS of 4-5 at 6 months.
Additionally, 27% of the patients died, and
the remaining were vegetative or severely
disabled. The control group had a 57%
mortality rate with only 33% achieving a
good outcome. Jiang et al.46 conducted
a similar study which included 486
patients. The results were similar favoring
the group who underwent a traditional
DHC versus a subtotal DHC.
Some of the most relevant data is from
Chibbaro et al.47 This prospective study
of 147 patients evaluated DHC following
TBI. Of these patients, 67% had a GOS
4-5 at a mean follow up of 26 months.
GOS was 2-3 in 19% of patients, and
mortality rate was just 14%. Subgroup
analysis was performed to determine
factors associated with improved
outcome. Good outcomes were
significantly associated with age less than 50
(p<0.0001) and operation within 9 hours
of trauma (p<0.03).
Throughout the literature, good outcome
rates vary from 30-50% in the DHC group,
with a mortality rate approximately
20%.48,49 DHC remains a controversial
option in the management of patients
following TBI. The surgery may decrease
mortality, and it appears, similar to other
studies evaluating DHC for other
indications, that timing plays a significant
role. However, studies in the form of
randomized controlled trials comparing
DHC to maximal medical management
are needed. Unfortunately, there remain
a number of barriers to studies of this
kind. The heterogeneity of TBI patients
will be a constant challenge. Mechanism
of injury, the presence or absence of a
mass lesion, and the possible presence of
other injury remain challenges for patient
randomization and data interpretation.
Additionally, researchers continue to
disagree about the surgery’s timing (early
versus late), use for mass lesions versus
diffuse edema, and even the preferred
In this review, we describe the current
evidence regarding the utility of DHC for
the management of elevated ICP due to
malignant MCA stroke, ICH, TBI, and SAH.
All of these disease processes share a
common pathophysiologic endpoint
of elevated ICP that can be refractory
to maximal medical therapy and lead
to herniation syndromes. It appears
that DHC can be safely performed with
minimal risk in these critically ill patients.
Furthermore, it appears that the earlier
DHC is performed the greater the
potential benefit. While DHC may be
a life-saving procedure, the patients
are nevertheless often left significantly
impaired. Therefore, it is imperative to
discuss the potential outcomes that are
possible with the patient or surrogate
decision maker. The issue of
prognostication of outcome in severe brain injury
is beyond the scope of this paper, but it
is clear that in all of the disease processes
reviewed that a potential exists for a good
functional recovery. Therefore, DHC
should be part of the armamentarium
in the management of elevated ICP in
the conditions discussed. Ultimately,
the decision to pursue DHC should be
individualized taking into consideration
the patient’s values and goals of care.
6. Ma, L., et al., Decompressive craniectomy in
addition to hematoma evacuation improves
mortality of patients with spontaneous basal
ganglia hemorrhage. J Stroke Cerebrovasc
Dis, 2010. 19(
): p. 294-8.
7. Kim, K.T., et al., Comparison of the effect
of decompressive craniectomy on different
neurosurgical diseases. Acta Neurochir (Wien),
): p. 21-30.
8. Fung, C., et al., Decompressive
hemicraniectomy in patients with supratentorial
intracerebral hemorrhage. Stroke, 2012. 43(12): p.
9. Dierssen, G., R. Carda, and J.M. Coca, The
influence of large decompressive
craniectomy on the outcome of surgical treatment in
spontaneous intracerebral haematomas. Acta
Neurochir (Wien), 1983. 69(
): p. 53-60.
10. Dorfer, C., et al., Decompressive
hemicraniectomy after aneurysmal subarachnoid
hemorrhage. World Neurosurg, 2010. 74(
11. Buschmann, U., et al., Decompressive
hemicraniectomy in patients with subarachnoid
hemorrhage and intractable intracranial
hypertension. Acta Neurochir (Wien), 2007.
): p. 59-65.
12. D’Ambrosio, A.L., et al., Decompressive
hemicraniectomy for poor-grade
aneurysmal subarachnoid hemorrhage patients
with associated intracerebral hemorrhage:
clinical outcome and quality of life
assessment. Neurosurgery, 2005. 56(
): p. 12-9;
13. Smith, E.R., B.S. Carter, and C.S. Ogilvy,
Proposed use of prophylactic
decompressive craniectomy in poor-grade aneurysmal
subarachnoid hemorrhage patients presenting
with associated large sylvian hematomas.
Neurosurgery, 2002. 51(
): p. 117-24;
14. Schirmer, C.M., D.A. Hoit, and A.M. Malek,
Decompressive hemicraniectomy for the
treatment of intractable intracranial
hypertension after aneurysmal subarachnoid
hemorrhage. Stroke, 2007. 38(
): p. 987-92.
15. Guresir, E., et al., Decompressive
hemicraniectomy in subarachnoid haemorrhage: the
influence of infarction, haemorrhage and
brain swelling. J Neurol Neurosurg Psychiatry,
2009. 80(7): p. 799-801.
16. Berrouschot, J., et al., Mortality of
spaceoccupying (‘malignant’) middle cerebral artery
infarction under conservative intensive care.
Intensive Care Med, 1998. 24(6): p. 620-3.
17. Wijdicks, E.F. and M.N. Diringer, Middle
cerebral artery territory infarction and early brain
swelling: progression and effect of age on
outcome. Mayo Clin Proc, 1998. 73(9): p.
Barak Bar, MD
Department of Neurological Surgery
Thomas Jefferson University Hospital
909 Walnut St, 3rd Floor
Philadelphia, PA 19107
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