Journal of Neurological Surgery Part A: Central European Neurosurgery, Table of Contents

J Neurol Surg A Cent Eur Neurosurg 2021; 82(05): 437-445
DOI: 10.1055/s-0040-1721001

Original Article

Complications Following Decompressive Craniectomy

Jan Mraček

¹Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic

²Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic

,

Jan Mork

¹Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic

²Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic

,

Jiri Dostal

¹Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic

²Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic

,

Radek Tupy

¹Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic

²Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic

,

Jolana Mrackova

¹Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic

²Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic

,

Vladimir Priban

¹Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic

²Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic

› Author Affiliations

MedOne

Abstract

Background Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications.

Methods We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed.

Results DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome.

Conclusions The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.

Keywords

Keywords

decompressive craniectomy - complications - traumatic brain injury - stroke

References
1 González Rabelino GA, Fons C, Rey A, Roussos I, Campistol J. Craniectomy in herpetic encephalitis. Pediatr Neurol 2008; 39 (03) 201-203
2 Adamo MA, Deshaies EM. Emergency decompressive craniectomy for fulminating infectious encephalitis. J Neurosurg 2008; 108 (01) 174-176
3 Ong YK, Goh KY, Chan C. Bifrontal decompressive craniectomy for acute subdural empyema. Childs Nerv Syst 2002; 18 (6–7): discussion 344 340-343
4 Badri S, Chen J, Barber J. et al. Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Med 2012; 38 (11) 1800-1809
5 Balestreri M, Czosnyka M, Hutchinson P. et al. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 2006; 4 (01) 8-13
6 Hase U, Reulen HJ, Meinig G, Schürmann K. The influence of the decompressive operation on the intracranial pressure and the pressure-volume relation in patients with severe head injuries. Acta Neurochir (Wien) 1978; 45 (1–2): 1-13
7 Timofeev I, Czosnyka M, Nortje J. et al. Effect of decompressive craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury. J Neurosurg 2008; 108 (01) 66-73
8 Taylor A, Butt W, Rosenfeld J. et al. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst 2001; 17 (03) 154-162
9 Cooper DJ, Rosenfeld JV, Murray L. DECRA Trial Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group. et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011; 364 (16) 1493-1502
10 Hutchinson PJ, Kolias AG, Timofeev IS. RESCUEicp Trial Collaborators. et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 2016; 375 (12) 1119-1130
11 Vahedi K, Vicaut E, Mateo J. DECIMAL Investigators. et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007; 38 (09) 2506-2517
12 Jüttler E, Schwab S, Schmiedek P. DESTINY Study Group. et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007; 38 (09) 2518-2525
13 Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB. HAMLET investigators. 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. Lancet Neurol 2009; 8 (04) 326-333
14 Vahedi K, Hofmeijer J, Juettler E. DECIMAL, DESTINY, and HAMLET investigators. et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6 (03) 215-222
15 Kurland DB, Khaladj-Ghom A, Stokum JA. et al. Complications associated with decompressive craniectomy: a systematic review. Neurocrit Care 2015; 23 (02) 292-304
16 Stiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 2009; 26 (06) E7
17 Yang XF, Wen L, Shen F. et al. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 2008; 150 (12) 1241-1247 , discussion 1248
18 Gopalakrishnan MS, Shanbhag NC, Shukla DP, Konar SK, Bhat DI, Devi BI. Complications of decompressive craniectomy. Front Neurol 2018; 9: 977
19 Honeybul S. Complications of decompressive craniectomy for head injury. J Clin Neurosci 2010; 17 (04) 430-435
20 Honeybul S, Ho KM. Decompressive craniectomy for severe traumatic brain injury: the relationship between surgical complications and the prediction of an unfavourable outcome. Injury 2014; 45 (09) 1332-1339
21 Mracek J, Hommerova J, Mork J, Richtr P, Priban V. Complications of cranioplasty using a bone flap sterilised by autoclaving following decompressive craniectomy. Acta Neurochir (Wien) 2015; 157 (03) 501-506
22 Yadla S, Campbell PG, Chitale R, Maltenfort MG, Jabbour P, Sharan AD. Effect of early surgery, material, and method of flap preservation on cranioplasty infections: a systematic review. Neurosurgery 2011; 68 (04) 1124-1129 , discussion 1130
23 Sundseth J, Sundseth A, Berg-Johnsen J, Sorteberg W, Lindegaard KF. Cranioplasty with autologous cryopreserved bone after decompressive craniectomy: complications and risk factors for developing surgical site infection. Acta Neurochir (Wien) 2014; 156 (04) 805-811 , discussion 811
24 Zanaty M, Chalouhi N, Starke RM. et al. Complications following cranioplasty: incidence and predictors in 348 cases. J Neurosurg 2015; 123 (01) 182-188
25 Honeybul S, Ho KM. Long-term complications of decompressive craniectomy for head injury. J Neurotrauma 2011; 28 (06) 929-935
26 André C, Py MdeO, Niemeyer-Filho P. Temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report. Arq Neuropsiquiatr 2003; 61 (3A): 682-686
27 Su TM, Lee TH, Chen WF, Lee TC, Cheng CH. Contralateral acute epidural hematoma after decompressive surgery of acute subdural hematoma: clinical features and outcome. J Trauma 2008; 65 (06) 1298-1302
28 Hejazi N, Witzmann A, Fae P. Unilateral decompressive craniectomy for children with severe brain injury. Report of seven cases and review of the relevant literature. Eur J Pediatr 2002; 161 (02) 99-104
29 De Bonis P, Sturiale CL, Anile C. et al. Decompressive craniectomy, interhemispheric hygroma and hydrocephalus: a timeline of events?. Clin Neurol Neurosurg 2013; 115 (08) 1308-1312
30 Flint AC, Manley GT, Gean AD, Hemphill III JC, Rosenthal G. Post-operative expansion of hemorrhagic contusions after unilateral decompressive hemicraniectomy in severe traumatic brain injury. J Neurotrauma 2008; 25 (05) 503-512
31 Kenning TJ, Gooch MR, Gandhi RH, Shaikh MP, Boulos AS, German JW. Cranial decompression for the treatment of malignant intracranial hypertension after ischemic cerebral infarction: decompressive craniectomy and hinge craniotomy. J Neurosurg 2012; 116 (06) 1289-1298
32 Takeuchi S, Nawashiro H, Wada K. et al. Ventriculomegaly after decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage. Clin Neurol Neurosurg 2013; 115 (03) 317-322
33 Heuts SG, Bruce SS, Zacharia BE. et al. Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis. Neurosurg Focus 2013; 34 (05) E4
34 Kan P, Amini A, Hansen K. et al. Outcomes after decompressive craniectomy for severe traumatic brain injury in children. J Neurosurg 2006; 105 (05) 337-342
35 Wang EC, Ang BT, Wong J, Lim J, Ng I. Characterization of cerebrovascular reactivity after craniectomy for acute brain injury. Br J Neurosurg 2006; 20 (01) 24-30
36 Bor-Seng-Shu E, Hirsch R, Teixeira MJ, De Andrade AF, Marino Jr R. Cerebral hemodynamic changes gauged by transcranial Doppler ultrasonography in patients with posttraumatic brain swelling treated by surgical decompression. J Neurosurg 2006; 104 (01) 93-100
37 Bor-Seng-Shu E, Figueiredo EG, Amorim RL. et al. Decompressive craniectomy: a meta-analysis of influences on intracranial pressure and cerebral perfusion pressure in the treatment of traumatic brain injury. J Neurosurg 2012; 117 (03) 589-596
38 Olivecrona M, Rodling-Wahlström M, Naredi S, Koskinen LO. Effective ICP reduction by decompressive craniectomy in patients with severe traumatic brain injury treated by an ICP-targeted therapy. J Neurotrauma 2007; 24 (06) 927-935
39 Missori P, Polli FM, Peschillo S, D'Avella E, Paolini S, Miscusi M. Double dural patch in decompressive craniectomy to preserve the temporal muscle: technical note. Surg Neurol 2008; 70 (04) 437-439 , discussion 439
40 Evins AI, Dutton J, Imam SS. et al. On-demand intraoperative 3-dimensional printing of custom cranioplastic prostheses. Oper Neurosurg (Hagerstown) 2018; 15 (03) 341-349
41 Creutzfeldt CJ, Tirschwell DL, Kim LJ, Schubert GB, Longstreth Jr WT, Becker KJ. Seizures after decompressive hemicraniectomy for ischaemic stroke. J Neurol Neurosurg Psychiatry 2014; 85 (07) 721-725
42 Santamarina E, Sueiras M, Toledo M. et al. Epilepsy in patients with malignant middle cerebral artery infarcts and decompressive craniectomies. Epilepsy Res 2015; 112: 130-136
43 Chen JW, Ruff RL, Eavey R, Wasterlain CG. Posttraumatic epilepsy and treatment. J Rehabil Res Dev 2009; 46 (06) 685-696
44 Di Rienzo A, Pangrazi PP, Riccio M, Colasanti R, Ghetti I, Iacoangeli M. Skin flap complications after decompressive craniectomy and cranioplasty: proposal of classification and treatment options. Surg Neurol Int 2016; 7 (Suppl. 28) S737-S745
45 Vieira E, Guimarães TC, Faquini IV. et al. Randomized controlled study comparing 2 surgical techniques for decompressive craniectomy: with watertight duraplasty and without watertight duraplasty. J Neurosurg 2018; 129 (04) 1017-1023
46 Yang HS, Hyun D, Oh CH, Shim YS, Park H, Kim E. A faster and wider skin incision technique for decompressive craniectomy: n-shaped incision for decompressive craniectomy. Korean J Neurotrauma 2016; 12 (02) 72-76
47 Mracek J, Choc M, Mork J, Vacek P, Mracek Z. Osteoplastic decompressive craniotomy: an alternative to decompressive craniectomy. Acta Neurochir (Wien) 2011; 153 (11) 2259-2263
48 Mracek J, Mracek Z, Choc M. Tactical and technical notes for decompression craniotomy: a review. Rozhl Chir 2007; 86 (05) 217-223
49 Lee MH, Yang JT, Weng HH. et al. Hydrocephalus following decompressive craniectomy for malignant middle cerebral artery infarction. Clin Neurol Neurosurg 2012; 114 (06) 555-559
50 Isago T, Nozaki M, Kikuchi Y, Honda T, Nakazawa H. Sinking skin flap syndrome: a case of improved cerebral blood flow after cranioplasty. Ann Plast Surg 2004; 53 (03) 288-292
51 Dujovny M, Agner C, Aviles A. Syndrome of the trephined: theory and facts. Crit Rev Neurosurg 1999; 9 (05) 271-278
52 Akins PT, Guppy KH. Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care 2008; 9 (02) 269-276
53 Jung HJ, Kim DM, Kim SW. Paradoxical transtentorial herniation caused by lumbar puncture after decompressive craniectomy. J Korean Neurosurg Soc 2012; 51 (02) 102-104
54 Fields JD, Lansberg MG, Skirboll SL, Kurien PA, Wijman CA. “Paradoxical” transtentorial herniation due to CSF drainage in the presence of a hemicraniectomy. Neurology 2006; 67 (08) 1513-1514
55 Oyelese AA, Steinberg GK, Huhn SL, Wijman CA. Paradoxical cerebral herniation secondary to lumbar puncture after decompressive craniectomy for a large space-occupying hemispheric stroke: case report. Neurosurgery 2005; 57 (03) E594 , discussion E594
56 Honeybul S. Decompressive craniectomy: a new complication. J Clin Neurosci 2009; 16 (05) 727-729
57 Ban SP, Son YJ, Yang HJ, Chung YS, Lee SH, Han DH. Analysis of complications following decompressive craniectomy for traumatic brain injury. J Korean Neurosurg Soc 2010; 48 (03) 244-250
58 Picetti E, Caspani ML, Iaccarino C. et al. Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury: a clinical study. Acta Neurochir (Wien) 2017; 159 (04) 615-622