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  • Review Article
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Decompressive craniectomy: past, present and future

Nature Reviews Neurology volume 9, pages 405–415 (2013)Cite this article

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Abstract

Decompressive craniectomy (DC)—a surgical procedure that involves removal of part of the skull to accommodate brain swelling—has been used for many years in the management of patients with brain oedema and/or intracranial hypertension, but its place in contemporary practice remains controversial. Results from a recent trial showed that early (neuroprotective) DC was not superior to medical management in patients with diffuse traumatic brain injury. An ongoing trial is investigating the clinical and cost effectiveness of secondary DC as a last-tier therapy for post-traumatic refractory intracranial hypertension. With regard to ischaemic stroke (malignant middle cerebral artery infarction), a recent Cochrane review concluded that DC improves survival compared with medical management, but that a higher proportion of DC survivors experience moderately severe or severe disability. Although many patients have a good outcome, the issue of DC-related disability raises important ethical issues. As DC and subsequent cranioplasty are associated with a number of complications, indiscriminate use of this surgery is not appropriate. Here, we review the evidence and present considerations regarding surgical technique, ethics and cost-effectiveness of DC. Prospective clinical trials and cohort studies are essential to enable optimization of patient care and outcomes.

Key Points

  • Decompressive craniectomy is a useful operation for management of brain oedema and intracranial hypertension

  • Early (neuroprotective) decompressive craniectomy is not superior to medical management in patients with diffuse traumatic brain injury

  • The role of decompressive craniectomy as a last-tier therapy for post-traumatic refractory intracranial hypertension is under investigation in an ongoing multicentre trial

  • Decompressive craniectomy improves survival rates in patients with malignant middle cerebral artery stroke, but some survivors have moderately severe or severe disability

  • Although associated with good outcome in many patients, the fact that some individuals survive with severe disability raises important ethical issues

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Figure 1: Effect of decompressive craniectomy on ICP.
Figure 2: Unilateral decompressive craniectomy.
Figure 3: Bifrontal decompressive craniectomy.

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Change history

  • 21 June 2013

    In the version of this article initially published online, two statements were incorrect. On page 410, paragraph 1, line 2: 'after surgery' should read 'before surgery'. On page 409 in the 'aneurysmal subarachnoid haemorrhage' section, line 3: '...in the acute phase of brain...' should read '...in the acute phase or brain...'.The errors have been corrected in the print, HTML and PDF versions of the article. In the version of this article initially published online, two statements were incorrect. On page 410, paragraph 1, line 2: 'after surgery' should read 'before surgery'. On page 409 in the 'aneurysmal subarachnoid haemorrhage' section, line 3: '...in the acute phase of brain...' should read '...in the acute phase or brain...'.The errors have been corrected in the print, HTML and PDF versions of the article.

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Acknowledgements

A. G. Kolias is supported by a Royal College of Surgeons of England Research Fellowship (funded by the Freemasons and the Rosetrees Trust), an National Institute of Health Research (NIHR) Academic Clinical Fellowship, and a Sackler Studentship. P. J. Hutchnson is supported by the NIHR Cambridge Biomedical Research Centre and has been appointed as the Surgical Specialty Lead for Neurosurgery, Royal College of Surgeons of England Clinical Research Initiative.

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  1. Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, CB2 0QQ, UK

    Angelos G. Kolias, Peter J. Kirkpatrick & Peter J. Hutchinson

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  1. Angelos G. Kolias
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  2. Peter J. Kirkpatrick
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  3. Peter J. Hutchinson
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All authors researched data for the article, provided substantial contribution to discussions of the content, wrote the article, and contributed equally to review and/or editing of the manuscript before submission.

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Correspondence to Angelos G. Kolias.

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Competing interests

A. G. Kolias is Chair of the British Neurosurgical Trainee Research Collaborative, which has been supported with an educational grant from Codman, UK. P. J. Hutchinson is a Director of Technicam Ltd, Newton Abbot, Devon, UK (a manufacturer of cranial access devices for neuro-monitoring). P. J. Kirkpatrick declares no competing interests.

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Kolias, A., Kirkpatrick, P. & Hutchinson, P. Decompressive craniectomy: past, present and future. Nat Rev Neurol 9, 405–415 (2013). https://doi.org/10.1038/nrneurol.2013.106

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