REVIEWS

Decompressive craniectomy: past, present

and future
Angelos G. Kolias, Peter J. Kirkpatrick and Peter J. Hutchinson
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.

Kolias, A. G. et al. Nat. Rev. Neurol. advance online publication 11 June 2013; doi:10.1038/nrneurol.2013.106

Introduction
Brain oedema can develop after traumatic brain injury
(TBI), ischaemic stroke and a number of other condi-
tions that affect the brain.1–6 Owing to the rigid nature of
the skull, escalating brain oedema leads to an increase in
intracranial pressure (ICP) which, in turn, causes reduc-
tion in cerebral perfusion pressure (CPP; mean arterial
blood pressure minus ICP), cerebral blood flow (CBF)
and oxygenation. These effects contribute to develop-
ment of additional brain oedema,1,7 forming part of a
‘vicious circle’ that, if not interrupted, can lead to brain
herniation and death.2,8
Decompressive craniectomy (DC)—a procedure
whereby part of the skull is removed and the under-
lying dura is opened—is attractive for management of
escalating brain oedema as it can provide additional
space for the swollen brain, thereby mitigating the risk
of ICP elevation and herniation. Strong evidence exists
to suggest that DC can be used to effectively reduce
ICP (Figure 1).9,10 Despite the passing of 100 years since
Kocher’s seminal description of DC in 1901, the role of
this technique in patient management continues to be
debated. The popularity of DC for treatment of patients
who experience a TBI or stroke has waxed and waned
Competing interests
A. G. Kolias declares an association with the British
Neurosurgical Trainee Research Collaborative (which has
received funding from Codman). P. J. Hutchinson declares an
association with the following company: Technicam Ltd. See the
article online for full details of the relationships. P. J. Kirkpatrick
declares no competing interests.
since the 1950s.11–15 Since the 1990s, advances in neuro-
imaging and in prehospital and neurointensive care have
led to a resurgence of interest in the use of DC, which
culminated in the publication of results from numerous
randomized trials in the 2000s.16,17–24 Recommendations
on the use of DC in patients with TBI and ischaemic
stroke have been introduced in clinical guidelines.25–27
However, the exact indications for DC, optimal timing
of treatment and effects of DC on long-term functional
outcome remain unclear, and a need to increase our
understanding of DC-associated complications and costs
has been recognized.28–32
In this Review, we summarize the available evidence
regarding the effectiveness of DC following TBI, ischae-
mic stroke and other neurological conditions. We also
consider surgical technique, ethics and cost-effectiveness
of DC, and suggest directions for future studies.
Historical aspects Division of
The practice of removing part of the skull dates back Neurosurgery,
to the beginning of the Neolithic period, around Department of Clinical
Neurosciences,
10,000 BC. 33 The terms ‘trepanation’ or ‘trephina- Addenbrooke’s Hospital
tion’ are etymologically derived from the ancient and University of
Cambridge, Cambridge,
Greek word trypanon: tool used for drilling holes. CB2 0QQ, UK
Archaeological evidence of the practice of trephina- (A. G. Kolias,
P. J. Kirkpatrick,
tion has been found in Europe, North America, Central P. J. Hutchinson).
America, South America, Africa and Asia.33 Hippocrates
(c.460 BC–c.370 BC) was the first to systematically Correspondence to:
A. G. Kolias
describe skull fractures and discuss which types of injury angeloskolias@
should be treated with trephination.34 Furthermore, he gmail.com

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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
recognized that visual loss—presumably due to elevated
ICP—could be treated with trephination.33
Further advances in the field of neuroanatomy
occurred during the late Middle Ages and Renaissance
period, and paved the way for the modern era of trephi-
nation.35 In 1901, Theodor Kocher—a Swiss surgeon who
was awarded the Nobel Prize in 1909—stated that “if
there is no cerebrospinal fluid (CSF) pressure, but brain
pressure exists, then pressure relief must be achieved by
opening the skull.”36 In 1908, following Kocher’s descrip-
tion of DC, Harvey Cushing presented a case series of
patients with head injuries who were treated with sub-
temporal DC.37 Cushing reported a surgery-associated
reduction in mortality from 50% to less than 15%.
Moreover, he asserted that the brain oedema and swell-
ing that accompany severe cerebral contusions were best
managed with a subtemporal DC.
Case series published throughout the 1950s to the
1970s presented different DC techniques such as
60
* large cohort studies have consistently shown that raised
50
40
ICP (mm Hg)
30
20
10
0
Baseline 24 h 3h 3h 24 h 48 h 72 h
Preoperation Postoperation
Figure 1 | Effect of decompressive craniectomy on ICP. In a study of 27 patients
who underwent DC (surgery performed at point of arrowhead) for post-traumatic
refractory intracranial hypertension, DC led to significant reduction in ICP, which
was sustained for at least 72 h after the operation. Boxplots show the temporal
relationship of ICP to DC. Circles denote outliers; asterisk indicates extreme
values. Abbreviations: ICP, intracranial pressure. Permission obtained from the
American Association of Neurological Surgeons © Timofeev, I. et al. J. Neurosurg.
108, 66–73 (2008).
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hemicraniectomy, circumferential DC and bifrontal
DC.13,14,38,39 This period was marked by wide variation in
opinions of DC, ranging from outright rejection of the
technique to calls for controlled studies.11,13,14 Advances
in neuroimaging, prehospital and neurointensive care
during the 1980s and 1990s led to a resurgence of interest
in DC.16–20 Findings from the majority of nonrandomized
studies performed during this time suggested that use
of DC led to a substantial reduction in mortality com-
pared with medical management. Nevertheless, varia-
tion in outcome between different series was marked,
and concern remained that DC might increase survival
at the expense of lifelong severe disability.40,41 Research
in DC at the beginning of the 21st century, therefore,
was characterized by efforts to strengthen the evidence
through randomized studies, particularly in the fields of
TBI and stroke.
Indications
Decompressive craniectomy has been used to control
brain oedema and intracranial hypertension in a wide
range of conditions such as aneurysmal subarachnoid
haemorrhage (SAH), spontaneous intracerebral haemor-
rhage (ICH), viral and bacterial encephalitis, acute dis-
seminated encephalomyelitis (ADEM), and cerebral
venous and sinus thrombosis.6,42–46 Evidence to support the
use of DC in these conditions, however, has largely been
obtained from uncontrolled case series and case reports.
The evidence base to support the use of DC in patients
with TBI and stroke is broader, albeit still developing.
Traumatic brain injury
Intracranial hypertension following TBI can develop
owing to diffuse brain oedema, blossoming of contu-
sions, pericontusional brain oedema or expanding
haematomas, alone or in combination. 1,47 Numerous
ICP (at levels of around 20–25 mmHg) is independently
associated with high risk of mortality after TBI. 48–51
Evidence also suggests that low CPP (at levels below
50–55 mmHg), together with resultant brain ischae-
mia, is one of the major contributors to unfavourable
clinical outcome.47–49 Modern intensive-care manage-
ment of severe TBI is, therefore, based on tiered ICP-
driven and CPP-driven therapeutic protocols.52–55 In
2012, a random ized trial that involved 324 patients
with severe TBI in Bolivia and Ecuador investigated the
clinical effectiveness of patient management using ICP-
monitoring versus imaging and clinical examination-
based monitoring.56 Care focused on maintenance of ICP
at or below 20 mmHg was not superior to care based on
imaging and clinical examination; however, patients in
both arms received tiered ICP-lowering therapies, and
DC was performed in 30% of patients in each arm. The
trial findings, therefore, do not challenge the belief that
brain oedema and raised ICP in patients with TBI should
be actively managed.57
In the modern era of TBI management, DC can be
grouped into two major categories: primary or second-
ary. Primary DC is usually used to describe surgery
www.nature.com/nrneurol

in which the bone flap is left out after evacuation of a
mass lesion in the acute phase.19,58,59 When DC is used
as part of tiered therapeutic protocols for intracranial
hypertension that is secondary to diffuse brain injury
and brain oedema, the procedure is termed secondary
or protocol-driven DC.
Primary decompressive craniectomy
Primary DC is usually performed during evacuation of
an acute subdural haematoma (ASDH), either because
the brain is swollen beyond the confines of the skull
or because the patient is thought to be at high risk of
worsening of brain swelling within the ensuing few
days.58,60 A recent international survey of 283 neuro-
surgeons showed that 56% of the respondents performed
a primary DC for at least 25% of their patients with
ASDH.61 In a nonrandomized cohort-comparison study
of patients with ASDH, the standardized morbidity ratio
was lower in individuals who received DC (0.75; 95% CI
0.51–1.07) than in those treated with a craniotomy (0.90;
95% CI 0.57–1.35).62 Although the confidence intervals
overlapped, this study suggests that primary DC could
be more effective than craniotomy for some patients with
ASDH. The Brain Trauma Foundation has identified
further research on DC versus craniotomy in patients
with ASDH as a priority, as this approach is likely to
improve patient care,60 and a pragmatic randomized
trial of primary DC versus craniotomy for patients with
ASDH is in the planning stages.63
Secondary decompressive craniectomy
Secondary DC is usually undertaken as a last-tier (life-
saving) therapy when a patient has intracranial hyper-
tension that is sustained at 20–35 mmHg and refractory
to medical management. 16,20,64,65 However, secondary
DC can also be undertaken earlier (that is, before the
stages of last-tier therapy) and in individuals with less-
sustained periods of intracranial hypertension. In such
cases, secondary DC can be regarded as a neuroprotec-
tive measure.21,66 The results of the first randomized trial
of secondary DC were published in 2001.21 The study
involved 27 paediatric patients with TBI and intracranial
hypertension who were randomly assigned to receive
either medical management alone or medical manage-
ment plus bi-temporal DC (removal of a disc of tem-
poral bone measuring about 3–4 cm, with extension of
the craniectomy to the floor of the middle cranial fossa;
dura mater was not opened). Although this pilot trial was
small and stopped early after an interim analysis, initial
findings showed that DC was associated with a risk ratio
of 0.54 (95% CI 0.29–1.01) for unfavourable outcome—
namely, death, vegetative status or severe disability—at
6 months after injury (nonsignificant trend).59 Notably,
however, these potentially encouraging results with early,
neuroprotective DC in a paediatric population were not
replicated in the DECRA study,24 which focused solely
on an adult population.
The DECRA study 24 was performed between 2002
and 2010. Investigators from Australia, New Zealand and
Saudi Arabia recruited 155 adults (up to the age of
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Box 1 | What is known about DC following TBI?
■ For patients with diffuse TBI, early bifrontal DC aimed
at neuroprotection does not lead to improvement
in functional outcomes over medical management;
however, DC is associated with a shorter duration
of mechanical ventilation and a shorter stay in the
intensive care unit (DECRA trial)24
■ DC may be beneficial as a last-tier therapy for
patients with post-traumatic intracranial hypertension
that is refractory to medical management, and is
under investigation in an ongoing randomized trial
(RESCUEicp trial)22
■ Primary DC may be more effective than craniotomy
for selected patients with head injuries who undergo
evacuation of an acute subdural haematoma, as will
be investigated in a planned randomized trial (RESCUE-
ASDH trial)63
Abbreviations: DC, decompressive craniectomy; TBI, traumatic
brain injury.
60 years) with diffuse TBI and moderate intracranial
hypertension, and randomly assigned these individuals
to receive either standard medical management alone or
medical management plus bifrontal DC. Patients were
assigned to treatment within the first 72 h postinjury if
their ICP exceeded 20 mmHg for more than 15 min (con-
tinuously or intermittently) within a 1-hour period, and
if they did not respond to optimized first-tier interven-
tions. At 6-month follow-up, the investigators observed
a higher rate of unfavourable outcomes in the DC group
than in the control group (70% versus 51%; OR 2.21; 95%
CI 1.14–4.26; P = 0.02). However, 27% of patients in the
surgical arm had bilaterally unreactive pupils compared
with only 12% in the control arm. As pupil reactivity is
known to be a major prognostic indicator of outcome
following TBI, the investigators performed a post-
hoc adjustment for pupil reactivity at baseline, which
revealed that the between-group difference in terms of
unfavourable outcome was not significant (adjusted OR
1.90; 95% CI 0.95–3.79).24
In contrast to the DECRA study of early DC for intra-
cranial hypertension, the on-going RESCUEicp trial is
examining the effectiveness of DC as a last-tier therapy
for patients with refractory intracranial hypertension.22
The RESCUEicp study differs from DECRA in a number
of features: sample size (400 patients in RESCUEicp
versus 155 patients in DECRA); surgical technique
(bifrontal DC or hemi-craniectomy versus bifrontal DC
alone); threshold for ICP (25 mmHg versus 20 mmHg);
duration of refractory intracranial hyper tension (at
least 1 h versus 15 min); timing of randomization (any
time when inclusion criteria are met versus within
72 h postinjury); and follow-up period (2 years versus
6 months).22,67 RESCUEicp has currently recruited more
than 90% of the required sample size, and the results
(primary end point) are expected in 2014.
Summary and recommendations
Overall, the existing evidence seems to suggest that early
(neuroprotective) DC is not superior to medical manage-
ment for patients with diffuse TBI (Box 1). Secondary
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Table 1 | Characteristics of four randomized trials of DC for malignant MCA stroke

Study Inclusion criteria Surgical intervention n Primary end point Reason for early termination
73
DECIMAL Patients aged 18–55 years, DC performed <6 h after 38 Favourable outcome Survival benefit with DC and
within 24 h of stroke onset, randomization and ≤30 h defined as mRS consideration that data would
and involvement of more after the onset of score ≤3 at be pooled with that of other
than 50% of the MCA symptoms 6 months trials
territory on CT or a DWI Mean time from onset of
infarct volume more than stroke to DC: 20.5 h
145 cm3 (95% CI 4.2–36.8)
DESTINY74 Patients aged 18–60 years, Onset of symptoms >12 h 32 Favourable outcome Survival benefit with DC and
within 48 h of stroke onset, and <36 h before a defined as mRS consideration that data would
and involvement of at least possible surgical score ≤3 at be pooled with that of other
two-thirds of MCA territory intervention 6 months and trials
including part of the basal Mean time from onset of 12 months
ganglia stroke to DC: 24.4 h
(95% CI 10.9–37.9)
HAMLET72 Patients aged 18–60 years, Treatment started within 64 Favourable outcome Data monitoring committee
within 96 h of stroke onset, 3 h of randomization defined as mRS advised that no statistically
and involvement of at least Median time from score ≤3 at significant difference would be
two-thirds of MCA territory symptom onset to 12 months found for the primary end point
randomization (DC arm): with the planned sample size
41 h (IQR 29–50)
Zhao Patients aged 18–80 years, Mean time from symptom 47 Favourable outcome Safety monitoring committee
et al.76 within 48 h of stroke onset, onset to randomization defined as mRS found a significant difference
and involvement of at least (DC arm): 23.6 h (95% CI score ≤4 at between the two arms in terms
two-thirds of MCA territory 11–36.2) 6 months of the primary end point during
the third interim analysis
Abbreviations: DC, decompressive craniectomy; DWI, diffusion-weighted imaging; IQR, interquartile range; MCA, middle cerebral artery; mRS, modified Rankin Scale.

DC as a last-tier therapy for refractory intracranial
hypertension and primary DC for patients with ASDH
are currently undergoing systematic evaluation. In
view of the current state of evidence, and owing to the
number of potential complications with DC (discussed
below), indiscriminate use of DC for patients with TBI
is not appropriate.
Ischaemic stroke
Brain oedema following ischaemic stroke often causes
adverse effects in patients with large-volume (space-
occupying) infarcts.68,69 Such infarcts are usually caused
by occlusion of large vessels such as the distal internal
carotid artery or the proximal middle cerebral artery
(MCA). The term ‘malignant MCA infarct’ is often used
as up to 80% of patients with such infarcts will deterio-
rate and die following herniation. 68,70 Approximately
two-thirds of patients with malignant MCA infarcts
deteriorate within 48 h of stroke onset.69 It has been sug-
gested that early reperfusion therapy can increase the
degree of oedema to critical levels within the first 24 h
after stroke.27
Evidence from noncontrolled series of patients with
malignant MCA has suggested a significant survival
benefit following hemicraniectomy,17,18,71 but the effect
of DC on functional outcome remained unclear. For
this reason, three randomized trials of DC versus best
medical management for treatment of malignant MCA
were conducted: the HAMLET trial performed in
the Netherlands, the DECIMAL study in France, and
DESTINY in Germany (Table 1).72,73,74 All three trials
completed recruitment in the early 2000s, and collec-
tively involved 134 adults (up to 60 years of age) with
malignant MCA infarction who were randomly assigned
to receive either hemicraniectomy or best medical man-
agement. A Cochrane review that included data from
all three trials showed that poor outcome—defined as
a modified Rankin scale (mRS) score of 4 (moderately
severe disability; unable to attend to own bodily needs
without assistance and unable to walk unassisted),
5 (severe disability) or 6 (death)—was not significantly
different between the two treatment arms at end of
follow-up (OR 0.56, 95% CI 0.27–1.15). When patients
with moderately severe disability were included in the
favourable outcome category, however, DC was found
to reduce the risk of poor outcome (OR 0.26, 95% CI
0.13–0.51).75 These findings suggest that DC improves
survival compared with best medical management, but
that an increased proportion of individuals treated with
DC survive with moderately severe or severe disability.75
Notably, the time window from stroke onset to
random ization and treatment differed in each trial
(Table 1). A pooled meta-analysis of all three trials,
based on a post-hoc subgroup of patients who were
randomly assigned to treatment group within 48 h after
stroke onset (n = 93), demonstrated that DC reduced the
risk of poor outcome (mRS score 4–6; OR 0.33, 95% CI
0.13–0.86).23 This finding suggests that early DC does
not increase the proportion of survivors with moderately
severe or severe disability. Given the post-hoc nature
of this subgroup meta-analysis, however, these results
should be interpreted with caution.
The results of another randomized trial, which involved
47 adults (≤80 years old) with malignant MCA infarction
who either did or did not receive DC, was published in
2012 (Table 1).76 Although this study has been criticized

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on several fronts—such as retrospective registration with
a clinical trials register after completion, and concerns
regarding the ethical standards in view of the inclusion
of patients younger than 60 years, despite the fact that
HAMLET, DECIMAL and DESTINY had published their
results more than 1 year before its launch—the results
confirmed that DC reduces the risk of poor outcome
(OR 0.14, 95% CI 0.04–0.44), provided that moderately
severe disability (mRS score 4) is considered a favourable
outcome.77 Interestingly, the researchers observed similar
results in a subgroup analysis of 29 elderly participants
(age 60 years or older).
In view of the above evidence, the guidelines of the
American Heart and Stroke Associations (AHA/ASA)
for early management of acute ischaemic stroke state
that although DC is effective and potentially lifesaving,
patients’ families should be advised about the potential
outcome of survival with severe disability.27 Importantly,
a number of unanswered questions remain (Box 2).
Owing to the unequivocal survival benefit with DC—
and despite calls for more trials,78,79—a further trial of
this surgical treatment for ischaemic stroke is unlikely to
be undertaken. Instead, large multicentre cohort studies
will probably provide answers to these questions, partic-
ularly if they are undertaken according to the principles
of comparative effectiveness research.80,81
Aneurysmal subarachnoid haemorrhage
In patients with aneurysmal SAH, DC has mostly been
used to control brain oedema associated with large
intracerebral haematomas in the acute phase of brain
oedema associated with delayed clinical deterioration.42,82
According to the two largest case series of consecutive
patients with SAH and long-term follow-up, the rate of
patients requiring DC is 7.0–8.5%. In both studies, DC was
most often performed to control elevated ICP that was
refractory to medical management, typically in patients
with poor-grade SAH. The rate of long-term favourable
clinical outcome (mRS score 0–3) at follow-up was approx-
imately 27% in both studies. One of the studies found that
the rate of favourable outcome following DC was higher in
patients with brain oedema associated with large haemato-
mas (16 of 46; 34.8%) than in patients with oedema associ-
ated with delayed ischaemia (2 of 20; 10%; P = 0.038),42 but
this finding was not corroborated by the second study.82
The paucity of evidence for efficacy of DC in SAH may
be related to the fact that ICP monitoring is not included
in existing guidelines for this condition and, therefore, is
not widely practiced.83–85 However, a number of studies,
including the two mentioned above,42,82 indicate that brain
oedema and intracranial hypertension can potentially
affect 10–20% of patients with SAH, and that these events
have an adverse effect on clinical outcome.3,86,87 In our
opinion, therefore, this area deserves further investigation
and attention by clinicians.
Spontaneous intracerebral haemorrhage
About one-third of the patients with spontaneous ICH
experience an increase in mass effect, which can poten-
tially lead to raised ICP.4 In the acute phase of ICH, mass
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Box 2 | DC for malignant MCA stroke—outstanding issues
■ A need remains for assessment of postsurgical outcome across a number
of domains such as emotional status, cognitive status and quality of life in
addition to functional status28
■ Whether a modified Rankin Scale score of 4 can be considered a favourable
outcome following DC remains unclear
■ The need for an absolute age limit for DC following MCA stroke remains
unclear,76,127 but evidence with regard to this issue will hopefully be provided
following completion of the ongoing DESTINY II trial, which is recruiting patients
over the age of 60 years with malignant MCA infarction128
■ It is not clear if a treatment window of 48 h should apply to all patients with
malignant MCA infarction, given that some will deteriorate later28
■ Some concerns remain with regard to offering DC to patients with dominant-
hemisphere malignant stroke, as aphasia can adverseley affect functional
outcome and quality of life; however, no conclusive evidence exists to
support the hypothesis that patients with dominant-hemisphere infarcts fare
significantly worse than patients with non-dominant hemisphere infarcts28
■ The prognostic significance of involvement of additional vascular territories
(such as the anterior cerebral artery and posterior cerebral artery) has not been
systematically studied
■ The health–economic consequences of managing malignant MCA infarct with
DC have not been systematically studied
Abbreviations: DC, decompressive craniectomy; MCA, middle cerebral artery.
effect usually increases owing to haematoma expansion.
Peri-haematomal oedema can also contribute to increas-
ing mass effect, but the severity of oedema seems to be
related to the baseline volume of the haematoma. 88,89
Surgical management of ICH remains a controversial
issue, but evacuation of the haematoma via a craniotomy
(a procedure in which the bone flap is replaced following
haematoma evacuation) is the usual treatment modal-
ity when surgery is required.90,91 In the limited literature
available, DC for spontaneous ICH has mostly been per-
formed in conjunction with haematoma evacuation in
patients with large haematomas of the basal ganglia,43,92
but has also been used as a stand-alone procedure for
patients with large spontaneous ICH.93,94 Owing to the
small number of patients involved and the retrospective
design of these studies, however, the conclusions that can
be drawn are limited.
Cerebral venous thrombosis
Thrombosis of the dural venous sinuses and/or cerebral
veins (cerebral venous thrombosis, CVT) accounts for
0.5–1.0% of all strokes, and usually affects young adults.
Patient outcomes following such stroke events are better
than with more-common ischaemic and haemorrhagic
types of stroke.95,96 ICP can be elevated owing to impair-
ment of the venous outflow and/or presence of mass
effect associated with large parenchymal infarction or
haemorrhage.96 One prospective observational study
of 624 patients with CVT reported a mortality rate of
4.3% during the acute phase, with the majority of deaths
being attributed to herniation following unilateral mass
effect or diffuse oedema with multiple parenchymal
lesions.5 A recent study of the role of DC for treatment
of CVT involved combination of data from a system-
atic review of the literature and a multicentre registry.46
The authors reported a low rate of postsurgical poor
outcome (approximately 22%), despite the fact that 72%
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a b c

1
2

Figure 2 | Unilateral decompressive craniectomy. a | The dotted line represents the usual skin incision made during unilateral
decompressive craniectomy. To preserve adequate vascular supply, the length of the incision (distance 2) should not exceed
its width (distance 1). b | A myocutaneous flap is reflected. The dotted line represents the usual extent of the craniectomy.
c | The dotted line on the dura mater represents our preferred method for opening the dura. The dura is opened in a C-shaped
fashion with its base along the sphenoid ridge. The dural incision is kept 5–10 mm away from the craniectomy edges to
minimise the risk of injury to the protruding brain. Permission obtained from Springer © Timofeev, I. et al. Adv. Tech. Stand.
Neurosurg. 38, 115–136 (2012).

of the patients were comatose , and about 60% had pupil-
lary abnormalities after surgery. In this study, DC was
performed in 65% of the patients, DC with haematoma
evacuation in 25%, and haematoma evacuation alone
in 10%. Notably, recent guidelines from the AHA/ASA
recommend that DC be considered for patients with
neurological deterioration due to severe mass effect or
intracranial haemorrhage that causes intractable intra-
cranial hypertension.96 A need remains, however, for
better evidence; such evidence will hopefully be provided
by a prospective international multicentre registry—the
International Study on Cerebral Vein and Dural Sinus
Thrombosis (ISCVT-2).46
Encephalitis
Brain oedema and intracranial hypertension can affect
patients with encephalitis caused by infection, especially in
individuals with a reduced level of consciousness.97 In the
context of encephalitis, DC has mostly been used as life-
saving measure in comatose patients with clinical and/
or radiological evidence of brain herniation.98 A recent
literature review identified 43 patients treated with a DC
for life-threatening brain oedema associated with bacte-
rial or viral encephalitis: mortality rate was 7%, and about
80% of the patients had a good recovery.44 The conclusions
that can be drawn are again limited, however, owing to the
small number of patients.
Acute disseminated encephalomyelitis
ADEM is an inflammatory demyelinating disorder of the
CNS that typically occurs following infection or vaccina-
tion.6 A fulminant course, which requires management
in the intensive care unit, occurs in up to one-third of
patients with ADEM and is associated with high mortal-
ity rates (up to 25%).6 Single-patient case reports indicate
that DC can be life-saving in patients with ADEM who
have severe brain oedema and clinical and/or radiological
evidence of brain herniation.6,45
Paediatric studies
Only one randomized trial of DC has been performed
in a paediatric population. This pilot trial involved
27 children (median age 120.9 months; range 13.6–
176.4 months) with head injuries who were randomly
assigned to receive medical management alone or
medical management plus bi-temporal DC. The study
showed that DC was associated with a risk ratio of 0.54
(95% CI 0.29–1.01) for unfavourable outcome (death,
vegetative status or severe disability) at 6 months after
injury (nonsignificant trend).21 Of the remaining pub-
lished trials discussed above, all had a lower age limit of
18 years, with the exception of the RESCUEicp trial, in
which the lower age limit was 10 years. Evidence for DC
in the paediatric population, therefore, is mostly derived
from case series.
A recently published systematic review of literature
from 1976 to 2010, which included only studies of
patients undergoing DC to lower intractably increased
ICP, identified a total of 172 paediatric patients treated
with DC.99 The underlying pathology in most cases was
TBI (80%), with the remaining conditions reported as
cerebral infarction (7.5%), intracerebral haemorrhage
(3%), or ‘other’ (10.5%). The overall rate of favourable
outcome was 62%. The authors of the review noted that
26 of 43 patients (60%) with unilateral pupillary dilata-
tion and 14 of 31 patients (45%) with bilateral pupillary
dilatation achieved a favourable outcome. These findings
suggest that, in contrast to adults, a favourable outcome
in children is attainable even in the presence of pupillary
abnormalities.99,100 Nevertheless, drawing firm conclu-
sions from this study is difficult owing to the overall low
level of evidence.
Surgical considerations
Unilateral DC (also termed hemicraniectomy) is
usually performed in cases with predominantly uni-
lateral hemispheric oedema—a feature that is evident
on brain imaging as a midline shift to the contralateral
side (Figure 2).7,101 Bifrontal DC, which extends from
the floor of the anterior cranial fossa anteriorly to the
coronal suture posteriorly and to the pterion laterally, is
usually performed in patients with diffuse brain oedema
(Figure 3).7,16 Removal of the inferior part of the tem-
poral bone to the floor of the middle cranial fossa is an

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© 2013 Macmillan Publishers Limited. All rights reserved
 REVIEWS

a b c

Figure 3 | Bifrontal decompressive craniectomy. a | The dotted line represents the usual skin incision for bifrontal
decompressive craniectomy, which should be kept behind the hairline. b | A bicoronal myocutaneous flap is relected
anteriorly. The dotted line on the skull represents the usual extent of the craniectomy. Subtemporal decompression is
optional. c | The bone flap has been removed. The dotted line on the dura mater represents our preferred method for
opening the dura. The dura is opened on either side of the midline in a C-shaped fashion with its base along the superior
sagittal sinus. Division of the superior sagittal sinus anteriorly and of the falx (red line) is optional. Permission obtained from
Springer © Timofeev, I. et al. Adv. Tech. Stand. Neurosurg. 38, 115–136 (2012).

important manoeuvre for both types of DC, especially in
the presence of temporal pole lesions or oedema causing
brainstem compression.
It is now well recognized that, during DC, the dura
mater has to be widely opened as bony decompres-
sion alone cannot sufficiently accommodate severe
brain swelling. Leaving the dura open while covering
the brain with a sheet of haemostatic material (such as
Surgicel®, Ethicon Inc., Somerville, NJ) is our preferred
option as it allows for faster closure with a low chance
of complications. 20,41,102 If a duraplasty is performed,
it should be wide enough to accommodate further
brain expansion.
Another important surgical consideration in DC is
the size of the bony decompression. This considera-
tion is of particular concern with regard to unilateral
DC. If the bone flap is too small, the swollen brain
can herniate through the craniectomy window, with
resultant compression of the bridging veins and venous
infarction.31,103 Such an occurrence can lead to further
brain injury and poor outcome.104 Consequently, when
discussing uni lateral DC, most authors recommend
that surgery involves a large bone flap in the fronto–
temporo parietal area, with a minimum diameter
of 11–12 cm.62,103,105
Postoperative management
Following DC, a number of early or delayed complica-
tions can occur;31 for example, in the context of TBI,
expansion of contusions and contralateral mass lesions
can occur.31,106 Monitoring and medical management
of ICP, therefore, should continue in the postoperative
period.101 In the first few weeks after DC, wound healing
problems and subdural or subgaleal collections of CSF
can develop.31,107 Hydrocephalus and the syndrome of the
trephined (also known as sinking skin-flap syndrome)
can affect patients in the first few months following DC;
these two conditions should be borne in mind especially
in patients whose neurological recovery stalls or those
who remain in a poor neurological state.31,101,108 Whether
DC or specific DC characteristics (such as size of bone
flap or distance of craniectomy from midline) can inde-
pendently increase the risk of development of hydro-
cephalus remains a matter of debate, as reports in the
literature are conflicting.109–112
Cranioplasty
Cranioplasty (skull reconstruction) is usually under-
taken a few months after DC. This procedure is asso-
ciated with a number of complications; infection and
wound-healing problems are particularly challenging
cranioplasty-related issues,113,114 whereas less common
complications include seizures, intracranial haemor-
rhage, and unsatisfactory appearance.114 Sudden post-
operative death due to diffuse brain swelling has also
been described.113
Although associated with risk of complications,
cranioplasty is recommended not only for brain protec-
tion but also for restoration of the original skull contour,
which is of cosmetic importance to the patient. Some
evidence suggests that cranioplasty can also alleviate
neurological symptoms attributable to the syndrome of
the trephined.108,115 However, whether early cranioplasty
can independently improve recovery of patients treated
with DC remains a matter of debate.116 Little consen-
sus currently exists with regard to the optimal timing
and optimal material (autologous bone, titanium or
synthetic) for cranioplasty,117–119 but a planned prospec-
tive multicentre cohort study in the UK will hopefully
provide answers to these important questions.120
Ethical considerations
Historically, the main concern surrounding the use
of DC has been the issue of increased survival at the
expense of moderately severe or severe disability in
treated individuals. Evidence from randomized trials
in the field of ischaemic stroke seems to suggest that this
concern is, indeed, warranted, which presents clinicians,

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© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS

patients and their families, and the wider society with a
number of challenging issues.121
First, evidence from randomized trials can provide
clinicians and families with information on efficacy and
potential complications of DC, but it cannot be used to
predict treatment effect in terms of survival and quality
of life at an individual patient level.122 Prognostic cal-
culators—which have now been developed for use in
the context of TBI—can be used to predict the risk of
mortality and poor outcome at 6 months in individual
patients on the basis of baseline characteristics.123 Such
prognostic models, however, are primarily designed for
use in research and for auditing of healthcare services;
they are not designed to determine whether an inter-
vention should be offered to individual patients.121,122
The poor validity of prognostic models at the individual
patient level is reinforced by the findings from a cohort
study in Australia. This study showed that for patients in
whom the risk of unfavourable outcome at 6 months was
61%–70%, the actual (observed) outcome at 18 months
was favourable in 75% of these individuals.65
Second, it remains unclear whether survival with
severe disability can be considered a satisfactory outcome
from the perspective of patients and their families. Two
recent community-based surveys of healthy adults have
yielded conflicting results over the degree of approval
of DC as a life-saving intervention that may lead to
severe disability.124,125 A recent systematic review of the
literature found that, despite a substantial proportion of
patients with stroke having survived DC with moderately
severe (46.8%) or severe (10.8%) disability and a high
rate of depression (56.1%), about three-quarters of the
patients and/or caregivers were satisfied with life and did
not regret having undergone DC.126
Finally, the cost-effectiveness of DC is an important
issue from the perspective of the wider society. In 2012,
results of a study were published in which researchers
used a decision-analytical model to compare different
treatment strategies for patients with severe TBI in terms
of their direct (acute and long-term medical care) and
indirect (loss of productivity) costs from the perspective
of society.32 They demonstrated that, when all the costs of
severe TBI are considered, ‘aggressive’ treatment with the
option of DC was significantly more cost effective than
were ‘less aggressive’ approaches. Nevertheless, there
remains a need for more systematic evaluation of the
long-term health–economic consequences of managing
patients with DC.
Conclusions
DC provides additional space for the swollen brain and
can effectively reduce ICP, thereby mitigating the risk
of herniation in patients with brain oedema. This surgi-
cal approach is used to control brain oedema and intra-
cranial hypertension on an ad hoc basis in a wide range
of conditions, but most of the available evidence for DC
comes from studies in TBI and ischaemic stroke.
In the field of TBI, a recently published trial (DECRA)
found that early (neuroprotective) DC was not superior to
medical management for patients with diffuse TBI.24 An
ongoing trial (RESCUEicp) is investigating the clinical and
cost effectiveness of secondary DC as a last-tier therapy
for patients with post-traumatic refractory intracranial
hypertension.22 A trial that will compare primary DC with
craniotomy for patients with ASDH (RESCUE-ASDH) is
currently being planned.63 These studies are expected to
consolidate the evidence base underpinning clinical prac-
tice guidelines for the management of patients with TBI.
In the field of ischaemic stroke (specifically, malignant
MCA infarction), a recent Cochrane review that included
data from three small randomized trials concluded that
DC improves survival but at the risk of moderately severe
or severe disability in survivors. 75 Large multicentre
cohort studies are urgently needed to provide answers
to important questions regarding the optimal use of DC
for patients with malignant MCA infarction.
In terms of surgical considerations regarding DC, it is
now well accepted that the dura mater has to be opened
and that the minimum diameter of unilateral DC should
be around 11–12 cm. Skull reconstruction (cranioplasty)
following DC is recommended. In view of the number of
unanswered questions on the optimal timing and optimal
material for cranioplasty, prospective multicentre cohort
studies and randomized trials on these questions would
also be beneficial.
Finally, given the number of ethical issues that arise
with regard to DC, a qualitative research approach to
provide a better understanding of the views of patients
and their families is warranted.
Review criteria
We searched PubMed for English-language full-text articles
published from January 2000 to December 2012 inclusive,
using the search terms “decompressive craniectomy”
and “hemi-craniectomy”. The following article types were
accepted: meta-analyses, randomized controlled trials,
systematic reviews, clinical trials, comparative studies.

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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.
Author contributions
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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