Decompressive craniectomy (DC) is a well-established intervention for refractory intracranial
hypertension caused by traumatic brain injury, malignant stroke, and other acute intracranial
processes.[1]
[2]
[3] While it can significantly reduce mortality, DC is associated with a high rate of
postoperative complications, including infection, hemorrhage, hydrocephalus, seizures,
and syndrome of the trephined.[4]
[5]
[6] Current literature brings a list of potential risk factors, but no concise, we strongly
believe that a user-friendly clinical rules to help frontline neurosurgeons quickly
identify high-risk patients. Moreover, the ability to anticipate complications could
improve operative planning, guide postoperative monitoring, and inform discussions
with patient families. In this article, we propose seven simple rules that are derived
from literature review and clinical reasoning that may help predict complications
after DC ([Table 1]). The proposed rules aim to help the provider to guide on complex risk factor data
into a manageable set of clinical heuristics. They are not intended as a formal scoring
system, and is just a proposal, but as an initial framework to prompt earlier recognition
of high-risk patients. This may guide perioperative optimization, such as aggressive
pulmonary care, earlier timing of surgery, and tailored cranioplasty planning.
Table 1
Proposed clinical rules for predicting complications following DC
|
Rule 1
|
History of significant pulmonary complications (e.g., chronic obstructive pulmonary
disease, recent pneumonia) → associated with increased postoperative pulmonary events
and prolonged ventilation
|
|
Rule 2
|
When we found a preoperative ICP > 30 mm Hg → linked with poor brain compliance and
higher risk of herniation syndromes
|
|
Rule 3
|
For any skull defect > 15 cm in diameter → correlates with higher rates of wound complications,
paradoxical herniation, and delayed cranioplasty challenges
|
|
Rule 4
|
Timing of DC > 72 hours after initial injury → associated with more pronounced cerebral
edema, adhesions, and higher infection risk
|
|
Rule 5
|
Preoperative osmotic therapy > 48 hours → may indicate ongoing refractory intracranial
hypertension and higher likelihood of secondary injury
|
|
Rule 6
|
Presence of brainstem compression signs preoperatively (e.g., pupillary asymmetry,
posturing) → predicts poor neurologic recovery and increased postoperative instability
|
|
Rule 7
|
Poor baseline functional status (mRS ≥ 3) → associated with reduced rehabilitation
potential and higher complication burden.
|
Abbreviations: DC, decompressive craniectomy; ICP, intracranial pressure; mRS, modified
Ranking scale.
Seven pragmatic clinical rules may assist neurosurgeons in anticipating complications
after DC. While not a substitute for comprehensive clinical judgment, they offer a
starting point for structured perioperative risk assessment. Validation in prospective
studies is warranted. We recognize that these rules have many limitations including
the absence of prospective validation and the potential variability of complication
definitions across studies. We recommend that these rules be tested in multicenter
cohorts to assess sensitivity, specificity, and predictive value.
