Decompressive Craniectomy and Cranioplasty: A Review of the Literature on Evolution, Indications, Surgical Techniques, and Complications

Decompressive craniectomy refers to removal of a portion of the skull without subsequent replacement, and cranioplasty involves subsequent repair of the skull vault defect. Over the past 3 decades, there has been considerable interest in the use of decompressive craniectomy as part of a second-level measure in the management of refractory raised intracranial pressure. Raised intracranial pressure can be secondary to various causes, including severe head injury, subarachnoid hemorrhage, infection, and acute ischemia. Although the procedure is thought to be effective, several factors should be taken into consideration, including patient selection, optimal time for intervention, risk of associated complications, and patient outcomes. After a craniectomy, patients may subsequently undergo cranioplasty for various reasons, including cosmetic improvement, protection of brain tissue, and as treatment for syndrome of the trephined. Several different materials have been trialed over the years, including biologic and nonbiologic substitutions. Perioperative imaging evaluation plays an important role in the management and follow-up of these patients. The focus of this article is on the expected radiologic appearances in the perioperative period as well as the complications that may arise. Surgical techniques, cranioplasty materials, and historic evolution of decompressive craniectomy and cranioplasty will also be discussed.

Learning Objective: To understand the rationale for decompressive craniectomy and cranioplasty as well as recognize the expected postoperative radiologic appearances and their associated complications.