Re-examining decompressive craniectomy medial margin distance from midline as a metric for calculating the risk of post-traumatic hydrocephalus


      Decompressive craniectomy (DC) is a life-saving procedure in severe traumatic brain injury, but is associated with higher rates of post-traumatic hydrocephalus (PTH). The relationship between the medial craniectomy margin’s proximity to midline and frequency of developing PTH is controversial. The primary study objective was to determine whether average medial craniectomy margin distance from midline was closer to midline in patients who developed PTH after DC for severe TBI compared to patients that did not. The secondary objective was to determine if a threshold distance from midline could be identified, at which the risk of developing PTH increased if the DC was performed closer to midline than this threshold. A retrospective review was performed of 380 patients undergoing DC at a single institution between March 2004 and November 2014. Clinical, operative and demographic variables were collected, including age, sex, DC parameters and occurrence of PTH. Statistical analysis compared mean axial craniectomy margin distance from midline in patients with versus without PTH. Distances from midline were tested as potential thresholds. No significant difference was identified in mean axial craniectomy margin distance from midline in patients developing PTH compared with patients with no PTH (n = 24, 12.8 mm versus n = 356, 16.6 mm respectively, p = 0.086). No significant cutoff distance from midline was identified (n = 212, p = 0.201). This study, the largest to date, was unable to identify a threshold with sufficient discrimination to support clinical recommendations in terms of DC margins with regard to midline, including thresholds reportedly significant in previously published research.


      AUC (area under the curve), CI (confidence interval), CSF (cerebrospinal fluid), CT (computed tomography), DC (decompressive craniectomy), GCS (Glasgow Coma Scale), iHTN (intracranial hypertension), OR (Odds ratio), PTH (post-traumatic hydrocephalus), ROC (receiver operating characteristic), TBI (traumatic brain injury)


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        • Aarabi B.
        • Hesdorffer D.C.
        • Ahn E.S.
        • Aresco C.
        • Scalea T.M.
        • Eisenberg H.M.
        Outcome following decompressive craniectomy for malignant swelling due to severe head injury.
        J Neurosurg. 2006; 104: 469-479
      1. Aarabi B, Hesdorffer DC, Simard JM, Ahn ES, Aresco C, Eisenberg HM, McCunn M, Scalea T. Comparative study of decompressive craniectomy after mass lesion evacuation in severe head injury. Neurosurgery 2009;64:927-939; discussion 939-940.

        • Aarabi B.
        • Simard J.M.
        Traumatic brain injury.
        Curr Opin Crit Care. 2009; 15: 548-553
        • Kaen A.
        • Jimenez-Roldan L.
        • Alday R.
        • Gomez P.A.
        • Lagares A.
        • Alen J.F.
        • et al.
        Interhemispheric hygroma after decompressive craniectomy: does it predict posttraumatic hydrocephalus?.
        J Neurosurg. 2010; 113: 1287-1293
      2. Sahuquillo J, Arikan F. Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury. Cochrane Database Syst Rev 2006; Jan 25 (1):CD003983. doi: 10.1002/14651858.CD003983.pub2.

      3. Yang XF, Wen L, Shen F, Li G, Lou R, Liu WG, Zhan RY. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 2008;150:1241-1247; discussion 1248.

        • Choi I.
        • Park H.K.
        • Chang J.C.
        • Cho S.J.
        • Choi S.K.
        • Byun B.J.
        Clinical factors for the development of posttraumatic hydrocephalus after decompressive craniectomy.
        J Korean Neurosurg Soc. 2008; 43: 227-231
      4. Waziri A, Fusco D, Mayer SA, McKhann GM 2 , Connolly ES Jr. Postoperative hydrocephalus in patients undergoing decompressive hemicraniectomy for ischemic or hemorrhagic stroke. Neurosurgery 2007;61:489-493; discussion 493-484.

        • De Bonis P.
        • Pompucci A.
        • Mangiola A.
        • Rigante L.
        • Anile C.
        Post-traumatic hydrocephalus after decompressive craniectomy: an underestimated risk factor.
        J Neurotrauma. 2010; 27: 1965-1970
        • Honeybul S.
        • Ho K.M.
        Incidence and risk factors for post-traumatic hydrocephalus following decompressive craniectomy for intractable intracranial hypertension and evacuation of mass lesions.
        J Neurotrauma. 2012; 29: 1872-1878
        • Cardoso E.R.
        • Galbraith S.
        Posttraumatic hydrocephalus–a retrospective review.
        Surg Neurol. 1985; 23: 261-264
        • Jiao Q.F.
        • Liu Z.
        • Li S.
        • Zhou L.X.
        • Li S.Z.
        • Tian W.
        • et al.
        Influencing factors for posttraumatic hydrocephalus in patients suffering from severe traumatic brain injuries.
        Chin J Traumatol. 2007; 10: 159-162
        • De Bonis P.
        • Sturiale C.L.
        • Anile C.
        • Gaudino S.
        • Mangiola A.
        • Martucci M.
        • et al.
        Decompressive craniectomy, interhemispheric hygroma and hydrocephalus: a timeline of events?.
        Clin Neurol Neurosurg. 2013; 115: 1308-1312
        • Stiver S.I.
        Complications of decompressive craniectomy for traumatic brain injury.
        Neurosurg Focus. 2009; 26: E7
        • Takeuchi S.
        • Nawashiro H.
        • Wada K.
        • Takasato Y.
        • Masaoka H.
        • Hayakawa T.
        • et al.
        Ventriculomegaly after decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage.
        Clin Neurol Neurosurg. 2013; 115: 317-322
        • Ding J.
        • Guo Y.
        • Tian H.
        The influence of decompressive craniectomy on the development of hydrocephalus: a review.
        Arq Neuropsiquiatr. 2014; 72: 715-720
        • Shi S.S.
        • Zhang G.L.
        • Zeng T.
        • Lin Y.F.
        Posttraumatic hydrocephalus associated with decompressive cranial defect in severe brain-injured patients.
        Chin J Traumatol. 2011; 14: 343-347
        • Fattahian R.
        • Bagheri S.R.
        • Sadeghi M.
        Development of posttraumatic hydrocephalus requiring ventriculoperitoneal shunt after decompressive craniectomy for traumatic brain injury: a systematic review and meta-analysis of retrospective studies.
        Med Arch. 2018; 72: 214-219
        • Su T.M.
        • Lan C.M.
        • Lee T.H.
        • Hsu S.W.
        • Tsai N.W.
        • Lu C.H.
        Risk factors for the development of posttraumatic hydrocephalus after unilateral decompressive craniectomy in patients with traumatic brain injury.
        J Clin Neurosci. 2019; 63: 62-67
        • Walsh S.
        • Donnan J.
        • Morrissey A.
        • Sikora L.
        • Bowen S.
        • Collins K.
        • et al.
        A systematic review of the risks factors associated with the onset and natural progression of hydrocephalus.
        Neurotoxicology. 2017; 61: 33-45
        • Fotakopoulos G.
        • Tsianaka E.
        • Siasios G.
        • Vagkopoulos K.
        • Fountas K.
        Posttraumatic hydrocephalus after decompressive craniectomy in 126 patients with severe traumatic brain injury.
        J Neurol Surg A Cent Eur Neurosurg. 2016; 77: 88-92
      5. Williams JR, Meyer RM, Richard J, Chesnut RM. 189 Decreased Distance From Midline in Decompressive Craniectomy Predicts Development of Hydrocephalus. Neurosurgery 2018;65(CN_suppl_1):111-112. doi:10.1093/neuros/nyy303.189.