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Updated: Jul 27, 2026
Microvascular Decompression: Salient Surgical Principles and Technical Nuances
Published on: July 5, 2011
Indications and scientific support for supratentorial unilateral decompressive craniectomy for different subgroups of
1Neurosurgery department, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, 83800, Cedex 9, Toulon, France. nathan.beucler@neurochirurgie.fr.
Insights
Decompressive craniectomy (DC) offers relief for intracranial hypertension. This review summarizes evidence for DC in traumatic brain injury, stroke, and other conditions, guiding clinical decisions.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Supratentorial unilateral decompressive craniectomy (DC) is a standard neurosurgical procedure for intractable intracranial hypertension.
- High-quality evidence supports DC primarily for traumatic brain injury and malignant middle cerebral artery infarction.
- This review examines evidence for established and less common indications of DC.
Purpose of the Study:
- To conduct a scoping review of the existing evidence for decompressive craniectomy (DC).
- To summarize the efficacy of DC for both validated and less validated clinical indications.
- To inform clinical decision-making regarding the use of DC.
Main Methods:
- Scoping review of Medline/PubMed from inception to present.
- Focused on seven potential indications for DC.
- Assessed study levels of evidence (Oxford scale) and quality (Newcastle-Ottawa, Cochrane Risk of Bias).
Main Results:
- DC shows efficacy in traumatic brain injury and malignant ischemic stroke.
- Evidence supports DC for acute subdural hematoma, malignant meningoencephalitis, and cerebral venous thrombosis.
- Limited evidence exists for DC in aneurysmal subarachnoid hemorrhage and intracerebral hemorrhage; insufficient for tumors.
Conclusions:
- Scientific evidence supports DC for selected cases of severe traumatic brain injury, acute subdural hematoma, and malignant ischemic stroke.
- DC is also supported for malignant meningoencephalitis and malignant cerebral venous thrombosis.
- Careful patient selection is crucial for DC in aneurysmal subarachnoid hemorrhage.
Context:
Even though supratentorial unilateral decompressive craniectomy (DC) has become the gold standard neurosurgical procedure aiming to provide long term relief of intractable intracranial hypertension, its indication has only been validated by high-quality evidence for traumatic brain injury and malignant middle cerebral artery infarction. This scoping review aims to summarize the available evidence regarding DC for these two recognized indications, but also for less validated indications that we may encounter in our daily clinical practice.
Materials And Methods:
A scoping review was conducted on Medline / Pubmed database from inception to present time looking for articles focused on 7 possible indications for DC indications. Studies' level of evidence was assessed using Oxford University level of evidence scale. Studies' quality was assessed using Newcastle-Ottawa scale for systematic reviews of cohort studies and Cochrane Risk of Bias Tool for randomized controlled trials.
Results:
Two randomized trials (level 1b) reported the possible efficacy of unilateral DC and the mitigated efficiency of bifrontal DC in the trauma setting. Five systematic reviews meta-analyses (level 2a) supported DC for severely injured young patients with acute subdural hematoma probably responsible for intraoperative brain swelling, while one randomized controlled trial (level 1b) showed comparable efficacy of DC and craniotomy for ASH with intraoperative neutral brain swelling. Three randomized controlled trials (level 1b) and two meta-analyses (level 1a and 3a) supported DC efficacy for malignant ischemic stroke. One systematic review (level 3a) supported DC efficacy for malignant meningoencephalitis. One systematic review meta-analysis (level 3a) supported DC efficacy for malignant cerebral venous thrombosis. The mitigated results of one randomized trial (level 1b) did not allow to conclude for DC efficacy for intracerebral hemorrhage. One systematic review (level 3a) reported the possible efficacy of primary DC and the mitigated efficacy of secondary DC for aneurysmal subarachnoid hemorrhage. Too weak evidence (level 4) precluded from drawing any conclusion for DC efficacy for intracranial tumors.
Conclusion:
To date, there is some scientific background to support clinicians in the decision making for DC for selected cases of severe traumatic brain injury, acute subdural hematoma, malignant ischemic stroke, malignant meningoencephalitis, malignant cerebral venous thrombosis, and highly selected cases of aneurysmal subarachnoid hemorrhage.
