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Expansive Craniotomy versus Standard Decompressive Craniectomy in Refractory Intracranial Hypertension: A Systematic

Rachel Saunders1, Jemima Rees1, Valentina Di Pietro1

  • 1Neuroscience and Ophthalmology, Department of Inflammation and Ageing, Institute of Infection, Inflammation and Immunology, University of Birmingham, Edgbaston, Birmingham, United Kingdom.

World Neurosurgery
|December 15, 2025
PubMed

Insights

Expansive craniotomy (EC) may be a viable alternative to decompressive craniectomy (DC) for managing intracranial pressure, showing similar mortality but improved outcomes. However, EC is linked to a higher reoperation rate, necessitating further research.

Area of Science:

  • Neurosurgery
  • Critical Care Medicine
  • Surgical Innovation

Background:

  • Elevated intracranial pressure poses significant risks to mortality and outcomes following acute brain injury.
  • Decompressive craniectomy (DC) is a standard procedure for refractory intracranial hypertension, but necessitates a subsequent cranioplasty.
  • Expansive craniotomy (EC) aims to avoid cranioplasty by partially fixing the bone flap, yet its comparative safety and efficacy remain unclear.

Purpose of the Study:

  • To systematically review and compare the safety and efficacy of expansive craniotomy (EC) versus decompressive craniectomy (DC).
  • To evaluate key outcomes including mortality, reoperation rates, and neurological recovery (Glasgow Outcome Scale).

Main Methods:

  • A systematic review adhering to PRISMA guidelines, including all study types except reviews.
  • Meta-analysis conducted on data from randomized controlled trials and case-control studies.
  • Outcomes assessed: mortality, acute reoperation rate, and Glasgow Outcome Scale (GOS).

Main Results:

  • No significant difference in mortality was observed between EC and DC.
  • Expansive craniotomy (EC) showed a trend towards improved GOS scores, potentially influenced by selection bias.
  • A marginal increase in early reoperation rates was associated with EC (risk difference 0.08, p = 0.05).
  • Risk of bias in the included studies was generally moderate to high.

Conclusions:

  • Existing evidence is insufficient to definitively guide clinical decisions regarding EC versus DC.
  • Expansive craniotomy (EC) shows promise as an alternative to DC in select patients, despite a potential for increased acute reoperation rates.
  • A robust, adequately powered randomized controlled trial is strongly recommended to rigorously evaluate expansive craniotomy (EC).
Abstract

Keywords:
Decompressive craniectomyIntracerebral hemorrhageIntracranial hypertensionIntracranial pressureMalignant middle cerebral artery infarctionStrokeTraumatic brain injury

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