Decompressive Craniectomy in Intraparenchymal (Intracerebral) Haemorrhage

Rationale

Current Guideline Positions

Specific Indications

1. Supratentorial ICH - Large/Deep (Primary Indication)

• Location: Deep supratentorial ICH (basal ganglia, thalamus, internal capsule)
• Volume: 30-100 mL haematoma
• Neurological severity: NIHSS 10-30, GCS 8-13
• Age: < 75 years
• Timing: DC performed within 72 hours of symptom onset
• Type: DC without haematoma evacuation

2. Cerebellar ICH with Brainstem Compression

• Obstructive hydrocephalus
• Direct brainstem compression
• Neurological deterioration despite medical management

3. Rescue Indication: Refractory Intracranial Hypertension

• Progressive neurological deterioration
• Clinical or radiological signs of cerebral herniation (pupillary dilation, Cushing response, progressive midline shift)
• ICP refractory to maximal medical therapy (osmotherapy, sedation, hyperventilation)

4. ICH with Large Midline Shift

What DC Is NOT Indicated For

• Routine use in ICH without the above criteria - no evidence supports prophylactic DC in mild or moderate ICH
• Brainstem ICH - no surgical role established
• Patients with pre-existing severe disability or very poor baseline functional status
• ICH deemed non-survivable regardless of intervention

Key Evidence Summary

Important Caveats

1. Mortality vs functional outcome disconnect: DC reduces mortality but the surviving patients often have significant disability (mRS 3-4 range). Shared decision-making with families is critical - improved survival may come at the cost of dependence.
2. DC alone vs DC + evacuation: The SWITCH trial specifically studied DC without haematoma evacuation. Whether adding hematoma evacuation confers additional benefit is uncertain.
3. Timing: The available evidence supports intervention within 72 hours of onset for deep ICH. Earlier may be better, but the exact window is not firmly established.
4. Age: Most trial data favours patients under 75 years of age; evidence in older patients is sparse and outcomes are generally poorer.
5. Lobar vs deep ICH: Most RCT data pertains to deep (ganglionic/thalamic) ICH. The role of DC in lobar ICH is less well defined.

Summary

Decompressive Craniectomy in Acute Ischemic Stroke

Overview

1. Malignant Middle Cerebral Artery (MCA) Infarction

What Is It?

Indication Criteria (Based on RCTs and AHA/ASA 2026 Guidelines)

Procedure

2. The Landmark RCTs: DECIMAL, DESTINY, HAMLET

3. The Age Question: DESTINY II Trial (Patients > 60 Years)

• Age <60: NNT to prevent one death = 2; NNT for mRS ≤3 survival = 4
• Age 60-75: DC reduces mortality but associated with severe sequelae - not recommended for routine use

4. Timing of Decompressive Craniectomy

• Early DC (< 24-48 h): Best supported by DECIMAL and DESTINY
• Later DC (up to 96 h): HAMLET showed benefit up to 96 hours; later surgery is less supported but may still be considered if the patient is deteriorating
• AHA/ASA position: Optimal timing is unknown; neurological deterioration is the key trigger, not a rigid time window
• General principle: Earlier is better; do not wait for complete herniation

5. Cerebellar Infarction with Mass Effect

Indications

• Neurological deterioration despite maximal medical therapy
• Brainstem compression (cranial nerve palsies, decreasing consciousness, Cushing response)
• Obstructive hydrocephalus from cerebellar swelling blocking the 4th ventricle

Procedure: Suboccipital Decompressive Craniectomy (SDC) with Dural Expansion

AHA/ASA Recommendation

"Suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarctions who deteriorate neurologically despite maximal medical therapy." (Class I, Level B)

Why Stronger Evidence?

• The cerebellar fossa is a rigid, small compartment - even modest swelling rapidly causes herniation
• Post-operative outcomes are generally better than hemispheric DC because the brainstem may be preserved with early intervention
• Meta-analyses: mortality ~20%, moderate-severe disability ~28%

6. Other Ischaemic Contexts (Less Established)

7. Absolute Contraindications / Exclusion Criteria (from RCTs)

• Significant pre-existing disability (mRS ≥ 2 at baseline)
• Contralateral infarction
• Haemorrhagic transformation with significant mass effect
• Bilateral fixed dilated pupils (brainstem already herniated - too late)
• Patient/family refusal after informed consent
• Terminal illness or very poor functional prognosis unrelated to stroke

8. Practical Triggers for Decision-Making

1. Clinical: Decreasing GCS/level of consciousness attributed to oedema
2. Radiological: CT showing progressive midline shift ≥ 5 mm, effacement of basal cisterns, early herniation signs
3. Failure of medical therapy: Osmotherapy (mannitol, hypertonic saline), head positioning, sedation, normothermia

Summary Table

Key Points

• Mortality vs quality-of-life tension: DC dramatically saves lives in malignant MCA infarction, but the conversation with families must address that many survivors - especially older patients - will be left with significant dependence.
• Timing is critical: Do not delay waiting for ICP data; clinical deterioration is the trigger. The goal is to operate before complete herniation.
• Age is not an absolute cut-off: Even in patients >60, DC is an option if the patient and family understand the likely functional outcome (mRS 4-5 range).
• Cerebellar stroke is different: The evidence and guideline strength are greater, outcomes are generally better, and the threshold for surgery should be lower than for supratentorial disease.