Craniectomy: Surgical Indications and Technique
Martin Holland, MD, and Peter Nakaji, MD
Intractable intracranial hypertension in trauma patients is asso-
ciated with high rates of morbidity and mortality. Decompressive
craniectomy offers a treatment option for this otherwise dire
situation. This article illustrates the techniques for both unilateral
hemicraniectomy and bifrontal craniectomy. The skin incisions,
degree of bone removal, and options for dealing with the bone
flap are discussed.
Copyright 2004, Elsevier Inc. All rights reserved.
n the United States trauma is the leading cause of death in
I individuals between the ages of 1 and 44 years. Most of these
deaths are attributable to traumatic brain injury (TBI). Among
the many problems that follow TBI, intracranial hypertension is
a major cause of complications and death. Consequently, neu-
rosurgeons devote considerable effort to controlling intracra-
nial pressure (ICP) in patients with TBI. Decompressive crani-
ectomy has been advocated as one strategy for managing ICP.
This article discusses the principles, indications, surgical anat-
omy, and technique associated with decompressive craniec-
tomy.
Principles
There are two phases of brain injury. The primary phase occurs
at the moment of impact. The secondary phase occurs in the
minutes, hours, or days after the initial injury. The concept of
secondary injury is supported by both animal and clinical stud-
ies that indicate that injured tissue is highly vulnerable to in-
sults readily tolerated by uninjured tissue. Secondary injury is
the single most important treatable cause of neurological deficit
and death after TBI.
Intracranial hypertension is a major cause of secondary brain
injury and often follows trauma or stroke. Because ICP varies
with changes in the volume of the intracranial contents, the
traditional approach for treating intracranial hypertension has
been to reduce the volume of one or more of the compartments,
which include brain parenchyma, cerebrospinal fluid (CSF),
and blood volume, either surgically or nonsurgically.
An alternate approach is to increase cranial volume by re-
moving the skull and opening the dura. The underlying brain
can then swell under the relatively distensible skin. The use of
From the UCSF Department of Neurological Surgery, University of
California, San Francisco, Clinical Director Brain and Spinal Injury Center,
San Francisco, CA, USA and Division of Neurological Surgery, Barrow
Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoe-
nix, AZ.
Address reprint requests to Peter Nakaji, MD, Neuroscience Publica-
tions, Barrow Neurological Institute, 350 W. Thomas Road, Phoenix, AZ
85013.
Copyright 2004, Elsevier Inc. All rights reserved.
1092-440X/04/0701-0003$30.00/0
doi:10.1053/j.otns.2004.04.006
10
decompressive craniectomy to control ICP has been advocated
for a number of disease processes, including stroke, tumors,
and trauma. The rationale for decompressive craniectomy is to
prevent secondary injury caused by intracranial hypertension.
Indications
There are no widely accepted indications for craniectomy. Most
studies are retrospective. In the few available prospective
studies, the procedure has been performed in patients with
medically refractory intracranial hypertension. Coplin and co-
workers, however, suggested that early “prophylactic” decom-
pressive craniectomy may be of some benefit. ICP is easier to
control after a craniectomy, and the therapeutic intensity of ICP
management is decreased in patients who have had craniecto-
mies.1 However, data correlating craniectomy and improved
outcome are suggestive at best.1-6
Early decompressive craniectomy can be considered for pa-
tients undergoing emergent evacuation of a hematoma. It is
reasonable to entertain craniectomy as a treatment option. The
decision to leave the bone flap off can be made intraoperatively
based on the patient’s mechanism of injury; age; degree of
underlying cerebral swelling, atrophy, or both; and the sur-
geon’s estimation of the likelihood that the patient will develop
severe intracranial hypertension.
Patients with significant cerebral atrophy (eg, chronic alco-
holics) are less likely to develop intracranial hypertension than
patients with full brains, primarily because they are able to
tolerate mass lesions better. Patients with subdural hematomas
caused by severe acceleration and deceleration forces often
have significant underlying brain injury and are more likely to
develop brain swelling and subsequent intracranial hyperten-
sion. Such patients may benefit from a craniectomy. If the
surgeon decides that a patient is likely to develop intracranial
hypertension, he or she may opt to leave the bone flap off with
the idea of performing a cranioplasty in the future.
Although craniectomies decrease ICP, complications are also
associated with the procedure. If the bone flap is too small, the
brain may mushroom through the opening and catch on the
edge of the craniectomy. The brain can be damaged by direct
pressure, possibly causing congestion of compressed cortical
veins. Another common postoperative problem is the develop-
ment of interhemispheric or contralateral subdural hygromas
or both. Hygromas are likely caused by deranged patterns of
CSF flow in the presence of low ICP.
Surgical Technique
Craniectomies can be divided into two categories: hemicrani-
ectomies and bilateral craniectomies. Hemicraniectomies in-
volve the removal of bone along one hemicranium whereas
bilateral craniectomies involve the removal of bone from both
hemispheres. The surgical technique for both is described.
Operative Techniques in Neurosurgery, Vol 7, No 1 (March), 2004: pp 10-15
Hemicraniectomy
The ideal hemicraniectomy involves the removal of bone along
the entire supratentorial hemicranium. It is essential to under-
stand the relationship between external and internal anatomi-
cal features such as the floor of the frontal and temporal fossa
and the lateral tentorial attachments. The root of the zygoma,
which identifies the floor of the temporal fossa, is the most
important landmark for performing this procedure.
Other important landmarks include the inion, asterion, mid-
line, keyhole, and glabella. The asterion, which marks the con-
fluence of the lamboid, occipitomastoid, and temporoparietal
sutures, indicates the area of transition between the transverse
and sigmoid sinuses. The superior extent of the transverse sinus
typically is found 1-cm rostral to the asterion. The great sinus
confluence usually underlies the inion. Thus, a line extending
from the root of the zygoma toward the inion and across the
asterion demarcates the inferior extent of the temporal and
occipital lobes.
The keyhole, another important landmark, identifies the pte-
rion and indicates the location of the frontal, temporal, and
orbital cavities. The floor of the frontal fossa is usually 1-cm
superior to the keyhole. The temporal tip underlies a point Fig 2. The T-shaped incision has the advantage that it can
1-cm posterior and inferior to the keyhole. The lateral orbital easily be expanded. Although less familiar to most neurosur-
wall is about 1-cm anterior and inferior to the keyhole. The geons, this incision provides easy access to the entire hemi-
midline delineates the course of the superior sagittal sinus. cranium and leaves flaps with a more robust blood supply.
Although the goal of the hemicraniectomy is to remove as much
bone as possible, the surgeon must avoid injuring the superior
horseshoe headholder or donut. We prefer the Mayfield head-
sagittal and transverse sinuses.
holder because it enables easier access to the entire hemicra-
Equally important as an understanding of the limits of bony
nium. The draping and skin incisions are thereby easier to
removal is an understanding of the skin incisions and position-
perform. Furthermore, the head is held firmly in position for
ing that allow the surgeon to expose the entire hemicranium so
retraction of the skin flap and for the subsequent craniectomy.
that the craniectomy can be performed without difficulty.
We also prefer to use a Leyla bar (Aesculap®, San Francisco,
We prefer to place the patient in a Mayfield headholder (Cod-
CA) to support the skin retractors. The Mayfield headholder,
man, Inc. Raynham, MA) even though this maneuver requires
however, is inappropriate for patients with severe diffuse com-
extra time. Two other options are to place the patient in a
minuted skull fractures.
The Mayfield pins are placed low and out of the way of the
incision. The two-prong side supports the suboccipital area,
and the single-pronged end is placed on the contralateral fore-
head. By placing the pins in these locations, the entire hemicra-
nium is accessible for shaving, sterile preparation, draping, and
the surgical procedure.
Once the patient’s head is placed in the Mayfield headholder,
the ideal position is for the sagittal plane of the head to be
horizontal to the floor. This position is not always possible to
attain because the patient’s cervical spine is not always cleared
before surgery. Some patients also have stiff cervical spines.
Under such circumstances, the patient’s head is turned as far as
is reasonable. The remainder of the turn can be achieved by
tilting the table. Tilting requires that the patient be securely
taped to the table.
To perform a full hemicraniectomy requires exposure of the
entire hemicranium. Two incisions permit this goal to be
achieved. The first option is a curvilinear incision that begins at
the widow’s peak and continues posteriorly along the midline
to the inion (Fig 1). It then turns sharply to the ear parallel to a
line extending from the inion to the root of the zygoma. The
incision should skirt the superior and anterior portions of the
ear as closely as possible and extend 1 cm below the root of the
Fig 1. The incision for unilateral hemicraniectomy is similar zygoma.
to the usual trauma flap but covers a larger area to allow This incision achieves several goals. First, the entire hemi-
access to the entire hemicranium for bone removal. cranium is exposed at the midline. Second, the bone is exposed

CRANIECTOMY 11
 the aid of a surgical sponge. At this point there are two options
for reflecting the temporalis muscle. The first option allows the
skin to be reflected anteriorly as a separate layer of muscle. This
maneuver allows the temporalis muscle to be reflected with
relative ease.
The second option involves reflecting the muscular and cu-
taneous flaps together; the skin flap is not separated from the
temporalis muscle. The advantage of this option is that the
muscle remains attached to the overlying scalp, keeping the
muscle in position in the absence of an underlying attachment
to the bone. We prefer this option because it preserves the
muscle and improves cosmesis when the bone flap is returned.
The major advantage of the curvilinear incision is that it is
quick and easy. Its major disadvantage is the potential risk of
flap ischemia and dehiscence of the wound, particularly at its
posterior margin.
The alternative skin incision for a hemicraniectomy is similar
to that described for a hemispherectomy. A midline incision
extends from the inion to the widow’s peak. Then, a “T” inci-
sion is created by extending another limb from about the coro-
nal suture down to a point 1 cm inferior to the root of the
zygoma (Fig 2). With this incision, the blood supply to both
skin flaps is much more robust than with the curvilinear inci-
sion. However, it requires slightly more time to execute and is a
little tricky. As with the curvilinear incision, the temporalis
muscle can be incised along with the skin or it can be handled
as a separate layer.
We recommend preserving the superficial temporal artery by
first starting the T incision behind the coronal suture. The
incision continues inferiorly and ends as close to the anterior
portion of the ear as possible. With this technique, we have seen
no dehiscence of the posterior portion of the incision.
Once the skin incision has been made and the entire hemi-
cranium has been exposed, fishhooks are used to retract the

Fig 3. (A) The extent of bone removal for the unilateral hemi-
craniectomy is illustrated. Unintentional underremoval of
bone is a common pitfall. (B). Computed tomography (CT)
scan of a typical case. Bone is left posteriorly for the head to
rest on. In this case, more bone could have been removed
anteriorly.

along the line of the transverse sinus. The amount of temporal

fossa exposed is also increased. Hugging the ear avoids the
superficial temporal artery, thus providing maximal blood flow
to the most distal corner of the skin flap. This blood supply is
most compromised at or near the inion.
Once the skin incision is made, usually with a No. 10 blade, Fig 4. The bone flap can be inserted into an abdominal
the periosteum can be incised with an electrocautery knife. The pocket. The pocket must be large enough to provide a
cutaneous flap can then be manually reflected anteriorly with tensionless closure.

12 HOLLAND AND NAKAJI

Fig 5. (A) A typical bicoronal incision is sufficient to create a bifrontal craniectomy. (B) The extent of bony removal for the
bifrontal craniectomy is shown. Special care must be taken to remove the bone along the supraorbital rim and subtemporal
region. CT scans on bone windows (C) and brain windows (D) show the craniectomy. (E) CT scan shows the subtemporal
windows. (Continued on next page)

skin flap inferiorly. In the case of the curvilinear incision, the
skin flap is retracted anteriorly. In the case of the T incision, the
skin is retracted both anteriorly and posteriorly. A single bur
hole is made just superior to the root of the zygoma, which
delineates the floor of the temporal fossa. Some piecemeal re-
moval of bone inferiorly may be required to reach the floor. The
asterion should be exposed by reflecting the soft tissue cau-
dally. This maneuver allows visualization of the inferior extent
of the temporal and occipital lobes.
Once the bur hole is made, the footplate is inserted. The bone
flap is turned by extending the beginning of the craniectomy
along the line toward the inion. To avoid injuring the transverse
sinus, it is best to stay at least 1-cm rostral to the asterion. As the
bone flap is extended posteriorly, the lambdoid suture is
crossed. At this point, the drill bit is turned parallel to and 1-cm
medial to the lambdoid suture until the surgeon reaches a point
1 cm from the midline. The drill is then turned parallel to the
sagittal sinus, again crossing the lambdoid suture. Drilling con-
tinues toward the supraorbital bar. The craniotomy is contin-
ued anteriorly by hugging the floor of the frontal fossa as closely

CRANIECTOMY 13

Fig 5. (Cont’d)
as possible, staying as close to the orbital rim as the anatomy
allows.
Next, the drill is turned posterolaterally toward the keyhole
and aimed as close to the pterion as possible. At this point, the
drill is removed and re-inserted into the bur hole at the root of
the zygoma. The second drill line is created by hugging the floor
of the temporal fossa and extending it as far anteriorly as pos-
sible toward the temporal tip. The bone flap is removed by
levering it using the pterion as fulcrum. Usually the pterion
cracks on removal and the dura can be dissected using Rhoton
dissectors. The full extent of bone removal is illustrated in
Fig 3.
Once the bone flap is removed, Leksell rongeurs are used to
remove excess bone at the temporal floor and temporal tip,
lateral floor, and pterion. Care is taken to ensure that the bone
edges are smooth so the brain does not catch on an edge as it
swells laterally. The dural opening extends in a C-shaped fash-
ion from the temporal tip to the frontal pole. To maximize the
opening, the dural incision should run within 1 cm of the bony
edge. Thus, the dural flap is based on the pterion and can be
reflected anteriorly to expose the hemisphere.
Dural release incisions can be performed on the dural edge
extending to the bone edge. This maneuver minimizes cerebral
hemisphere catching on the dura as it swells laterally. If needed,
peripheral dural tack-up stitches can be placed to control epi-
dural hemorrhage.
At this point, underlying hematomas can be evacuated. In the
case of subdural hematomas, the bridging veins can be accessed
to ensure that they are no longer bleeding. Once hemostasis is
ensured, the dura can be laid back on the brain. A large piece of
Gelfilm® (Upjohn, Kalamazoo, MI) is placed along the entire
hemicranial defect to make subsequent dissection for a cranio-
plasty easier to perform. The skin is closed over the Gelfilm
using 2-0 Vicryl (Ethicon, Johnson & Johnson Professionals,
Inc., Somerville, NJ) stitches for the galea. Typically, staples are
used to close the skin.
There are three options for dealing with the craniectomy
bone flap. One is to discard it. The second is to create a separate
14
abdominal subcutaneous incision to place the bone flap, which
is then accessed at the time of the cranioplasty (Fig 4). The third
is to preserve the bone flap in a tissue bank. We prefer the last
option. Discarding the flap requires that the cranioplasty be
performed with intraoperative reconstruction, usually titanium
mesh, methylmethacrylate cement, or with a prefashioned
computer-generated bone flap. Cosmetically, these options are
suboptimal and more expensive than using the patient’s own
bone. Placing the bone flap in the abdominal subcutaneous
cavity is an acceptable alternative. However, the body usually
remolds the bone edges to some degree, leaving it knobby and
slightly enlarged. This remolding adversely affects the ability to
obtain a tight bone edge at the time of cranioplasty. Keeping the
bone frozen in a bone bank is associated with excellent cos-
metic outcomes. There is no risk of bone remodeling and re-
placement is easy. An alternative technique involving ethylene
oxide sterilization and preservation at room temperature has
also been described.7
Bilateral Craniectomies
An alternative method of cranial decompression is to remove
the skull bone bilaterally. Two options also exist for this
method. The first involves performing two hemicraniectomies
as described above. A strip of bone about 2 to 3 cm wide is left
along the midline covering the superior sagittal sinus. Either
incision described above can be used. However, a second hemi-
craniectomy usually precludes use of the Mayfield headholder.
The technique is otherwise identical.
Alternatively, a bifrontal craniectomy has been described by
Venes and Collins,8 Polin and co-workers,9 and Fisher and
Ojemann,10 among others. Posterior to the coronal suture, a
coronal incision is extended from 1 cm below the root of the
zygoma bilaterally to the vertex. The musculocutaneous flap is
retracted anteriorly and inferiorly to expose the frontal and
temporal areas down to the floor of the temporal fossa bilater-
ally.
Bur holes are made at the root of the zygoma bilaterally. The
first cranial drill line extends from zygoma to zygoma crossing
the superior sagittal sinus. We do not place bur holes on either
side of the superior sagittal sinus to perform subsequent dural
dissection, although this technique has its proponents.
Two other bur holes can be placed at the keyhole bilaterally.
A second dural line extends from keyhole to keyhole across the
midline about 1 cm parallel and superior to the orbital rim. This
line crosses the floor of the frontal fossa. Crossing midline is
sometimes difficult because the inner table of the bone dives
inward. If this situation is encountered, the cranial drill line is
created bilaterally toward the midline. The gap can be jumped
using osteotomes.
The final two drill lines are made from the zygomatic bur
hole anteriorly by hugging the floor of the temporal fossa to-
ward the temporal tip and extending superiorly and anteriorly
toward the keyhole. The bifrontal craniectomy can then be
removed as one piece (Fig 5). The subtemporal craniectomy
can be enlarged in piecemeal fashion with a Leksell rongeur.
Alternatively, the bifrontal craniectomy can be removed in
two pieces by leaving a strip of bone attached to the superior
sagittal sinus at the midline and performing two craniectomies
(Fig 6). This technique is most useful for patients whose pri-
mary problem is bilateral frontal contusions. The dura is re-
leased by making a C-shaped dural incision that extends from
HOLLAND AND NAKAJI

Fig 6. The alternate technique of bifrontal craniectomy is
almost identical to the unilateral technique except that the
bone is taken in two flaps, sparing the midline. To avoid
potential harm to the swollen brain, the strip left in the middle
must not be too wide.
the temporal tip along the floor of the temporal fossa and
continues posteriorly and superiorly parallel to the posterior
edge of the craniectomy site toward the superior sagittal sinus.
The dural incision extends from the frontal pole laterally, hug-
ging the floor of the frontal fossa toward the pterion. As de-
scribed for the hemicraniectomy, the bone of the temporal and
frontal fossae and pterion should be shaved with Leksell ron-
geurs. The bony rims are smoothed so that egress of the swollen
brain will not be impeded. This maneuver also permits the
dural incision along the floor of the frontal fossa to connect
with the dural incision at the temporal tip. Thus, a large dural
flap is created based on the superior sagittal sinus bilaterally.
Gelfilm is placed over the entire craniectomy defect. The skin
is closed with 2-0 Vicryl sutures and stapled. The bone flap can
be handled as described in the section on hemicraniectomy.
The timing of bone flap replacement or cranioplasty is left to
the discretion of the surgeon based on the patient’s clinical
status. We typically offer placement 6 months after the cranio-
CRANIECTOMY
plasty to allow the underlying brain to have recovered maxi-
mally and to minimize the risk of infection.
Neurological recovery after cranioplasty has been docu-
mented11,12 (about 50% of cases in our experience). Recovery
usually involves improved motor strength or language function
within the first several weeks of the cranioplasty.
Conclusions
Decompressive cranioplasty is an effective technique for de-
creasing ICP and for decreasing the intensity of therapy needed
to control intracranial hypertension. Clear-cut indications for
performing such a procedure have not yet been delineated. A
prospective, randomized study is needed. Nevertheless, anec-
dotal experience and the outcomes of preliminary studies of
craniectomies suggest that this option may be viable for pa-
tients at risk for developing high ICP after stroke or trauma.
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