Acta Neurol Scand 2011: 123: 239–244 DOI: 10.1111/j.1600-0404.2010.01397.
x  2010 John Wiley & Sons A ⁄ S
Review Article
Decompressive craniectomy: technical note
Quinn TM, Taylor JJ, Magarik JA, Vought E, Kindy MS, Ellegala DB.
Decompressive craniectomy: technical note.
Acta Neurol Scand: 2011: 123: 239–244.
 2010 John Wiley & Sons A ⁄ S.
Decompressive craniectomy is a neurosurgical technique in which a
portion of the skull is removed to reduce intracranial pressure. The
rationale for this procedure is based on the Monro-Kellie Doctrine;
expanding the physical space confining edematous brain tissue after
traumatic brain injury will reduce intracranial pressure. There is
significant debate over the efficacy of decompressive craniectomy
despite its sound rationale and historical significance. Considerable
variation in the employment of decompressive craniectomy,
particularly for secondary brain injury, explains the inconsistent results
and mixed opinions of this potentially valuable technique. One way to
address these concerns is to establish a consistent methodology for
performing decompressive craniectomies. The purpose of this paper is
to begin accomplishing this goal and to emphasize the critical points of
the hemicraniectomy and bicoronal (Kjellberg type) craniectomy.
Introduction
Increased intracranial pressure (ICP), a common
sequela of traumatic brain injury (TBI), is com-
monly managed with medical, surgical, or com-
bined interventions (1–6). Current protocols for
the management of TBI patients follow a sequen-
tial pattern, one that escalates the level of care as
patient condition deteriorates. Recent studies have
shown that decompressive craniectomy (DC) is an
effective method for reducing ICP following TBI.
The rationale for this procedure is based in the
Monro-Kellie Doctrine; increasing the size or
volume of the intracranial space will reduce ICP
and increase compliance in the event of worsening
cerebral edema (7–12). As a result, adequate
cerebral perfusion pressure is preserved and
viable brain tissue is protected from mass effect.
The benefits of DC directly depend upon
surgical technique and degree of decompression
achieved. The goal of DC is to provide ade-
quate bony decompression of the anterior and
middle fossa without compromising dural venous
drainage.
The most common types of craniectomy per-
formed in the management of TBI are hemicrani-
ACTA NEUROLOGICA
SCANDINAVICA
T. M. Quinn1, J. J. Taylor1,
J. A. Magarik1, E. Vought1,
M. S. Kindy2,3, D. B. Ellegala1
1
Division of Neurosurgery, Department of
Neurosciences, Medical University of South Carolina,
Charleston, SC, USA; 2Division of Research, Department
of Neurosciences, Medical University of South Carolina,
Charleston, SC, USA; 3Ralph H. Johnson VA Medical
Center, Research Service, Charleston, SC, USA
Key words: cerebral edema; decompressive
craniectomy; intracranial pressure; patient
management; traumatic brain injury
Dilantha B. Ellegala, MD, Division of Neurosurgery,
Department of Neurosciences, Medical University of
South Carolina, Room CSB 428, 96 Jonathan Lucas
Street, Charleston, SC 29425, USA
Tel.: +1 843 792 2019
Fax: +1 843 792 9279
e-mail: ellegala@musc.edu
Accepted for publication May 14, 2010
ectomy and bicoronal (Kjellberg type) craniectomy.
(6, 13–31) Lesion location and underlying pathology
dictate which method of craniectomy should be
performed. However, profound variability exists
in surgical technique, and to date there are no
technical papers that establish a consistent meth-
odology for DC. Here, we present technical
instructions that emphasize the critical points of
each procedure.
It is important to note that there are currently no
studies that compare the efficacy of various DC
protocols. We acknowledge that the methods
presented in this paper represent one of many
ways to approach DC. Nevertheless, we propose
the following conventional protocols to establish
standards that can be systematically evaluated with
clinical evidence.
Decompressive Hemicraniectomy
Decompressive hemicraniectomy is the most com-
monly performed craniectomy and can be used in
trauma cases, hemispheric infarction, and impend-
ing brain herniation from multiple etiologies.
The procedures for performing a decompressive
hemicraniectomy are as follows:
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1. Patient is under general anesthesia and C- spine A

precaution if appropriate.
2. Patient is placed in the supine position. Elevate
the ipsilateral shoulder, with a large shoulder
role.
3. PatientÕs head is turned until the craniectomy
side faces upward, 0–15 from the horizontal
plane.
4. Place patientÕs head on a donut or secure with
horseshoe headholder as Mayfield clamp
restricts the size of the incision.
5. Mark the caution area on the surface anatomy:
5.1. Superior Sagittal sinus: located on the midline
from nasion to the external occipital protuber-
ance.
5.2. Transverse sinus: located on the line between B
the tragus and the external occipital protuber-
ance.
5.3. Arachnoid granulations and venous lake:
located along the sagittal sinus up to 2 cm
away from the midline.
5.4. Frontal hairline and coronal suture. Figure 1. Decompressive craniotomy, A, midline; B, incision
in skin.
6. Mark the incision:
6.1. The incision begins anterior to the tragus
starting at the zygomatic arch.
6.2. Draw the incision line cranially to the point
just above the summit of the pinna and then turn
occipitally just above the transverse sinus to the
external occipital protuberance. Then turn cra-
nially to the vertex ending at the hairline.
7. Infiltrate the local anesthesia along the incision.
8. Prep and drape the patientÕs head in sterile
fashion.
9. Make the incision as marked previously and
carefully avoid the superficial temporal artery
and the frontal branch of the facial nerve at the B
beginning of the incision (Fig. 1). They are
located approximately 1 cm anterior to the
tragus.
10. Stop any major scalp bleeding or use the
Rainey clip and minimize cauterization of hair
follicles.
11. The scalp can be detached easily from the A
periosteum by the loose aereolar connective
tissue. If able, create a pericranial graft during Figure 2. Decompressive craniotomy, (14.1, 14.2, 14.3, 14.4),
dissection in case it is needed for later use in the burr holes in skull; A, cut in bone connecting burr holes;
frontal sinus. B, area of bone removed after bone flap removal.
12. Reflect the skin flap frontally and hook it. Place
a sponge under the skin flap, which helps 14.2. Parietal area just posterior to the parietal
maintain blood supply to the scalp. bone and close to the skin incision
13. Both temporal areas contain a small pad of fat 14.3. Frontal area 2 cm in front of the coronal
on each side. Elevate the temporalis muscle suture and closed to the skin incision
bilaterally with the scalp to preserve the fat pad 14.4. Key hole area behind the zygomatic arch of
and facial nerve. the frontal bone
14. Make burr holes in the following area (Fig. 2): 15. Detach the dura from the skull epidurally. Be
14.1. Temporal squama careful when operating:

240

A viable brain will be more pulsatile.
B 27. In the case of entering the frontal paranasal
Figure 3. Decompressive craniotomy, A, additional area of
bone removal; B, area of the temporal floor at the lesser wing
of the sphenoid bone.
15.1. On older patients as the dura can adhere
tightly to the skull.
15.2. Near the sagittal sinus.
16. Connect all of the burr hole sites epidurally
(Fig. 3):
16.1. Make the curve parallel to the skin incision
and curve frontally along the scalp flap and
remove the skull cap.
16.2. Be careful, as the superior sagittal sinus is
located in the midline anteriorly but extends to
the right of midline as one progresses posteriorly
and arachnoid granulation are located 2 cm
away from the midline along the superior sagittal
sinus.
16.3. The sphenoid ridge region can bleed exces-
sively because of the presence of diploic veins
and the middle meningeal artery that traverse
it. Wax the bleeding diploic veins with bone
wax.
17. Remove additional bone from the squamous
part of the temporal bone down to the temporal
floor and at the lesser wing of the sphenoid
bone.
18. Make a tiny hole to tack up to the dura – 2 cm
apart – along the rim of the craniotomy.
18.1. Tack the dura up to the skull.
19. Make durotomy in stellate or semicircular
fashion (surgeon preference) and extend durot-
omy linearly down to the base of the middle
cranial fossa to decompress the temporal lobe
and the middle cranial fossa.
20. Stop all bleeding from dural vessels using a
bipolar cautery.
21. The brain is exposed, frontal lobe, parietal
lobe, temporal lobe and occipital lobe.
Decompressive craniectomy
22. Inspect the brain and underlying pathology. A
23. Once the underlying pathology is surgically
corrected reflect the dura loosely over the
exposed brain using the dural substitute to
cover areas of bony defect.
24. Place a drain.
25. Reflect back the scalp flap and inspect the
bleeding.
26. Suture the galeal and scalp.
sinuses pericranial graft, fat or muscle can be
used to obliterate the sinus.
Bicoronal craniectomy
This approach is most useful in the cases of
bilateral frontal contusions or in the case of
generalized cerebral edema without focal lesion.
The procedures for bifrontal craniectomy are as
follows:
1. Patient is under general anesthesia and C- spine
precaution if appropriate.
2. Patient is placed in the supine position and 90
to the horizontal plane.
3. Place head on Horseshoe headholder or May-
field clamp. The patientÕs head should be in a
supine and neutral position on a donut, horse-
shoe or in pins.
4. Mark the caution area on the surface anatomy:
4.1. Superior Sagittal sinus: located on the midline
from the nasion to the external occipital protu-
berance.
4.2. Arachnoid granulations and venous lake:
located along the sagittal sinus up to 2 cm
from the midline.
4.3. Frontal hairline and coronal suture.
5. Mark the skin incision and begin anterior to the
tragus on each side and curve cranially 2–3 cm
posterior to the coronal suture. Incisions should
join in the midline using either V-midline,
curvilinear or zig-zag pattern (at the surgeonÕs
preference).
6. Infiltrate the local anesthesia along the incision
line.
6.1. Prep and drape the patientÕs head in sterile
fashion.
7. Make the skin incision carefully avoiding the
facial nerve and superficial temporal artery as
they are located 1 cm anterior to the tragus
(Fig. 4) and apply Rainey clips.
8. Incise the temporalis muscle.
9. The scalp and temporalis muscle can be reflected
anteriorily and secured using fishhooks. Place a
sponge beneath the scalp, which helps maintain
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Quinn et al.

A
A

B
Figure 5. Bicoronal craniectomy, (13.1, 13.2, 13.3), burr holes
in skull; A, cut in bone connecting burr holes; B, area of
additional bone removed after bone flap removal.
Figure 4. Bicoronal craniectomy, A, midline; B, incision in
skin.

blood supply to the scalp. Also be cautious of A

increasing ocular pressure once scalp is reflected
anteriorily.
10. Expose both supraorbital nerves (V1), which
emerge from the supraorbital foramen being
careful not to injure these nerves.
11. Once bone is exposed make burr holes in the
following areas (Fig. 5): B
11.1. Both key hole areas
11.2. Both squamous parts of the temporal bones.
11.3. Make the other two burr holes just behind the
coronal suture, 1 cm apart from midline on each
side.
12. Perform the craniotomy as indicated with the
last cut being across (over) the SSS.
Figure 6. Bicoronal craniectomy, A, additional area of bone
12.1. Elderly patients – the dura can adhere to the removal; B, area of the temporal floor at the lesser wing of the
skull. sphenoid bone.
12.2. The area of the superior sagittal sinus where
the dura can adhere to the skull and injury can 13.4. Connect both supraorbital areas carefully in
result in rapid blood loss. the midline region so as not to enter the frontal
13. Connect all of the burr hole sites epidurally and paranasal sinus.
remove the skull cap (Fig. 6). 13.5. Wax the diploic vein with bone wax.
13.1. Connect the coronal and temporal areas on 14. Remove additional bone at the squamous part
both sides. of temporal bone and the lesser wing of
13.2. Connect the temporal and key hole areas on sphenoid bone. Be careful of the middle men-
both sides. ingeal artery and diploic veins that traverse it.
13.3. Connect both key hole and supraorbital areas 15. Make a tiny hole to tack up the dura 2 cm
on each side just above the floor of the anterior apart along the craniectomy rim. Tack the dura
cranial fossa. up to the skull.

242

16. Stop the bleeding from the sagittal sinus by
placing a strip of surgicel and ⁄ or gelfoam on to
it and weight with the soaked cottonoid.
17. Make durotomy in stellate or semicircular
fashion (surgeon preference) and extend durot-
omy linearly down to the base of the middle
cranial fossa to decompress the temporal lobe
and the middle cranial fossa (Fig. 7).
18. Make a small durotomy distal to the superior
sagittal sinus and parallel to the anterior cranial
fossa. Now extend it horizontally to both key
hole areas and curve it along the craniectomy
rim.
19. Make other durotomy from aside of the
anterior most part of superior sagittal sinus to
the coronal area on both sides – parallel to the
superior sagittal sinus.
20. Ligate the anterior most part of the superior
sagittal sinus and stop all bleeding from the
dural vessels using a bipolar cautery.
21. Cut the falx cerebri where the sinus was ligated
using caution at the deepest portions to avoid
damaging the anterior cerebral arteries.
22. The brain is exposed bifrontally. Inspect the
brain and underlying pathology. The viable
brain is pulsatile.
23. Once the underlying pathology is surgically
corrected reflect the dura loosely over the
exposed brain using the dural substitute to
cover areas of bony defect.
24. Place a drain.
B C
A Craniectomy. Neurocrit Care 2008;8:456–70.
Figure 7. Bicoronal craniectomy, A, area for durotomy; B,
area of ligation of the superior sagittal sinus; C, cut in the falx
cerebri.
Decompressive craniectomy
25. Reflect back the scalp flap and inspect the
bleeding.
26. Suture the galea and the scalp.
27. In the case of entering the frontal paranasal
sinuses pericranial graft, fat or muscle can be
used to obliterate the sinus.
Concluding remarks
We have presented technical instructions on
performing hemicaniectomy and bicoronal crani-
ectomy, two techniques that frequently yield
inconsistent results. Debates about the utility and
efficacy of these procedures can be found through-
out the literature (32, 33). The purpose of this
paper was to review two conventional approaches
to DC and to promote standardization. Establish-
ing consistent methodology is the only way for
ongoing multicenter clinical trials like RESCUE
ICP (34) and DECRA (35) to accurately evaluate
DC as a life-saving and outcome-improving mea-
sure. We invite the field to critically evaluate these
protocols and to improve upon them as more
clinical data become available.
Disclosure ⁄ Disclaimer
The authors do not have any conflicts of interest. This work
was supported in part by grants from the Veterans Adminis-
tration (MSK).
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