Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score–based analysis

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Traumatic intracerebral hemorrhage (TICH) represents approximately 13%–48% of the lesions after a traumatic brain injury (TBI), and hemorrhagic progression (HP) occurs in 38%–63% of cases. In previous studies, decompressive craniectomy (DC) has been characterized as a risk factor in the HP of TICH; however, few studies have focused exclusively on this relationship. The object of the present study was to analyze the relationship between DC and the growth of TICH and to reveal any correlation with the size of the craniectomy, degree of cerebral parenchymal herniation (CPH), or volumetric expansion of the TICH.


The authors retrospectively analyzed the records of 497 adult patients who had been consecutively admitted after suffering a severe or moderate closed TBI. An inclusion criterion was presentation with one or more TICHs on the initial or control CT. Demographic, clinical, radiological, and treatment variables were assessed for associations.


Two hundred three patients presenting with 401 individual TICHs met the selection criteria. TICH growth was observed in 281 cases (70.1%). Eighty-two cases (20.4%) underwent craniectomy without TICH evacuation. In the craniectomy group, HP was observed in 71 cases (86.6%); in the noncraniectomy group (319 cases), HP occurred in 210 cases (65.8%). The difference in the incidence of HP between the two groups was statistically significant (OR 3.41, p < 0.01). The mean area of the craniectomy was 104.94 ± 27.5 cm2, and the mean CPH distance through the craniectomy was 17.85 ± 11.1 mm. The mean increase in the TICH volume was greater in the groups with a craniectomy area > 115 cm2 and CPH > 25 mm (16.12 and 14.47 cm3, respectively, p = 0.01 and 0.02). After calculating the propensity score (PS), the authors followed three statistical methods—matching, stratification, and inverse probability treatment weighting (IPTW)—thereby obtaining an adequate balance of the covariates. A statistically significant relationship was found between HP and craniectomy (OR 2.77, p = 0.004). This correlation was confirmed with the three methodologies based on the PS with odds greater than 2.


DC is a risk factor for the growth of TICH, and there is also an association between the size of the DC and the magnitude of the volume increase in the TICH.

ABBREVIATIONS aPTT = activated partial thromboplastin time; ASDH = acute subdural hematoma; DC = decompressive craniectomy; GCS = Glasgow Coma Scale; GEE = generalized estimating equation; HP = hemorrhagic progression; IPTW = inverse probability treatment weighting; PA = prothrombin activity; PS = propensity score; SMD = standardized mean differences; TBI = traumatic brain injury; TICH = traumatic intracerebral hemorrhage.

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Article Information

Correspondence Santiago Cepeda: University Hospital Río Hortega, Valladolid, Spain. cepeda_santiago@hotmail.com.

INCLUDE WHEN CITING Published online April 26, 2019; DOI: 10.3171/2019.2.JNS182025.

Disclosures This research was jointly funded by the ISCIII and FEDER European institutions, with FIS project number PI14/0157. The sponsor had no role in the design or conduct of this research.

© AANS, except where prohibited by US copyright law.



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    Schematic representation of the methodology applied in measurements of craniectomy size and parenchymal herniation in axial (left) and coronal (right) CT slices. a = maximal hemicraniectomy diameter; b = maximal anteroposterior skull diameter; c = magnitude of external cerebral herniation; d = horizontal brain diameter; e = brain width of side of the hemicraniectomy; f = brain width on the contralateral side; g = maximal hemicraniectomy diameter in coronal view; x = point of maximal parenchymal herniation. Figure is available in color online only.

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    Flow diagram of patients who met the inclusion and exclusion criteria for the study. Figure is available in color online only.

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    A: Estimated PS in matched and control groups. B: Example of PS distribution in matched and control groups divided into craniectomy (green) and noncraniectomy cases (pink), according to the cisternal compression variable. C: Schema of the distribution of PSs and balances after matching adjust across the two groups mentioned above. Figure is available in color online only.

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    Covariate balance assessment represented by the SMDs (x-axis) following the three methodologies: matching, stratification, and IPTW. Figure is available in color online only.




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