Practical Clinical Rules for Predicting Complications after Decompressive Craniectomy

Decompressive craniectomy (DC) is a well-established intervention for refractory intracranial hypertension caused by traumatic brain injury, malignant stroke, and other acute intracranial processes.[ 1 ] [ 2 ] [ 3 ] While it can significantly reduce mortality, DC is associated with a high rate of postoperative complications, including infection, hemorrhage, hydrocephalus, seizures, and syndrome of the trephined.[ 4 ] [ 5 ] [ 6 ] Current literature brings a list of potential risk factors, but no concise, we strongly believe that a user-friendly clinical rules to help frontline neurosurgeons quickly identify high-risk patients. Moreover, the ability to anticipate complications could improve operative planning, guide postoperative monitoring, and inform discussions with patient families. In this article, we propose seven simple rules that are derived from literature review and clinical reasoning that may help predict complications after DC ([ Table 1 ]). The proposed rules aim to help the provider to guide on complex risk factor data into a manageable set of clinical heuristics. They are not intended as a formal scoring system, and is just a proposal, but as an initial framework to prompt earlier recognition of high-risk patients. This may guide perioperative optimization, such as aggressive pulmonary care, earlier timing of surgery, and tailored cranioplasty planning. Table 1 Proposed clinical rules for predicting complications following DC Rule 1 History of significant pulmonary complications (e.g., chronic obstructive pulmonary disease, recent pneumonia) → associated with increased postoperative pulmonary events and prolonged ventilation Rule 2 When we found a preoperative ICP > 30 mm Hg → linked with poor brain compliance and higher risk of herniation syndromes Rule 3 For any skull defect > 15 cm in diameter → correlates with higher rates of wound complications, paradoxical herniation, and delayed cranioplasty challenges Rule 4 Timing of DC > 72 hours after initial injury → associated with more pronounced cerebral edema, adhesions, and higher infection risk Rule 5 Preoperative osmotic therapy > 48 hours → may indicate ongoing refractory intracranial hypertension and higher likelihood of secondary injury Rule 6 Presence of brainstem compression signs preoperatively (e.g., pupillary asymmetry, posturing) → predicts poor neurologic recovery and increased postoperative instability Rule 7 Poor baseline functional status (mRS ≥ 3) → associated with reduced rehabilitation potential and higher complication burden. Abbreviations: DC, decompressive craniectomy; ICP, intracranial pressure; mRS, modified Ranking scale. Seven pragmatic clinical rules may assist neurosurgeons in anticipating complications after DC. While not a substitute for comprehensive clinical judgment, they offer a starting point for structured perioperative risk assessment. Validation in prospective studies is warranted. We recognize that these rules have many limitations including the absence of prospective validation and the potential variability of complication definitions across studies. We recommend that these rules be tested in multicenter cohorts to assess sensitivity, specificity, and predictive value. Publication History Article published online: 22 September 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

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