Practical Clinical Rules for Predicting Complications after Decompressive Craniectomy
Bibliographic record
Abstract
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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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.003 | 0.025 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.004 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.002 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.005 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".