Neurosurg Focus. 2025 Nov 1;59(5):E3. doi: 10.3171/2025.8.FOCUS25683.
ABSTRACT
OBJECTIVE: Cerebral infection syndromes are life-threatening diseases with high mortality and morbidity rates worldwide. They are often associated with refractory elevated intracranial pressure (ICP). The role and clinical outcomes of decompressive craniectomy (DC) in patients with intracranial infections are still a controversial topic. The authors aimed to provide the largest known retrospective analysis on the effect of DC in intracranial infections.
METHODS: A retrospective cohort study was designed based on patients who underwent DC between 2010 and 2024 at the Department of Neurosurgery and Neurointervention, Semmelweis University. Seventeen cases were selected in which the indication for surgery was elevated ICP due to cerebral infection (encephalitis, meningitis, meningoencephalitis, subdural empyema, or brain abscess). Patient demographics, preoperative clinical status, timing of surgery, imaging findings, and microbiological results were analyzed. Functional outcome was assessed using the Glasgow Outcome Scale (GOS) at discharge and the 6-month follow-up.
RESULTS: Seventeen patients (9 pediatric, 8 adults; mean age 25.9 years) were included. Subdural empyema (41.2%) and viral encephalitis (35.3%) were the most common diagnoses. A preoperative Glasgow Coma Scale score ≤ 8 was seen in 82.4%, and midline shift was detected in all cases (mean 7.49 mm). ICP monitoring was performed in 35.3% of patients, with a mean preoperative ICP of 28.3 mm Hg. DC was unilateral in 47.1% and bilateral in 52.9%. At discharge, the median GOS score was 2; at the 6-month follow-up, the median GOS score improved to 5. Excellent long-term outcome (GOS score of 5) was achieved in 41.2%, and the inpatient mortality rate was 5.9%. Cranioplasty was completed in 47.1%, and residual epilepsy occurred in 29.4%. ICP monitoring and the absence of pupillary asymmetry were associated with better outcomes.
CONCLUSIONS: DC may offer substantial survival and functional benefits in patients with cerebral infections and medically refractory elevated ICP. Invasive ICP monitoring and early surgical intervention may improve functional outcome. This study presents the largest known retrospective analysis of DC in infectious intracranial pathologies and underscores the need for larger prospective studies to establish clinical guidelines.
PMID:41175411 | DOI:10.3171/2025.8.FOCUS25683
