Decompressive craniectomy in the modern era: Indications, technique, outcomes, and emerging alternatives

Refractory intracranial hypertension remains one of the major causes of mortality and morbidity in various acute neurological conditions, including severe traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, and malignant middle cerebral artery infarction. When medical management fails to control intracranial pressure, decompressive craniectomy (DC) represents the best surgical option to restore cerebral perfusion and prevent herniation. This review article summarizes the pathophysiological basis for surgical decompression, indications, patient selection, and timing of intervention. Key evidence from major clinical trials is also discussed to highlight survival benefits. Operative principles, including extent of bone removal, dural opening, duroplasty techniques, and bone flap preservation, are reviewed with emphasis on practical surgical nuances. In addition, emerging and minimally invasive alternatives – such as keyhole decompression, hinged craniotomy, expansive duraplasty, focused ultrasound, and tubular retractor systems – are explored as adjuncts to conventional surgery. DC remains a complex but life-saving intervention, requiring careful patient selection, technical precision, and integrated neurocritical care to optimize meaningful neurological outcomes.