Decompressive craniectomy for severe central nervous system infection: a 15-year Swedish multicentre case-series

BACKGROUND: Severe community-acquired central nervous system (CNS) infections may, in rare cases, cause life-threatening cerebral oedema. This study aimed to investigate the utilisation, indications, and outcomes of decompressive craniectomy (DC) as a last-tier intervention for intracranial hypertension for these conditions in a Swedish multicentre setting. METHODS: In this retrospective multicentre case series, we included all patients who underwent DC for severe CNS infection between 2008 and 2022 (only 2008-2018 at one centre) at five neurosurgical departments, covering approximately 80% of the Swedish population. Demographic, clinical, radiological, surgical, and outcome data were extracted from medical records. Functional outcome at approximately 6 months was assessed using the Glasgow Outcome Scale (GOS), with favourable outcome defined as GOS > 3. RESULTS: Ten patients underwent DC during the 15-year study period, corresponding to an annual rate of approximately 0.1 cases per million inhabitants. Seven patients had community-acquired bacterial meningitis (CABM), two viral encephalitis, and one brain abscess. Three CABM patients exhibited diffuse cerebral oedema without midline shift and underwent bifrontal DC, whereas seven patients with focal pathology and lateralised mass effect, including CABM with subdural empyema, viral encephalitis, or brain abscess, were treated with hemicraniectomy. In nearly all cases, extensive ICP-lowering therapies had been exhausted prior to DC. DC resulted in reduced midline shift and improved basal cistern patency and was associated with a low complication rate. One patient underwent reoperation for DC extension; no postoperative haemorrhages, infections, or chronic hydrocephalus occurred. Mortality was 30%, contrasted by 50% who achieved a favourable functional outcome. CONCLUSIONS: DC for severe CNS infections is exceedingly rare and reserved for highly selected patients with refractory intracranial hypertension. The observed complication burden and functional outcomes are descriptive only and should not be interpreted as evidence of treatment efficacy.