Factors associated with the development and outcome of hydrocephalus after decompressive craniectomy for traumatic brain injury


Posttraumatic hydrocephalus (PTH) is common in patients undergoing decompressive craniectomy (DC) for traumatic brain injury (TBI), but the incidence, mechanisms, and risk factors have not been fully elucidated. This study aimed to determine the incidence of and the factors associated with PTH. We retrospectively reviewed patients who underwent DC for TBI at our institute between January 2014 and December 2018. We identified and compared the demographic, clinical, and radiological data, and 12-month functional outcome (as assessed by the Glasgow Outcome Scale [GOS]) between patients who developed PTH and those who did not. Logistic regression analyses were performed to identify risk factors for PTH. Additionally, the influence of PTH on unfavorable functional outcome was analyzed. PTH developed in 18 (18.95%) of the 95 patients who survived at 1 month after DC. A multivariate analysis indicated that postoperative intraventricular hemorrhage (odds ratio [OR] 4.493, P = 0.020), postoperative subdural hygroma (OR 4.074, P = 0.021), and postoperative hypothermia treatment (OR 9.705, P = 0.010) were significantly associated with PTH. The 12-month functional outcome significantly differed between the patients who developed PTH and those who did not (P = 0.049). Patients who developed PTH had significantly poorer 12-month functional outcomes than those who did not (P = 0.049). Another multivariate analysis indicated that subdural hemorrhage (OR 6.814, P = 0.031) and the presence of at least one dilated pupil before DC (OR 8.202, P = 0.000) were significantly associated with unfavorable functional outcomes (GOS grades 1–3). Although the influence of PTH (OR 5.122, P = 0.056) was not statistically significant in the multivariate analysis, it had a great impact on unfavorable functional outcomes. PTH considerably affects functional outcomes at 12 months after DC for TBI. Furthermore, postoperative imaging findings such as intraventricular hemorrhage and subdural hygroma can predict the development of PTH; therefore, careful observation is required during the follow-up period.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    Moon JW, Hyun DK (2017) Decompressive craniectomy in traumatic brain injury: a review article. Kor J Neurotrauma 13:1–8

    Article  Google Scholar 

  2. 2.

    Giammattei L, Messerer M, Cherian I, Starnoni D, Maduri R, Kasper EM, Daniel RT (2018) Current perspectives in the surgical treatment of severe traumatic brain injury. World Neurosurg 116:322–328

    Article  Google Scholar 

  3. 3.

    Brown D, Wijdicks E (2017) Decompressive craniectomy in acute brain injury. In: Handbook of clinical neurology. Elsevier, pp 299–318

  4. 4.

    Sasidharan GM, Shanbhag NC, Shukla DP, Konar SK, Bhat DI, Bhagavatula ID (2018) Complications of decompressive craniectomy. Front Neurol 9:977

    Article  Google Scholar 

  5. 5.

    Choi I, Park H-K, Chang J-C, Cho S-J, Choi S-K, Byun B-J (2008) Clinical factors for the development of posttraumatic hydrocephalus after decompressive craniectomy. J Kor Neurosurg Soc 43:227–231

    Article  Google Scholar 

  6. 6.

    De Bonis P, Sturiale CL, Anile C, Gaudino S, Mangiola A, Martucci M, Colosimo C, Rigante L, Pompucci A (2013) Decompressive craniectomy, interhemispheric hygroma and hydrocephalus: a timeline of events? Clin Neurol Neurosurg 115:1308–1312

    Article  Google Scholar 

  7. 7.

    Fotakopoulos G, Tsianaka E, Siasios G, Vagkopoulos K, Fountas K (2016) Posttraumatic hydrocephalus after decompressive craniectomy in 126 patients with severe traumatic brain injury. Journal of Neurological Surgery Part A: Central European Neurosurgery 77:088–092

    Google Scholar 

  8. 8.

    Honeybul S, Ho KM (2012) Incidence and risk factors for post-traumatic hydrocephalus following decompressive craniectomy for intractable intracranial hypertension and evacuation of mass lesions. J Neurotrauma 29:1872–1878

    Article  Google Scholar 

  9. 9.

    Ki HJ, Lee H-J, Lee H-J, Yi J-S, Yang J-H, Lee I-W (2015) The risk factors for hydrocephalus and subdural hygroma after decompressive craniectomy in head injured patients. J Kor Neurosurg Soc 58:254

    CAS  Article  Google Scholar 

  10. 10.

    Vedantam A, Yamal J-M, Hwang H, Robertson CS, Gopinath SP (2018) Factors associated with shunt-dependent hydrocephalus after decompressive craniectomy for traumatic brain injury. J Neurosurg 128:1547–1552

    Article  Google Scholar 

  11. 11.

    Carney N, Totten AM, O'reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N (2017) Guidelines for the management of severe traumatic brain injury. Neurosurgery 80:6–15

    Article  Google Scholar 

  12. 12.

    Kim H, Lee HS, Ahn SY, Park SC, Huh W (2017) Factors associated postoperative hydrocephalus in patients with traumatic acute subdural hemorrhage. J Korean Neurosurg Soc 60:730–737

    Article  Google Scholar 

  13. 13.

    Woo J-Y, Lee S-B, Yoo D-S, Cho K-S, Huh P-W, Kang S-G, Kim D-S, Park C-K (2006) Differential diagnostic method between the external hydrocephalus and simple subdural hygroma. J Kor Neurotrauma Soc 2:31–36

    Article  Google Scholar 

  14. 14.

    Gudeman S, Kishore P, Becker DP, Lipper MH, Girevendulis A, Jeffries B, Butterworth J 4th (1981) Computed tomography in the evaluation of incidence and significance of post-traumatic hydrocephalus. Radiology 141:397–402

    CAS  Article  Google Scholar 

  15. 15.

    Kocher T (1901) Hirnerschütterung, hirndruck und chirurgische eingriffe bei hirnkrankheiten. A. Hölder

  16. 16.

    Fattahian R, Bagheri SR, Sadeghi M (2018) Development of posttraumatic hydrocephalus requiring ventriculoperitoneal shunt after decompressive craniectomy for traumatic brain injury: a systematic review and meta-analysis of retrospective studies. Med Arch 72:214–219

    Article  Google Scholar 

  17. 17.

    Cho B-R, Lee H-J, Lee H-J, Yi J-S, Yang J-H, Lee I-W (2012) Risk factors for the post-traumatic hydrocephalus following decompressive craniectomy in severe traumatic injury patients. Kor J Neurotrauma 8:110–114

    Article  Google Scholar 

  18. 18.

    De Bonis P, Pompucci A, Mangiola A, Rigante L, Anile C (2010) Post-traumatic hydrocephalus after decompressive craniectomy: an underestimated risk factor. J Neurotrauma 27:1965–1970

    Article  Google Scholar 

  19. 19.

    Honeybul S, Ho KM (2011) Long-term complications of decompressive craniectomy for head injury. J Neurotrauma 28:929–935

    Article  Google Scholar 

  20. 20.

    Jeon SW, Choi JH, Jang TW, Moon S-M, Hwang H-S, Jeong JH (2011) Risk factors associated with subdural hygroma after decompressive craniectomy in patients with traumatic brain injury: a comparative study. J Kor Neurosurg Soc 49:355–358

    Article  Google Scholar 

  21. 21.

    Jiao Q, Liu Z, Li S, Zhou L, Li S, Tian W, You C (2007) Influencing factors for posttraumatic hydrocephalus in patients suffering from severe traumatic brain injuries. Chin J Traumatol= Zhonghua chuang shang za zhi 10:159–162

    PubMed  Google Scholar 

  22. 22.

    Tian H-L, Xu T, Hu J, Y-h C, Chen H, Zhou L-F (2008) Risk factors related to hydrocephalus after traumatic subarachnoid hemorrhage. Surg Neurol 69:241–246

    Article  Google Scholar 

  23. 23.

    Yang X, Hong G, Su S, Yang S (2003) Complications induced by decompressive craniectomies after traumatic brain injury. Chinese Journal of Traumatology= Zhonghua chuang shang za zhi 6:99–103

    PubMed  Google Scholar 

  24. 24.

    Ding J, Guo Y, Tian H (2014) The influence of decompressive craniectomy on the development of hydrocephalus: a review. Arq Neuropsiquiatr 72:715–720

    Article  Google Scholar 

  25. 25.

    Iencean S, Ianovici N, Ciurea A (2009) Intracranial pressure monitoring study in severe traumatic brain injury and post-traumatic hydrocephalus. Romanian Neurosurgery 16:17–19

    Google Scholar 

  26. 26.

    Mazzini L, Campini R, Angelino E, Rognone F, Pastore I, Oliveri G (2003) Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome. Arch Phys Med Rehabil 84:1637–1641

    Article  Google Scholar 

  27. 27.

    Takeuchi S, Nagatani K, Wada K, Nawashiro H, Otani N, Osada H, Kobayashi H, Suzuki T, Shima K (2013) Is decompressive craniectomy a risk factor for ventriculomegaly? Brain Edema XV. Springer, In, pp 281–283

    Google Scholar 

  28. 28.

    Kaen A, Jimenez-Roldan L, Alday R, Gomez PA, Lagares A, Alen JF, Lobato RD (2010) Interhemispheric hygroma after decompressive craniectomy: does it predict posttraumatic hydrocephalus? J Neurosurg 113:1287–1293

    Article  Google Scholar 

  29. 29.

    Low CY, Low YY, Lee KK, Chan SP, Ang BT (2013) Post-traumatic hydrocephalus after ventricular shunt placement in a Singaporean neurosurgical unit. J Clin Neurosci 20:867–872

    Article  Google Scholar 

  30. 30.

    Poca MA, Sahuquillo J, Mataro M, Benejam B, Arikan F, Baguena M (2005) Ventricular enlargement after moderate or severe head injury: a frequent and neglected problem. J Neurotrauma 22:1303–1310

    Article  Google Scholar 

  31. 31.

    Honeybul S, Ho KM (2014) Decompressive craniectomy for severe traumatic brain injury: the relationship between surgical complications and the prediction of an unfavourable outcome. Injury 45:1332–1339

    Article  Google Scholar 

  32. 32.

    Chen H, Yuan F, Chen SW, Guo Y, Wang G, Deng ZF, Tian HL (2017) Predicting posttraumatic hydrocephalus: derivation and validation of a risk scoring system based on clinical characteristics. Metab Brain Dis 32:1427–1435

    Article  Google Scholar 

  33. 33.

    Di G, Zhang Y, Liu H, Jiang X, Liu Y, Yang K, Chen J (2019) Postoperative complications influencing the long-term outcome of head-injured patients after decompressive craniectomy 9:e01179

  34. 34.

    Khalili H, Niakan A, Ghaffarpasand F, Kiani A, Behjat R (2017) Outcome determinants of decompressive craniectomy in patients with traumatic brain injury; a single center experience from southern Iran. Bull Emerg Trauma 5:190–196

    PubMed  PubMed Central  Google Scholar 

  35. 35.

    Nasi D, Dobran M, Di Rienzo A, di Somma L, Gladi M, Moriconi E, Scerrati M, Iacoangeli M (2018) Decompressive craniectomy for traumatic brain injury: the role of cranioplasty and hydrocephalus on outcome. World Neurosurg 116:e543–e549

    Article  Google Scholar 

  36. 36.

    Chibbaro S, Di Rocco F, Mirone G, Fricia M, Makiese O, Di Emidio P, Romano A, Vicaut E, Menichelli A, Reiss A, Mateo J, Payen D, Guichard JP, George B, Bresson D (2011) Decompressive craniectomy and early cranioplasty for the management of severe head injury: a prospective multicenter study on 147 patients. World Neurosurg 75:558–562

    Article  Google Scholar 

  37. 37.

    Khan F, Valliani A, Rehman A, Bari ME (2018) Factors affecting functional outcome after decompressive craniectomy performed for traumatic brain injury: a retrospective, cross-sectional study. Asian J Neurosurg 13:730–736

    Article  Google Scholar 

  38. 38.

    Liang W, Xiaofeng Y, Weiguo L, Gang S, Xuesheng Z, Fei C, Gu L (2007) Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma. J Craniofac Surg 18:526–532

    Article  Google Scholar 

  39. 39.

    Nalbach SV, Ropper AE, Dunn IF, Gormley WB (2012) Craniectomy-associated progressive extra-axial collections with treated hydrocephalus (CAPECTH): redefining a common complication of decompressive craniectomy. J Clin Neurosci 19:1222–1227

    Article  Google Scholar 

  40. 40.

    Sun S, Zhou H, Ding ZZ, Shi H (2018) Risk factors associated with the outcome of post-traumatic hydrocephalus. Scand J Surg:1457496918812210

  41. 41.

    Yu P, Tian Q, Wen X, Zhang Z, Jiang R (2015) Analysis of long-term prognosis and prognostic predictors in severe brain injury patients undergoing decompressive craniectomy and standard care. J Craniofac Surg 26:e635–e641

    Article  Google Scholar 

  42. 42.

    Zhang K, Jiang W, Ma T, Wu H (2016) Comparison of early and late decompressive craniectomy on the long-term outcome in patients with moderate and severe traumatic brain injury: a meta-analysis. Br J Neurosurg 30:251–257

    CAS  Article  Google Scholar 

Download references


We would like to thank So Young Park, Byung Min Kim, Sang Woo Cho, Jae Min Lee, and Young Nam Kim for their assistance with this study.

Author information



Corresponding author

Correspondence to In Bok Chang.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

This study was approved by the Institutional Review Board (IRB) of the local hospital (IRB No. 2019-05-032) and carried out in accordance with the Declaration of Helsinki.

Informed consent

Informed consent was waived by the IRB as this was a recording-based study with no patient contact.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kim, J.H., Ahn, J.H., Oh, J.K. et al. Factors associated with the development and outcome of hydrocephalus after decompressive craniectomy for traumatic brain injury. Neurosurg Rev 44, 471–478 (2021). https://doi.org/10.1007/s10143-019-01179-0

Download citation


  • Complication
  • Decompressive craniectomy
  • Hydrocephalus
  • Outcome
  • Posttraumatic hydrocephalus
  • Traumatic brain injury