When is decompressive craniectomy indicated for a supratentorial intracerebral hemorrhage (ICH) >30 ml with ≥5 mm midline shift and Glasgow Coma Scale (GCS) ≤8 in a patient <70 years with good premorbid functional status despite optimal medical therapy?

Decompressive Craniectomy for Supratentorial ICH

Decompressive craniectomy with or without hematoma evacuation should be performed in this patient to reduce mortality, as they meet all critical criteria: supratentorial ICH >30 mL, ≥5 mm midline shift, GCS ≤8, age <70 years, and refractory to medical management. 1, 2

Primary Indication Framework

Your patient meets the established threshold criteria for surgical intervention:

• Hematoma volume >30 mL is a powerful predictor of mortality and constitutes indication for decompressive intervention 2, 3
• Midline shift ≥5 mm is the established threshold for considering surgical evacuation, particularly when combined with neurological deterioration 4, 2
• GCS ≤8 (comatose state) represents severe neurological compromise warranting decompressive surgery 1, 2
• Age <70 years with good premorbid status places the patient in the optimal surgical candidate category 2, 5

Mortality Benefit vs Functional Outcome

The evidence strongly supports a mortality reduction with decompressive craniectomy in this clinical scenario:

• Meta-analyses demonstrate 26% mortality with decompressive craniectomy versus 53% with medical management alone in matched cohorts 2, 6
• The American Heart Association/American Stroke Association provides a Class 2b recommendation (Level C-LD) for mortality reduction 1, 2

However, functional outcomes remain uncertain. The AHA/ASA explicitly states that while mortality may be reduced, evidence for functional benefit is lacking 1, 2. This critical distinction must be discussed with the family—surgery is life-saving but does not guarantee good functional recovery.

Surgical Approach: With or Without Hematoma Evacuation

The decision between decompressive craniectomy alone versus combined with hematoma evacuation depends on specific patient factors:

Decompressive Craniectomy WITH Hematoma Evacuation:

• Preferred when: Patient is younger (age 30-70 years), has subcortical hematoma location, minimal intraventricular extension, and preoperative GCS 6-12 5
• One RCT showed 70% favorable outcomes (mRS 0-4) with DC plus expansive duraplasty and hematoma evacuation versus 20% with evacuation alone 2, 5
• Particularly beneficial in right hemispheric hemorrhages in younger patients 3

Decompressive Craniectomy WITHOUT Hematoma Evacuation:

• Equally effective for mortality reduction when the primary goal is ICP control 1, 6
• Feasibility demonstrated with 75% survival and 75% good outcomes (mRS 0-4) in selected cohorts 6
• May be preferred when hematoma is deep (basal ganglia) and evacuation carries higher surgical risk 2

No clear superiority has been demonstrated between DC with versus without clot evacuation for mortality reduction. 1

Timing of Intervention

Surgical intervention should occur within 8 hours of hemorrhage onset to optimize outcomes 2, 4:

• Meta-analyses suggest improved outcomes with surgery within 8 hours 4
• Critical pitfall: Ultra-early surgery within 4 hours increases rebleeding risk and should be avoided 2, 4
• Optimal window appears to be 4-8 hours after symptom onset 2, 4

Technical Surgical Considerations

The craniectomy must be adequate to achieve decompressive effect:

• Minimum craniectomy size: 150 mm diameter 6
• Dural opening is mandatory to achieve effective decompression 1, 6
• Expansive duraplasty should be performed when combined with hematoma evacuation 5

Post-Operative Management

Following decompressive craniectomy, critical care priorities include:

• ICP monitoring is essential in patients with severe deficits or large hematomas 7
• Maintain cerebral perfusion pressure 60-70 mmHg 7
• Monitor for complications: pneumocephalus, rebleeding (especially if surgery <4 hours), hydrocephalus (15-20% incidence), and infection 2, 5
• Normothermia (36-37°C) and glucose control (6-10 mmol/L) should be maintained 7

Critical Pitfalls to Avoid

1. Do not use baseline severity scores as the sole basis for limiting life-sustaining treatment 2—while GCS and ICH scores predict mortality, they should frame communication, not dictate withdrawal decisions

2. Do not place external ventricular drain alone when significant mass effect is present; it must be combined with surgical decompression 7

3. Do not delay surgery beyond 8 hours unless compelling contraindications exist 7, 4

4. Do not operate within 4 hours due to increased rebleeding risk 2, 4

5. Ensure adequate craniectomy size (≥150 mm)—inadequate decompression negates the benefit 6

Prognostic Factors That Favor Better Outcomes

Even within surgical candidates, certain factors predict superior functional recovery:

• Higher admission GCS (6-12 versus 4-5) 5
• Younger age (30-70 years, particularly <50 years) 5, 3
• Smaller hematoma volume (though >30 mL still warrants surgery) 5
• Subcortical location versus deep basal ganglia 5
• Absent or minimal midline shift preoperatively 5
• Absent intraventricular extension 5, 8
• Normal oculocephalic reflex preoperatively 3

Your patient's age <70 years and good premorbid status are favorable prognostic indicators within the surgical cohort 2, 5.