Emergency Radiology

, Volume 26, Issue 1, pp 99–107 | Cite as

Post-operative complications of craniotomy and craniectomy

  • Komal A. Chughtai
  • Omar P. Nemer
  • Alexander T. Kessler
  • Alok A. BhattEmail author
Pictorial Essay


Craniotomy and craniectomy are widely performed emergent neurosurgical procedures and are the prescribed treatment for a variety of conditions from trauma to cancer. It is vital for the emergency radiologist to be aware of expected neuroimaging findings in post-craniotomy and craniectomy patients in order to avoid false positives. It is just as necessary to be familiar with postsurgical complications in these patients to avoid delay in lifesaving treatment. This article will review the commonly encountered normal and abnormal findings in post-craniotomy and craniectomy patients. The expected postoperative CT and MRI appearance of these procedures are discussed, followed by complications. These include hemorrhage, tension pneumocephalus, wound/soft tissue infection, bone flap infection and extradural abscesses. Complications specifically related to craniectomies include extracranial herniation, external brain tamponade, paradoxical herniation, and trephine syndrome.


Craniotomy Tension pneumocephalus Abscess Trephine syndrome 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Donovan DJ et al (2006) Cranial burr holes and emergency craniotomy: review of indications and technique. J Neurosurg 122(5):1113–1119Google Scholar
  2. 2.
    Gooch MR, Gin GE, Kenning TJ, German JW (2009) Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurg Focus 26(6):E9CrossRefGoogle Scholar
  3. 3.
    Lonjaret L, Guyonnet M, Berard E, Vironneau M, Peres F, Sacrista S, Ferrier A, Ramonda V, Vuillaume C, Roux FE, Fourcade O, Geeraerts T (2017) Postoperative complications after craniotomy for brain tumor surgery. Anaesth Crit Care Pain Med 36(4):213–218CrossRefGoogle Scholar
  4. 4.
    Sinclair AG, Scoffings DJ (2010) Imaging of the post-operative cranium. Radiographics 30(2):461–482CrossRefPubMedGoogle Scholar
  5. 5.
    Elster AD, DiPersio DA (1990) Cranial postoperative site: assessment with contrast-enhanced MR imaging. Radiology 174(1):93–98CrossRefPubMedGoogle Scholar
  6. 6.
    Sato N, Bronen RA, Sze G, Kawamura Y, Coughlin W, Putman CM, Spencer DD (1997) Postoperative changes in the brain: MR imaging findings in patients without neoplasms. Radiology 204(3):839–846CrossRefPubMedGoogle Scholar
  7. 7.
    Meyding-Lamadé U et al (1993) Accelerated methemoglobin formation: potential pitfall in early postoperative MRI. Neuroradiology 35(3):178–180CrossRefPubMedGoogle Scholar
  8. 8.
    Reasoner DK, Todd MM, Scamman FL, Warner DS (1994) The incidence of pneumocephalus after supra-tentorial craniotomy: observations on the disappearance of intracranial air. Anesthesiology 80(5):1008–1012CrossRefGoogle Scholar
  9. 9.
    Carrau RL et al (1991) Computerized tomography and magnetic resonance imaging following cranial base surgery. Laryngoscope 101(9):951–959CrossRefPubMedGoogle Scholar
  10. 10.
    Henegar MM, Moran CJ, Silbergeld DL (1996) Early postoperative magnetic resonance imaging following nonneoplastic cortical resection. J Neurosurg 84(2):174–179CrossRefPubMedGoogle Scholar
  11. 11.
    Michel SJ (2004) The Mount Fuji sign. Radiology 232(2):449–450CrossRefPubMedGoogle Scholar
  12. 12.
    Shi ZH, Xu M, Wang YZ, Luo XY, Chen GQ, Wang X, Wang T, Tang MZ, Zhou JX (2017) Post-craniotomy intracranial infection in patients with brain tumors: a retrospective analysis of 5723 consecutive patients. Br J Neurosurg 31(1):5–9CrossRefPubMedGoogle Scholar
  13. 13.
    Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Galacho-Harriero AM, Rodríguez-Salazar A (2009) Preservation of bone flap after craniotomy infection. Neurocirugia (Astur) 20(2):124–131CrossRefGoogle Scholar
  14. 14.
    Hlavin ML et al (1994) Intracranial suppuration: a modern decade of postoperative subdural empyema and epidural abscess. Neurosurgery 34(6):974–981PubMedGoogle Scholar
  15. 15.
    Farrell CJ, Hoh BL, Pisculli ML, Henson JW, Barker FG II, Curry WT Jr (2008) Limitations of diffusion-weighted imaging in the diagnosis of postoperative infections. Neurosurgery 62(3):577–583CrossRefGoogle Scholar
  16. 16.
    Mollman HD, Haines SJ (1986) Risk factors for postoperative neurosurgical wound infection: a case-control study. J Neurosurg 64(6):902–906CrossRefPubMedGoogle Scholar
  17. 17.
    Lanzieri CF, Som PM, Sacher M, Solodnik P, Moore F (1986) The postcraniectomy site: CT appearance. Radiology 159(1):165–170CrossRefPubMedGoogle Scholar
  18. 18.
    Seifman MA, Lewis PM, Rosenfeld JV, Hwang PYK (2011) Postoperative intracranial haemorrhage: a review. Neurosurg Rev 34:393–407CrossRefGoogle Scholar
  19. 19.
    Jeon JS et al (2006) Immediate postoperative epidural hematomas adjacent to the craniotomy site. J Korean Neurosurg Soc 39(5):335–339Google Scholar
  20. 20.
    Desai VR et al (2016) Incidence of intracranial hemorrhage after a cranial operation. Cureus 8(5):e616PubMedPubMedCentralGoogle Scholar
  21. 21.
    Pandey P, Madhugiri VS, Sattur MG, Devi B I (2008) Remote supratentorial extradural hematoma following posterior fossa surgery. Childs Nerv Syst 24(7):851–854CrossRefPubMedGoogle Scholar
  22. 22.
    Wolfsberger S, Gruber A, Czech T (2004) Multiple supra-tentorial epidural hematomas after posterior fossa surgery. Neurosurg Rev 27(2):128–132CrossRefGoogle Scholar
  23. 23.
    Fukamachi A, Koizumi H, Nukui H (1985) Postoperative intracerebral hemorrhages: a survey of computed tomographic findings after 1074 intracranial operations. Surg Neurol 23(6):575–580CrossRefGoogle Scholar
  24. 24.
    Heit JJ, Iv M, Wintermark M (2017) Imaging of intracranial hemorrhage. J Stroke 19(1):11–27CrossRefPubMedGoogle Scholar
  25. 25.
    Stiver SI (2009) Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 26(6):E7CrossRefGoogle Scholar
  26. 26.
    Chauhan NS, Banday IA, Morey P, Deshmukh A (2017) External brain tamponade: a rare complication of decompressive craniectomy. Intern Emerg Med 12:117–118CrossRefPubMedGoogle Scholar
  27. 27.
    Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM (2006) Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 104:469–479CrossRefGoogle Scholar
  28. 28.
    Akins PT, Guppy KH (2008) Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care 9(2):269–276CrossRefPubMedGoogle Scholar
  29. 29.
    Han PY, Kim JH, Kang HI, Kim JS (2008) Syndrome of the sinking skin-flap secondary to the ventriculoperitoneal shunt after craniectomy. J Korean Neurosurg Soc 43(1):51–53CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© American Society of Emergency Radiology 2018

Authors and Affiliations

  1. 1.Department of Imaging SciencesUniversity of Rochester Medical CenterRochesterUSA
  2. 2.Department of Radiology, Buffalo VA Medical CenterUniversity at Buffalo School of Medicine and Biomedical SciencesBuffaloUSA

Personalised recommendations