• Aislyn C DiRisio, Brittany M Stopa, Yuri A Pompeu, Viren Vasudeva, Ayaz M Khawaja, Saef Izzy, and William B Gormley.
• Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address: Aislyn.dirisio@icahn.mssm.edu.
• World Neurosurg. 2021 May 1; 149: e188-e196.

BackgroundExtra-axial fluid collections (EACs) frequently develop after decompressive craniectomy. Management of EACs remains poorly understood, and information on how to predict their clinical course is inadequate. We aimed to better characterize EACs, understand predictors of their resolution, and delineate the best treatment paradigm for patients.MethodsWe reviewed patients who developed EACs after undergoing decompressive craniectomy for treatment of refractory intracranial pressure elevations. We excluded patients who had an ischemic stroke, as EACs in these patients have a different clinical course. We performed univariate analysis and multiple linear regression to find variables associated with earlier resolution of EACs and stratified our analyses by EAC phenotype (complicated vs. uncomplicated). We conducted a systematic review to compare our findings with the literature.ResultsOf 96 included patients, 73% were male, and median age was 42.5 years. EACs resolved after a median of 60 days. Complicated EACs were common (62.5%) and required multiple drainage methods before cranioplasty. These were not associated with a protracted course or increased risk of death (P > 0.05). Early bone flap restoration with simultaneous drainage was independently associated with earlier resolution of EACs (β = 0.56, P < 0.001). Systematic review confirmed lack of standardized direction with respect to EAC management.ConclusionsOur analyses reveal 2 clinically relevant phenotypes of EAC: complicated and uncomplicated. Our proposed treatment algorithm involves replacing the bone flap as soon as it is safe to do so and draining refractory EACs aggressively. Further studies to assess long-term clinical outcomes of EACs are warranted.Copyright © 2021 Elsevier Inc. All rights reserved.

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