Extra-axial fluid collections (EAC) frequently develop following decompressive craniectomy (DC). Management of EAC remains poorly understood, and there is a dearth of information on how to predict their clinical course. Thus, we aim to better characterize EAC, understand predictors of their resolution, and delineate the best treatment paradigm for these patients. We reviewed patients who developed EAC after undergoing DC for treatment of refractory intracranial pressure (ICP) elevations, excluding those who had an ischemic stroke as those EACs have a different clinical course. We performed univariate analysis and multiple linear regression to find variables associated with earlier resolution of EAC, and stratified our analyses by EAC phenotype (complicated vs uncomplicated). A systematic review was performed to compare our findings with the literature. Of 96 included patients, 73% were male and the 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 prior to 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 (beta: 0.56, p<0.001). Systematic review confirmed lack of standardized direction with respect to EAC management. Our analyses reveal two 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 the long-term clinical outcomes of EAC are warranted.
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