Intracranial hypertension in subarachnoid hamorrhage: outcome after decompressive craniectomy

The role of decompressive craniectomy following microsurgical repair of a ruptured aneurysm: Analysis of a South Australian cerebrovascular registry

OBJECTIVE

Decompressive craniectomy (DC) remains a controversial intervention for intracranial hypertension among patients with aneurysmal subarachnoid haemorrhage (aSAH).

METHODS

We identified aSAH patients who underwent DC following microsurgical aneurysm repair from a prospectively maintained registry and compared their outcomes with a propensity-matched cohort who did not. Logistic regression was used to identify predictors of undergoing decompressive surgery and post-operative outcome. Outcomes of interest were inpatient mortality, unfavourable outcome, NIS-Subarachnoid Hemorrhage Outcome Measure and modified Rankin Score (mRS).

RESULTS

A total of 246 patients with aSAH underwent clipping of the culprit aneurysm between 01/09/2011 and 20/07/2020. Of these, 46 underwent DC and were included in the final analysis. Unsurprisingly, DC patients had a greater chance of unfavourable outcome (p < 0.001) and higher median mRS (p < 0.001) at final follow-up. Despite this, almost two-thirds (64.1 %) of DC patients had a favourable outcome at this time-point. When compared with a propensity-matched cohort who did not, patients treated with DC fared worse at all endpoints. Multivariable logistic regression revealed that the presence of intracerebral haemorrhage and increased pre-operative mid-line shift were predictive of undergoing DC, and WFNS grade ≥ 4 and a delayed ischaemic neurological deficit requiring endovascular angioplasty were associated with an unfavourable outcome.

CONCLUSIONS

Our data suggest that DC can be performed with acceptable rates of morbidity and mortality. Further research is required to determine the superiority, or otherwise, of DC compared with structured medical management of intracranial hypertension in this context, and to identify predictors of requiring decompressive surgery and patient outcome.

Size of Craniectomy Predicts Approach-Related Shear Bleeding in Poor-Grade Subarachnoid Hemorrhage

Decompressive craniectomy is an option to decrease elevated intracranial pressure in poor-grade aneurysmal subarachnoid hemorrhage (SAH) patients. The aim of the present study was to analyze the size of the bone flap according to approach-related complications in patients with poor-grade SAH. We retrospectively analyzed poor-grade SAH patients (WFNS 4 and 5) who underwent aneurysm clipping and craniectomy (DC or ommitance of bone flap reinsertion). Postoperative CT scans were analyzed for approach-related tissue injury at the margin of the craniectomy (shear bleeding). The size of the bone flap was calculated using the De Bonis equation. Between 01/2012 and 01/2020, 67 poor-grade SAH patients underwent clipping and craniectomy at our institution. We found 14 patients with new shear bleeding lesion in postoperative CT scan. In patients with shear bleeding, the size of the bone flap was significantly smaller compared to patients without shear bleeding (102.1 ± 45.2 cm2 vs. 150.8 ± 37.43 cm2, p > 0.0001). However, we found no difference in mortality rates (10/14 vs. 23/53, p = 0.07) or number of implanted VP shunts (2/14 vs. 18/53, p = 0.2). We found no difference regarding modified Rankin Scale (mRS) 6 months postoperatively. In poor-grade aneurysmal SAH, the initial planning of DC—if deemed necessary —and enlargement of the flap size seems to decrease the rate of postoperatively developed shear bleeding lesions.

PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is associated with poor neurological outcome and high mortality. A major factor influencing morbidity and mortality is brain swelling in the acute phase. Decompressive craniectomy (DC) is currently used as an option in order to reduce intractably elevated intracranial pressure (ICP). However, execution and optimal timing of DC remain unclear.

METHODS

PICASSO resembles a multicentric, prospective, 1:1 randomized standard treatment-controlled trial which analyzes whether primary DC (pDC) performed within 24 h combined with the best medical treatment in patients with poor-grade SAH reduces mortality and severe disability in comparison to best medical treatment alone and secondary craniectomy as ultima ratio therapy for elevated ICP. Consecutive patients presenting with poor-grade SAH, defined as grade 4-5 according to the World Federation of Neurosurgical Societies (WFNS), will be screened for eligibility. Two hundred sixteen patients will be randomized to receive either pDC additional to best medical treatment or best medical treatment alone. The primary outcome is the clinical outcome according to the modified Rankin Scale (mRS) at 12 months, which is dichotomized to favorable (mRS 0-4) and unfavorable (mRS 5-6). Secondary outcomes include morbidity and mortality, time to death, length of intensive care unit (ICU) stay and hospital stay, quality of life, rate of secondary DC due to intractably elevated ICP, effect of size of DC on outcome, use of duraplasty, and complications of DC.

DISCUSSION

This multicenter trial aims to generate the first confirmatory data in a controlled randomized fashion that pDC improves the outcome in a clinically relevant endpoint in poor-grade SAH patients.

TRIAL REGISTRATION

DRKS DRKS00017650. Registered on 09 June 2019.

Surface Area of Decompressive Craniectomy Predicts Bone Flap Failure after Autologous Cranioplasty: A Radiographic Cohort Study

Skull bone graft failure is a potential complication of autologous cranioplasty after decompressive craniectomy (DC). Our objective was to investigate the association of graft size with subsequent bone graft failure after autologous cranioplasty. This single-center retrospective cohort study included patients age ≥18 years who underwent primary autologous cranioplasty between 2010 and 2017. The primary outcome was bone flap failure requiring graft removal. Demographic, clinical, and radiographic factors were recorded; three-dimensional (3D) reconstructive imaging was used to perform accurate measurements. Univariate and multi-variate regression analysis were performed to identify risk factors for the primary outcome. Of the 131 patients who underwent primary autologous cranioplasty, 25 (19.0%) underwent removal of the graft after identification of bone flap necrosis on computed tomography (CT); 16 (64%) of these were culture positive. The mean surface area of craniectomy defect was 128.5 cm² for patients with bone necrosis and 114.9 cm² for those without bone necrosis. Linear regression analysis demonstrated that size of craniectomy defect was independently associated with subsequent bone flap failure; logistic regression analysis demonstrated a defect area >125 cm² was independently associated with failure (odds ratio [OR] 3.29; confidence interval [CI]: 0.249-2.135). Patient- and operation-specific variables were not significant predictors of bone necrosis. Our results showed that increased size of antecedent DC is an independent risk factor for bone flap failure after autologous cranioplasty. Given these findings, clinicians should consider the increased potential of bone flap failure after autologous cranioplasty among patients whose initial DC was >125 cm².

Primary decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage: long-term outcome in a single-center study and systematic review of literature

Primary decompressive craniectomy (PDC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in order to decrease elevated intracranial pressure (ICP) is controversially discussed. The aim of this study was to analyze the effect of PDC on long-term clinical outcome in these patients in a single-center cohort and to perform a systematic review of literature. Eighty-seven consecutive poor-grade SAH patients (World Federation of Neurosurgical Societies (WFNS) grades IV and V) were analyzed between October 2012 and August 2017 at the author’s institution. PDC was performed due to clinical signs of herniation or brain swelling according to the treating surgeon. Outcome was analyzed according to the modified Rankin Scale (mRS). Literature was systematically reviewed up to August 2019, and data of poor-grade aSAH patients who underwent PDC was extracted for statistical analyses. Of 87 patients with poor-grade aSAH in the single-center cohort, 38 underwent PDC and 49 did not. Favorable outcome at 2 years post-hemorrhage did not differ significantly between the two groups (26% versus 20%). Systematic literature review revealed 9 studies: Overall, a favorable outcome could be achieved in nearly half of the patients (49%), with an overall mortality of 24% (median follow-up 11 months). Despite a worse clinical status at presentation (significantly higher rate of mydriasis and additional ICH), poor-grade aSAH patients with PDC achieve favorable outcome in a significant number of patients. Therefore, treatment and PDC should not be omitted in this severely ill patient collective. Prospective controlled studies are warranted.

Experiences with a temporary synthetic skin substitute after decompressive craniectomy: a retrospective two-center analysis

BACKGROUND

Decompressive craniectomy is a commonly performed procedure. It reduces intracranial pressure, improves survival, and thus might have a positive impact on several neurosurgical diseases and emergencies. Sometimes primary skin closure is not possible due to cerebral herniation or extensive skin defects. In order to prevent further restriction of the underlying tissue, a temporary skin expansion might be necessary.

METHODS AND MATERIAL

We retrospectively reviewed patients in need for a temporary skin substitute because skin closure was not possible after craniectomy without violating brain tissue underneath in a time period of 6 years (2011-2016). With this study, we present initial experiences of Epigard (Biovision, Germany) as an artificial temporary skin replacement. We performed this analysis at two level-1 trauma centers (Trauma Center Murnau, Germany; University Hospital of St. Poelten, Austria). Demographic data, injury and surgical characteristics, and complication rates were analyzed via chart review. We identified nine patients within our study period. Six patients suffered from severe traumatic brain injury and developed pronounced cerebral herniation in the acute or subacute phase. Three patients presented with non-traumatic conditions (one atypical intracerebral hemorrhage and two patients with extensive destructive tumors invading the skull and scalp).

RESULTS

A total of 20 Epigard exchanges (range 1-4) were necessary before skin closure was possible. A CSF fistula due to a leaky Epigard at the interface to the skin was observed in two patients (22%). Additional complications were four wound infections, three CNS infections, and three patients developed a shunt dependency. Three patients died within the first month after injury.

CONCLUSIONS

Temporary skin closure with Epigard as a substitute is feasible for a variety of neurosurgical conditions. The high complication and mortality rate reflect the complexity of the encountered pathologies and need to be considered when counseling the patient and their families.

Clinical observation of the time course of raised intracranial pressure after subarachnoid hemorrhage

The time course of intracranial pressure (ICP) after subarachnoid hemorrhage (SAH) is not well known. This retrospective study was conducted to investigate the occurrence and the dynamic variation of raised ICP post-SAH. ICP was prospectively studied in 120 patients with SAH who were admitted to neurocritical care within 24 h of hemorrhage. Patients underwent continuous ICP monitoring for at least 7 days, unless they died. Clinical status on admission, radiographic tests, treatment details and neurological outcome on discharge were analyzed in relation to ICP. The highest daily mean ICP and the day when ICP reduced to normal levels were assessed. Of the 120 patients studied, 112 (93.3 %) encountered ICP elevation whilst in hospital. The daily mean ICP was higher in Hunt and Hess grades IV-V patients than grades I-III patients (P = 0.01). The elevated ICP remained at a higher level for the initial 3 days (grades I-III patients) or 4 days (grades IV-V patients), after which the pressure decreased towards normal levels. The in-patient mortality was significantly increased in the high ICP variability group (P = 0.001), which was divided by the cutoff point using receiver operating characteristic curve analysis. Raised ICP mainly occurs within 8 days post-SAH, especially the initial 3-4 days. Those highlight the need for earlier management of ICP after SAH.