Decompressive craniectomies, facts and fiction: a retrospective analysis of 526 cases

Efficacy of decompressive craniectomy: A retrospective case series study with 321 patients and an update on controversies

Decompressive craniectomy (DC) is considered a cornerstone in the management of refractory intracranial hypertension. For decades, DC was known as an occasionally lifesaving procedure; however, it was associated with numerous severe complications. The present study is a single-center retrospective case series study on with 321 patients who underwent DC between January, 2010 and December, 2020. All patients were divided into four groups as follows: Group A included patients who suffered from a space-occupying middle cerebral artery (MCA) ischemic event; group B included individuals who developed intracerebral hemorrhage; group C included patients admitted for traumatic brain injury; and group D included patients with other neurosurgical entities that underwent DC, such as subarachnoid hemorrhage, tumors, brain abscess and cerebral ventricular sinus thrombosis events. The present study enrolled a total of 321 patients who underwent DC. Group A included 52 out of the 321 (16.1%) patients, group B included 51 (15.8%) patients, group C included 164 (51.0%) patients, and group D included 54 (16.8%) patients. Of the 321 patients, 235 (73.2%) were males, and the median age was 53.7 years. Multivariate analysis revealed that only the group A parameter was an independent factor associated with a Glasgow outcome scale score >2 during follow-up (P<0.05). On the whole, the results of the present study suggest that among patients who underwent DC with different neurological entities, those who had experienced MCA events had more favorable outcomes.

The role of the craniotomy size in the surgical evacuation of acute subdural hematomas in elderly patients: a retrospective multicentric study

BACKGROUND

Elderly patients operated for an acute subdural hematoma (ASDH) frequently have a poor outcome, with a high frequency of death, vegetative status, or severe disability (Glasgow Outcome Score [GOS] 1-3). Minicraniotomy has been proposed as a minimally invasive surgical treatment to reduce the impact of surgery in the elderly population. The present study aimed to compare the influence of the size of the craniotomy on the functional outcome in patients undergoing surgical treatment for ASDH.

METHODS

We selected patients ≥70 years old admitted to 5 Italian tertiary referral neurosurgical for the treatment of a post-traumatic ASDH between January 1, 2016, and December 31, 2019. We collected demographic data, clinical data (GCS, GOS, Charlson Comorbidity Index [CCI], antiplatelet/anticoagulant therapy, neurological deficits, seizure, pupillary size, length of stay), surgical data (craniotomy size, dividing the patients into 3 groups based on the corresponding tertile, and surgery duration), radiological data (ASDH side and thickness, midline shift, other post-traumatic lesions, extent of ASDH evacuation) and we assessed the functional outcome at hospital discharge and 6-month follow-up considering GOS=1-3 as a poor outcome. ANOVA and χ2 Tests and logistic regression models were used to assess differences in and associations between clinical-radiological characteristics and functional outcomes.

RESULTS

We included 136 patients (76 males) with a mean age of 78±6 years. Forty-five patients underwent a small craniotomy, 47 a medium size, and 44 a large craniotomy. Among the different craniotomy size groups, there were no differences in gender, anticoagulant/antithrombotic therapy, CCI, side of ASDH, ASDH thickness, preoperative GCS, focal deficits, seizures, and presence of other post-traumatic lesions. Patients undergoing small craniotomies were older than patients undergoing medium-large craniotomies; ASDH treated with medium size craniotomy were thinner than the others; patients undergoing large craniotomies showed greater midline shift and a higher rate of anisocoria. The three groups did not differ for functional outcome and postoperative midline shift, but the length of surgery and the rate of >50% of ASDH evacuation were lower in the small craniotomy group.

CONCLUSIONS

A small craniotomy was not inferior to larger craniotomies in determining functional outcomes in the treatment of ASDH in the elderly.

Comparing surgical outcomes: Craniotomy versus decompressive craniectomy in acute subdural hematoma - A systematic review and meta-analysis

Introduction

Acute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making.

Methods

Following PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model.

Results

The meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure.

Conclusion

The meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.

Poroelastic modelling of brain tissue swelling and decompressive craniectomy treatment in ischaemic stroke

Brain oedema or tissue swelling that develops after ischaemic stroke can cause detrimental effects, including brain herniation and increased intracranial pressure (ICP). These effects can be reduced by performing a decompressive craniectomy (DC) operation, in which a portion of the skull is removed to allow swollen brain tissue to expand outside the skull. In this study, a poroelastic model is used to investigate the effect of brain ischaemic infarct size and location on the severity of brain tissue swelling. Furthermore, the model will also be used to evaluate the effectiveness of DC surgery as a treatment for brain tissue swelling after ischaemia. The poroelastic model consists of two equations: one describing the elasticity of the brain tissue and the other describing the changes in the interstitial tissue pressure. The model is applied on an idealized brain geometry, and it is found that infarcts with radius larger than approximately 14 mm and located near the lateral ventricle produce worse brain midline shift, measured through lateral ventricle compression. Furthermore, the model is also able to show the positive effect of DC treatment in reducing the brain midline shift by allowing part of the brain tissue to expand through the skull opening. However, the model does not show a decrease in the interstitial pressure during DC treatment. Further improvement and validation could enhance the capability of the proposed poroelastic model in predicting the occurrence of brain tissue swelling and DC treatment post ischaemia.

Modifying skin flaps for achieving very large decompressive craniectomies in malignant middle cerebral artery territory infarcts: A technical note

INTRODUCTION

Decompressive craniectomy is a well described treatment to salvage life in large middle cerebral artery (MCA) territory infarcts. The size of the craniectomy is limited by the size of the skin incision and very large craniectomies need large skin flaps that are prone to necrosis at the wound margins.

MATERIAL AND METHODS

We describe two modifications in the skin flap that we have used in 7 patients to achieve very large bony decompressions in malignant MCA infarctions without compromising on flap vascularity. One consists of a linear extension posteriorly from the question mark or reverse question mark incision while the other is an "n" shaped incision.

RESULTS

With these modifications we achieved craniectomies of size 15.6-17.8 cm in the anteroposterior and 10.7-12 cm in vertical axis of the bone flap removed in our patients. There were no additional procedural or wound related complications in a 6-month follow up.

CONCLUSIONS

Removal of a standard size bone flap may achieve suboptimal decompression in cases of large MCA territory infarctions. Imaginative tailoring of skin flaps helps to remove larger volumes of skull with no added procedural morbidity.

Closure intracranial pressure is an objective intraoperative determinant of the adequacy of surgical decompression in traumatic acute subdural haematoma: a multicentre observational study

PURPOSE

Acute subdural haematoma (ASDH) is associated with severe traumatic brain injury and poor outcomes. Although guidelines exist for the decompression of ASDH, the question of adequate decompression remains unanswered. The authors examined the relationship of intracranial pressure (ICP) on closure with outcomes to determine its utility in the determination of adequate ASDH decompression.

METHODS

A multicentre retrospective review of 105 consecutive patients with ASDH who underwent decompressive surgery was performed. Receiver operating characteristic (ROC) analysis with internal validation was performed to determine an ICP threshold for the division of patients into the inadequate and good ICP groups. Multivariable analyses were performed for both inpatient and long-term outcomes.

RESULTS

An ICP threshold of 10 mmHg was identified with a 91.5% specificity, 45.7% sensitivity, and a positive and negative predictive value of 80.8% and 68.4%. There were 26 patients (24.8%) and 79 patients (75.2%) in the inadequate and good ICP groups, respectively. After adjustment, the inadequate ICP group was associated with increased postoperative usage of mannitol (OR 14.2, p < 0.001) and barbiturates (OR 150, p = 0.001). Inadequate ICP was also associated with increased inpatient mortality (OR 24.9, p < 0.001), and a lower rate of favourable MRS at 1 year (OR 0.08, p = 0.008). The complication rate was similar amongst the groups.

CONCLUSIONS

Closure ICP is a novel, objective, and actionable intraoperative biomarker that correlates with inpatient and long-term outcomes in ASDH. Various surgical manoeuvres can be undertaken to achieve this target safely. Large-scale prospective studies should be performed to validate this ICP threshold.

The Effect of Size of Decompressive Craniectomy on Outcome in Deep Spontaneous Intracerebral Hemorrhage

Introduction Spontaneous intracerebral hemorrhage (SICH) is one of the most devastating forms of stroke with a mortality of 30 to 40%. We aimed to evaluate the effect of craniotomy size and volume of decompression on surgical outcome, complications, mortality, and morbidity in patients with supratentorial capsuloganglionic bleeds who underwent a decompressive craniectomy (DC) at our institute.

Materials and Methods It is a retrospective study done between January 2015 and December 2019. All patients with capsuloganglionic bleeds who had DC and hematoma evacuation were included in the study.

Results A total of 55 patients underwent DC for SICH at our hospital during the study period. Mean anteroposterior (AP) diameter of the bone flap was 12.42 cm. The volume of decompression did not influence mortality and morbidity in our study but a larger AP diameter was associated with a higher incidence of hydrocephalus. A smaller craniectomy with an AP diameter of < 12 cm caused a lesser reduction in midline shift (MLS). Persistent postoperative MLS had a significant impact on mortality and its reduction was dependent on the size of craniectomy (p =–0.037)

Conclusion DC with a recommended AP diameter of 12 to 13 cm achieves optimal results in terms of reduction in MLS. Larger DC volume carries a higher risk of hydrocephalus and requires close follow-up.

Transcranial direct current stimulation in patients after decompressive craniectomy: a finite element model to investigate factors affecting the cortical electric field

Objective

To simulate the process of transcranial direct current stimulation (tDCS) on patients after decompressive craniectomy (DC), and to model cortical electric field distributions under different electrode montages, we constructed a finite element model that represented the human head at high resolution.

Methods

Using computed tomography images, we constructed a human head model with high geometrical similarity. The removed bone flap was simplified to be circular with a diameter of 12 cm. We then constructed finite element models according to bioelectrical parameters. Finally, we simulated tDCS on the finite element models under different electrode montages.

Results

Inward current had a linear relationship with peak electric field value, but almost no effect on electric field distribution. If the anode was not over the skull hole (configuration 2), there was almost no difference in electric field magnitude and focality between the circular and square electrodes. However, if the anode was right over the hole (configuration 1), the circular electrodes led to higher peak electric field values and worse focality. In addition, configuration 1 significantly decreased focality compared with configuration 2.

Conclusion

Our results might serve as guidelines for selecting current and electrode montage settings when performing tDCS on patients after DC.

The utility of decompressive craniectomy in severe traumatic brain injury in Saudi Arabia trauma centers

Background: Decompressive craniectomy (DC) represents an effective method for intracranial pressure (ICP) reduction in cases of severe traumatic brain injury (TBI). However, little is known regarding the attitude of practicing neurosurgeons toward decompressive craniectomy (DC) in Saudi Arabia.Objective: We aimed to explore the perspective on DC among neurosurgeons in Saudi Arabia.Methods: An electronic survey was distributed via e-mail to members of the Saudi Association of Neurological Surgery (SANS).Results: A total of 52 neurosurgeons participated in this survey. The majority of these neurosurgeons practice in a governmental (95.2%), tertiary hospital (75.5%) with academic affiliations (77.6%). Most surgeons (71.4%) agreed that the DC approach for managing refractory ICP is supported by evidence-based medicine. The majority of the participants choose to perform DC on a unilateral basis (80%). Interestingly, DC followed by duraplasty was performed by only 71% of these surgeons, with 29% of the respondents not performing expansive duraplasty.Conclusion: In Saudi Arabia, the utility of DC in cases of TBI with refractory intracranial hypertension has not been clearly defined among practicing neurosurgeons. The development of appropriate, widely adopted TBI guidelines should thus be a priority in Saudi Arabia to reduce variability among TBI care practices. In addition, a national TBI registry should be established for documenting different practices and longitudinal outcomes.

Inadequate Decompressive Craniectomy Following a Wartime Traumatic Brain Injury - An Illustrative Case of Why Size Matters

Traumatic brain injury has been called the "signature injury" of the wars in Iraq and Afghanistan, and the management of severe and penetrating brain injury has evolved considerably based on the experiences of military neurosurgeons. Current guidelines recommend that decompressive hemicraniectomy be performed with large, frontotemporoparietal bone flaps, but practice patterns vary markedly. The following case is illustrative of potential clinical courses, complications, and efforts to salvage inadequately-sized decompressive craniectomies performed for combat-related severe and penetrating brain injury. The authors follow this with a review of the current literature pertaining to decompressive craniectomy, and finally provide their recommendations for some of the technical nuances of performing decompressive hemicraniectomy after severe or penetrating brain injury.

How I do it: supra-tentorial unilateral decompressive craniectomy

BACKGROUND

Decompressive craniectomy is a surgical way to treat intracranial hypertension, by removing a large flap of skull bone.

METHOD

We report the case of a 48 years old right-handed man presenting an acute ischaemic stroke of all the right sylvian artery area, with rapid clinic deterioration then coma. Severe intracranial hypertension was confirmed by transcranial Doppler. In emergency, we decided to perform a right-side decompressive craniectomy.

CONCLUSION

Six months later, he is in rehabilitation with "only" a left hemiplegia and a very good relational life. His modified Rankin score is 3. Decompressive craniectomy saved this patient's life, that is why we think this surgical technique must be explained and mastered.

Comparison between autologous bone grafts and acrylic (PMMA) implants - A retrospective analysis of 286 cranioplasty procedures

Decompressive craniectomy (DC) is an accepted surgical technique for reducing life-threatening levels of intracranial pressure. Remodelling the cranial vault following DC can constitute a reconstructive challenge and is known to carry significant morbidity. The aim of our study was to evaluate acrylic versus autologous cranioplasty with regard to specific complication rates. A retrospective analysis was conducted of 286 consecutive adult patients who underwent cranioplasty following supratentorial decompressive craniectomy at our institution between January 2003 and June 2013. The patients were followed based on medical records, operative reports, imaging and outpatient contacts in the postoperative course. A total of 221/286 patients in our series received an autologous bone flap. 65/286 cranioplasty procedures were carried out using acrylic (PMMA) implants to cover uni- or bilateral defects. Within the follow-up period a total of 100 operative revisions were performed. 33.3% patients in the autologous bone group and 40.6% of patients in the acrylic group developed complications requiring surgical attention. The main reason for revision was infection with a total of 37 revisions necessary to treat disturbed wound healing. Postoperative sub- and epidural hematomas requiring revision were more frequent in the acrylic group. Resorption of the autologous bone flap requiring operative revision was seen in 8/222 (3.6%) cases. Other complications included loosening of the implant or dislocation. From our data it can be concluded that cranioplasty procedures using autologous bone-flaps and acrylic implants carry signifikant morbidity, but that both are justifiable techniques for cranioplasty in adult patients.

Decompressive Craniectomy for Traumatic Brain Injury: The Role of Cranioplasty and Hydrocephalus on Outcome

OBJECTIVE

After severe traumatic brain injury (sTBI) associated with uncontrollable high intracranial pressure (ICP), today the main challenge for neurosurgeons remains to identify who may obtain benefit from decompressive craniectomy (DC) and which factors after DC influence the prognosis of these patients. The aim of this paper was to identify the pre- and postoperative determinants of outcome after DC.

METHODS

This retrospective study included all patients undergoing DC for sTBI from 2003 to 2011. The 6-month outcome, assessed using the Glasgow Outcome Scale (GOS), was dichotomized into favorable (GOS scores 4 and 5) and unfavorable (GOS scores 1-3) outcome. Predictors of outcome were identified by uni- and multivariate analysis.

RESULTS

There were 190 patients who underwent DC for sTBI in this study. Sixty patients (31.6%) died within 30 days after DC. Independent prognostic factors for survival after 30 days were Glasgow Coma Scale score at admission greater than 5 (P = 0.002) and bilateral pupil reactivity (P < 0.0001). Thirty days after DC, 67 patients (51.5%) out of 130 had unfavorable outcome (GOS scores 1-3) and 63 patients (49.5%) presented favorable outcome (GOS scores 4 and 5). The independent preoperative prognostic factors for poor outcome were age over 65 years (P < 0.0001) and bilateral absence of pupil reactivity (P = 0.0165). After DC, onset of postoperative hydrocephalus and delayed cranioplasty (3 months after DC) was associated with unfavorable outcome at multivariate analysis (P = 0.002 and P < 0.0001, respectively).

CONCLUSIONS

In our study, the development of hydrocephalus after DC for sTBI and delayed cranial reconstruction were associated with unfavorable outcome.

Compare the Intracranial Pressure Trend after the Decompressive Craniectomy between Massive Intracerebral Hemorrhagic and Major Ischemic Stroke Patients

Objective

Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance.

Methods

One hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality.

Results

Initial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007).

Conclusion

The results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.

Bulging brains

Brain swelling is a serious condition associated with an accumulation of fluid inside the brain that can be caused by trauma, stroke, infection, or tumors. It increases the pressure inside the skull and reduces blood and oxygen supply. To relieve the intracranial pressure, neurosurgeons remove part of the skull and allow the swollen brain to bulge outward, a procedure known as decompressive craniectomy. Decompressive craniectomy has been preformed for more than a century; yet, its effects on the swollen brain remain poorly understood. Here we characterize the deformation, strain, and stretch in bulging brains using the nonlinear field theories of mechanics. Our study shows that even small swelling volumes of 28 to 56 ml induce maximum principal strains in excess of 30%. For radially outward-pointing axons, we observe maximal normal stretches of 1.3 deep inside the bulge and maximal tangential stretches of 1.3 around the craniectomy edge. While the stretch magnitude varies with opening site and swelling region, our study suggests that the locations of maximum stretch are universally shared amongst all bulging brains. Our model has the potential to inform neurosurgeons and rationalize the shape and position of the skull opening, with the ultimate goal to reduce brain damage and improve the structural and functional outcomes of decompressive craniectomy in trauma patients.

Decompressive Craniectomy in Traumatic Brain Injury: A Review Article

The importance of treating traumatic brain injury (TBI) is well known worldwide. Although many studies have been conducted in this topic, there is still much uncertainty about the effectiveness of surgical treatment in TBI. Recently, good randomized controlled trial (RCT) papers about the effectiveness of decompressive craniectomy (DC) in TBI has been published. In this article, we will review the overall contents of the DC (historical base, surgical technic, rationale, complications) and the results of the recently published RCT paper.

Complicações pós-operatórias em neurocirurgia eletiva e não eletiva

Resumo Objetivo Avaliar a incidência de complicações pós-operatorias e mortalidade entre pacientes submetidos a neurocirurcia eletiva e não eletiva. Metodos Estudo de coorte prospectivo com pacientes adultos, acompanhados desde o período pré-operatório até a alta hospitalar ou óbito. Resultados Foram incluídos 127 pacientes no grupo cirúrgico eletivo e 75 pacientes no grupo cirúrgico não eletivo. O grupo eletivo teve mais vômitos (p=0,010) e dor (p<0,001) e o grupo não eletivo apresentou mais hipertensão intracraniana (p=0,001), anisocoria (p=0,002), vasoespasmo cerebral (p=0,043), pupilas não fotorreagentes (p=0,006) e reoperação (p=0,046). A taxa de mortalidade foi de 5,5% no grupo de cirurgia eletiva e 26,7% no grupo de cirurgia não eletiva (p<0,001). Conclusão Os procedimentos eletivos em neurocirurgia estão relacionados a maior frequência de complicações sistêmicas, enquanto as cirurgias não eletivas tiveram taxas significativamente mais altas de complicações neurológicas e mortalidade.

Decompressive craniectomy in acute brain injury

Decompressive surgery to reduce pressure under the skull varies from a burrhole, bone flap to removal of a large skull segment. Decompressive craniectomy is the removal of a large enough segment of skull to reduce refractory intracranial pressure and to maintain cerebral compliance for the purpose of preventing neurologic deterioration. Decompressive hemicraniectomy and bifrontal craniectomy are the most commonly performed procedures. Bifrontal craniectomy is most often utilized with generalized cerebral edema in the absence of a focal mass lesion and when there are bilateral frontal contusions. Decompressive hemicraniectomy is most commonly considered for malignant middle cerebral artery infarcts. The ethical predicament of deciding to go ahead with a major neurosurgical procedure with the purpose of avoiding brain death from displacement, but resulting in prolonged severe disability in many, are addressed. This chapter describes indications, surgical techniques, and complications. It reviews results of recent clinical trials and provides a reasonable assessment for practice.

Measurement of Bone Flap Surface Area and Midline Shift to Predict Overall Survival After Decompressive Craniectomy

BACKGROUND

There is uncertainty about the optimal method for measuring the decompressive craniectomy (DC) surface area and how large the DC should be.

METHODS

A radiological technique for measuring the surface area of removed bone flaps in a series of 73 DCs was developed. Preoperative and early postoperative computed tomography scans of each patient were evaluated. Midline shift (MLS) was considered the key factor for successful DC and was assigned to either normal (0-4 mm) or pathological (≥5 mm) ranges. The association between postoperative MLS and patient survival at 12 months was assessed.

RESULTS

Measurements of all removed bone flaps yielded a mean surface area of 7759 mm². The surface area of the removed bone flap did not influence survival (surviving 7643 mm² vs. deceased 7372 mm²). The only factor associated with survival was reduced postoperative MLS (P < 0.034). Risk of death was 14.4 (3.0-70.1)-fold greater in patients with postoperative shift ≥5 mm (P < 0.001).

CONCLUSION

The ideal surface area for "large" square bone flaps should result in an MLS of <5 mm. Enlargement of the craniectomy edges should be considered for patients in whom MLS ≥5 mm persists according to early postoperative computed tomography scans.

Decompressive Craniectomy for Severe Traumatic Brain Injury: A Systematic Review

OBJECTIVE

Systematic review of the literature to evaluate the role of decompressive craniectomy (DC) after severe traumatic brain injury (TBI), comparing the first major randomized clinical trial on this topic (DECRA) with subsequent literature.

METHODS

A systematic literature search was performed from 2011 to 2015. Citations were selected using the following inclusion criteria: closed severe TBI and DC. Exclusion criteria included most patients ≤18 years old, ≤20 participants, review articles, DC for reasons other than TBI, or surgical procedures other than DC. Primary outcomes included mortality and Glasgow Outcome Scale (GOS) at discharge, 6 months, and 1 year after injury. Assessment of risk of bias of the randomized controlled trials was also performed.

RESULTS

Only 12 of 5528 articles satisfied the eligibility criteria; of these studies, 3 were randomized controlled trials. DC in specific populations does not offer GOS or mortality advantages compared with medical treatment; on the other hand, when DC with open dural flap was compared with an alternative means of decompression, e.g., DC with multiple dural stabs, the latter showed significant advantage in mortality and GOS. Nonrandomized studies showed decreased mortality and increased GOS in patients aged ≤50 years when DC was performed <5 hours after TBI and with Glasgow Coma Scale score >5.

CONCLUSIONS

Our study underscores the importance of continued international prospective data collection for assessing types of surgical interventions in addition to DC and their timing in patients who have severe TBI. In addition, in geographic areas with limited access to advanced medical treatment for severe TBI, DC is of benefit when performed <5 hours after injury in younger patients with Glasgow Coma Scale >5.

Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications

OBJECTIVE

To analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy.

METHODS

Retrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed.

RESULTS

A total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome.

CONCLUSION

This study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population.

The role of decompressive craniectomy in children with severe traumatic brain injury

OBJECTIVE

Severe traumatic brain injury (TBI) remains the leading cause of death in children. The present study analyses the outcome of children after severe TBI treated by decompressive craniectomy (DC) due to elevated intracranial pressure (ICP) in a single centre.

METHODS

Fifty-six consecutive children (age < 16 years) were treated for severe TBI at our institution between 2001 and 2011. For study purposes, children with severe generalized traumatic brain swelling without concomitant mass lesion were further analysed. Descriptive statistics were used to report clinical conditions as well as outcome measurements after conservative treatment only in comparison to secondary decompressive craniectomy.

RESULTS

Of 56 children, a total of eight children presented with generalized and progressive traumatic brain swelling and impending brain herniation. Four children were treated conservatively following standardized local protocol for anti-oedematous management, with ICP amenable to intensified therapy. Four children required decompressive surgery due to progressive oedema refractory to intensified conservative management. Children receiving secondary DC had a longer stay in the intensive care unit as well as a longer average time of assisted ventilation compared to children treated conservatively. Concomitant injuries were more severe in the DC subgroup. Yet, Glasgow Outcome Scale was equally distributed in both groups.

CONCLUSION

In children with refractory ICP conditions due to severe TBI, decompressive surgery might lead to a similar favourable outcome compared to children in whom ICP can be controlled only by conservative management. Timing of surgery depends on the neurological deterioration of the patients and a continuous ICP monitoring.

Clinical applications of intracranial pressure monitoring in traumatic brain injury : report of the Milan consensus conference

BACKGROUND

Intracranial pressure (ICP) monitoring has been for decades a cornerstone of traumatic brain injury (TBI) management. Nevertheless, in recent years, its usefulness has been questioned in several reports. A group of neurosurgeons and neurointensivists met to openly discuss, and provide consensus on, practical applications of ICP in severe adult TBI.

METHODS

A consensus conference was held in Milan on October 5, 2013, putting together neurosurgeons and intensivists with recognized expertise in treatment of TBI. Four topics have been selected and addressed in pro-con presentations: 1) ICP indications in diffuse brain injury, 2) cerebral contusions, 3) secondary decompressive craniectomy (DC), and 4) after evacuation of intracranial traumatic hematomas. The participants were asked to elaborate on the existing published evidence (without a systematic review) and their personal clinical experience. Based on the presentations and discussions of the conference, some drafts were circulated among the attendants. After remarks and further contributions were collected, a final document was approved by the participants. The group made the following recommendations: 1) in comatose TBI patients, in case of normal computed tomography (CT) scan, there is no indication for ICP monitoring; 2) ICP monitoring is indicated in comatose TBI patients with cerebral contusions in whom the interruption of sedation to check neurological status is dangerous and when the clinical examination is not completely reliable. The probe should be positioned on the side of the larger contusion; 3) ICP monitoring is generally recommended following a secondary DC in order to assess the effectiveness of DC in terms of ICP control and guide further therapy; 4) ICP monitoring after evacuation of an acute supratentorial intracranial hematoma should be considered for salvageable patients at increased risk of intracranial hypertension with particular perioperative features.

Decompressive craniectomy for management of traumatic brain injury: an update

Decompressive craniectomy (DC) for the management of severe traumatic brain injury (TBI) has a long history but remains controversial. Although DC has been shown to improve both survival and functional outcome in patients with malignant cerebral infarctions, evidence of benefit in patients with TBI is decidedly more mixed. Craniectomy can clearly be life-saving in the presence of medically intractable elevations of intracranial pressure. Craniectomy also has been consistently demonstrated to reduce "therapeutic intensity" in the ICU, to reduce the need for intracranial-pressure-directed and brain-oxygen-directed interventions, and to reduce ICU length of stay. Still, the only randomized trial of DC in TBI failed to demonstrate any benefit. Studies of therapies for TBI, including hemicraniectomy, are challenging owing to the inherent heterogeneity in the pathophysiology observed in this disease. Craniectomy can be life-saving for patients with severe TBI, but many questions remain regarding its ideal application, and the outcome remains highly correlated with the severity of the initial injury.

Specific intensive care management of patients with traumatic brain injury: Present and future

Traumatic brain injury (TBI) is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation (BTF) 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.

Intracranial hypertension in subarachnoid hamorrhage: outcome after decompressive craniectomy

Intracranial hypertension can occur following aneurysmal subarachnoid haemorrhage (SAH). It can be treated with decompressive craniectomy (DC) with the aim of reducing intracranial pressure, increasing cerebral perfusion and reducing further morbidity and mortality. We studied the outcome of patients undergoing DC following SAH at our institution, to ascertain whether the use of this treatment can be rationalized.

Feasibility of the custom-made titanium cranioplasty CRANIOTOP(®)

Background:

With decompressive craniectomy for ischemic stroke, traumatic brain injury, and skull-infiltrating tumors, the need for cranioplasty has increased. Different materials for custom-made cranioplasties have been evaluated, but a gold standard could not yet be established. We report our experience with the new custom-made titanium CRANIOTOP^®cranioplasty (CL Instruments, Germany).

Methods:

A total of 50 consecutive patients received a CRANIOTOP cranioplasty within a 2 year interval. We reviewed the charts for time between initial surgery and cranioplasty, indication, complications, operative time, and cosmetic outcome. Postoperative imaging (computed tomography [CT] scan n = 48, magnetic resonance imaging (MRI) n = 5) was screened for fitting accuracy and for hemorrhages.

Results:

The most common indication for craniectomy were diffuse edema due to traumatic brain injury (n = 17, 34%) and ischemic stroke (n = 12, 24%). All patients were satisfied with the cosmetic result. In the postoperative CT scan accurate fitting was confirmed in all patients, the postoperative MRI was free of artifacts. Surgical revision was necessary in five patients because of empyema (n = 2), wound exposure (n = 2), and one cerebrospinal fluid fistula. Thus, the surgical morbidity was 10%.

Conclusion:

With due consideration of the limitations of this retrospective study, we feel the present data allow concluding that the custom-made titanium cranioplasty CRANIOTOP^®is safe and feasible.

Decompressive craniectomy: past, present and future

Decompressive craniectomy (DC)--a surgical procedure that involves removal of part of the skull to accommodate brain swelling--has been used for many years in the management of patients with brain oedema and/or intracranial hypertension, but its place in contemporary practice remains controversial. Results from a recent trial showed that early (neuroprotective) DC was not superior to medical management in patients with diffuse traumatic brain injury. An ongoing trial is investigating the clinical and cost effectiveness of secondary DC as a last-tier therapy for post-traumatic refractory intracranial hypertension. With regard to ischaemic stroke (malignant middle cerebral artery infarction), a recent Cochrane review concluded that DC improves survival compared with medical management, but that a higher proportion of DC survivors experience moderately severe or severe disability. Although many patients have a good outcome, the issue of DC-related disability raises important ethical issues. As DC and subsequent cranioplasty are associated with a number of complications, indiscriminate use of this surgery is not appropriate. Here, we review the evidence and present considerations regarding surgical technique, ethics and cost-effectiveness of DC. Prospective clinical trials and cohort studies are essential to enable optimization of patient care and outcomes.

Outcome following evacuation of acute subdural haematomas: a comparison of craniotomy with decompressive craniectomy

BACKGROUND

Acute subdural haematomas (ASDH) occur commonly following traumatic brain injury and may be evacuated by either craniotomy (CR) or decompressive craniectomy (DC). We reviewed a series of consecutive patients undergoing evacuation of a traumatic ASDH at a regional centre, comparing observed clinical outcomes (assessed by Glasgow Outcome Scale at six months) with those predicted by the CRASH-CT prognostic model.

METHODS

Retrospective review of prospectively collected data.

RESULTS

Ninety-one patients were identified (51 DC and 40 CR ). Eighty-five had available admission data sets from which predicted outcome could be calculated. The DC group were younger than the CR group (p = 0.015). The DC group also had a greater proportion of patients whose pre-intubation GCS was ≤8 (p = 0.001), with significant extracranial injuries (p = 0.001) and obliterated basal cisterns (p = 0.001) on their pre-operative CT scan. Bone flaps in the DC group (n = 45) were longer (mean 11.6 cm; 95 % CI: 11.1-12.1) in comparison to bone flaps in the CR (n = 34) group [(mean 10.2 cm; 95 % CI: 9.35 - 10.9); p = 0.0024] The mean CRASH-CT predicted risk of 14-day mortality and of unfavourable outcome at six months was significantly higher in the DC group compared with the CR group. Eighty-eight patients had available 6-month Glasgow Outcome Scale scores. Favourable outcomes were observed in 42 % of DC versus 45 % of CR (p = 0.83). The overall mortality rate was 38 % in DC versus 32 % in CR (p = 0.65). The standardised morbidity ratio (observed/expected unfavourable outcomes) was 0.75 (95 % CI: 0.51-1.07) for DC and 0.90 (95 % CI: 0.57-1.35) for CR.

CONCLUSIONS

CR and DC for traumatic ASDH are both commonly used for primary evacuation of ASDH. Primary DC may be more effective than CR for selected patients with ASDH. Class I evidence is required in order to refine the indications for DC following evacuation of ASDH.