Bilateral decompressive craniectomy for worsening coma in acute subarachnoid hemorrhage. Observations in support of the procedure

Management of Poor-Grade Aneurysmal Subarachnoid Hemorrhage and Key Pearls for Achieving Favorable Outcomes: An Illustrative Case

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high patient mortality. Despite recent advances in management strategies, the prognosis for poor-grade aSAH remains dismal. We present a challenging case of a patient presenting with poor-grade aSAH. A 46-year-old female presented to the emergency department after losing consciousness following a sudden headache. The examination showed a dilated left pupil and a Glasgow Coma Scale of 4. Imaging revealed a ruptured anterior communicating artery (ACoM) aneurysm, after which the patient was subsequently taken to the neuro-interventional radiology suite. We showed that carefully managing blood pressure and intracranial pressure (ICP) makes it possible to achieve a favorable outcome and reduce the risk of secondary brain injury in aSAH, regardless of patient presentation. We propose maintaining blood pressure at <160 mmHg prior to intervention, after which it can be permitted to increase to 160-240 mmHg for the purpose of preventing vasospasm. Additionally, transcranial doppler (TCD) is essential to detect vasospasm due to the subtility of symptoms in patients with aSAH. Once identified, vasospasm can be successfully treated with balloon angioplasty. Finally, targeted temperature management (TTM), mannitol, hypertonic saline, and neuromuscular paralysis are essential for the postoperative management of ICP levels.

Delayed Progressive Mass Effect After Secured Ruptured Middle Cerebral Artery Aneurysm: Risk Factors and Outcomes

Objective

Delayed progressive mass effect (DPME) after securing an aneurysm is uncommon following microsurgical or endovascular repair and leads to a poor clinical outcome. Patients with ruptured middle cerebral artery (MCA) aneurysms have a high risk of postoperative oedema and mass effect, which may require decompressive treatment. Because few studies have discussed the risk and predictive factors, we focused on ruptured MCA aneurysms and evaluated the outcomes of these patients and the necessity of salvage surgery when DPME presented.

Methods

Data on 891 patients with aneurysmal subarachnoid haemorrhage (aSAH) treated between January 2011 and February 2020 were extracted from the medical database of a tertiary referral centre. A total of 113 patients with aSAH resulting from at least one MCA aneurysm were identified. After excluding patients with several clinical confounders, we enrolled 80 patients with surgically treated aSAH. We examined the characteristics of aneurysms and hematomas, perioperative contrast pooling patterns, presence of distal hematomas, perisylvian low density, occlusive treatment modality, management strategies, the need for salvage surgical decompression, and postoperative 90-day outcomes to identify possible risk factors.

Results

DPME was observed in 27 of the 80 patients (33.7%). The DPME and non-DPME group differed significantly in some respects. The DPME group had a higher risk of salvage surgery (p < 0.001) and poorer outcomes (mRS at day 90; p = 0.0018). The univariate analysis indicated that the presence of hematoma, CTA spot signs, perisylvian low density, and distal hematoma were independent risk factors for DPME. We also noted that DPME remained an independent predictor of a poorer 90-day functional outcome (mRS ≤ 2).

Conclusion

DPME can lead to salvage decompression surgery and directly relates to poor outcomes for patients with a ruptured MCA aneurysm. Distal hematoma, perisylvian low density, and CTA spot signs on preoperative images can predict DPME.

Outcomes of high-grade aneurysmal subarachnoid hemorrhage patients treated with coiling and ventricular intracranial pressure monitoring

BACKGROUND

High-grade aneurysmal subarachnoid hemorrhage is a devastating disease with a low favorable outcome. Elevated intracranial pressure is a substantial feature of high-grade aneurysmal subarachnoid hemorrhage that can result to secondary brain injury. Early control of intracranial pressure including decompressive craniectomy and external ventricular drainage had been reported to be associated with improved outcomes. But in recent years, little is known whether external ventricular drainage and intracranial pressure monitoring after coiling could improve outcomes in high-grade aneurysmal subarachnoid hemorrhage.

AIM

To investigate the outcomes of high-grade aneurysmal subarachnoid hemorrhage patients with coiling and ventricular intracranial pressure monitoring.

METHODS

A retrospective analysis of a consecutive series of high-grade patients treated between Jan 2016 and Jun 2017 was performed. In our center, followed by continuous intracranial pressure monitoring, the use of ventricular pressure probe for endovascular coiling and invasive intracranial pressure monitoring in the acute phase is considered to be the first choice for the treatment of high-grade patients. We retrospectively analyzed patient characteristics, radiological features, intracranial pressure monitoring parameters, complications, mortality and outcome.

RESULTS

A total of 36 patients were included, and 32 (88.89%) survived. The overall mortality rate was 11.11%. No patient suffered from aneurysm re-rupture. The intracranial pressure in 33 patients (91.67%) was maintained within the normal range by ventricular drainage during the treatment. A favorable outcome was achieved in 18 patients (50%) with 6 mo follow-up. Delayed cerebral ischemia and Glasgow coma scale were considered as significant predictors of outcome (2.066 and -0.296, respectively, P < 0.05).

CONCLUSION

Ventricular intracranial pressure monitoring may effectively maintain the intracranial pressure within the normal range. Despite the small number of cases in the current work, high-grade patients may benefit from a combination therapy of early coiling and subsequent ventricular intracranial pressure monitoring.

Resection of swollen temporal muscles in patients with intractable intracranial hypertension after decompressive craniectomy

BACKGROUND

Decompressive craniectomy is employed as treatment for traumatic brain swelling in selected patients. We discussed the effect of temporal muscle resection in patients with intractable intracranial hypertension and temporal muscle swelling after craniectomy.

METHODS

Records of 280 craniectomies performed on 258 patients who were admitted with severe head injury were retrospectively reviewed. Eight patients developed intractable increased intracranial pressure with temporal muscle swelling within 24 h after craniectomy and were treated by muscle resection.

RESULTS

The initial Glasgow Coma Scale score was 7 ± 1. The mean intracranial pressure was 41.7 ± 8.59 mmHg before muscle resection and 14.81 ± 8.07 mmHg immediately after surgery. Five patients had skull fracture and epidural hematoma at the craniectomy site. The mean intensive care unit stay was 11.25 ± 5.99 days. Glasgow Outcome Scale-Extended scoring performed during the 12-month follow-up visit showed that 6 patients (75%) had a favorable outcome.

CONCLUSIONS

Our study findings indicate that a direct impact on the temporal region during trauma may lead to subsequent temporal muscle swelling. Under certain circumstances, muscle resection can effectively control intracranial pressure.

Role of decompressive craniectomy in the management of poor-grade aneurysmal subarachnoid hemorrhage: short- and long-term outcomes in a matched-pair study

OBJECTIVE

To evaluate the short- and long-term therapeutic effect and possibility of decompressive craniectomy (DC) for patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Patients suffering from aSAH (Hunt-Hess grades IV, V) who underwent DC from January 2008 to April 2016 were enrolled in this study, and a sample-matched control group was set up. Information regarding participants' demography, clinical characteristics, and neuroimaging findings was systematically established. The outcome of a 6-month to 3-year follow-up was assessed according to the Glasgow outcome scale (GOS), modified Rankin Scale (mRS) and Barthel Index (BI).

RESULTS

Patients who had DC (21) experienced a statistically significant decrease in short-term mortality compared with those without DC (24, p < 0.05) and showed a decrease in intracranial pressure (ICP) after surgery. However, there was no significant difference in the long-term assessment (GOS/mRS/BI) between the two groups.

CONCLUSIONS

Some critical patients who have refractory ICP after poor-grade aSAH would benefit from DC for prolonging life in the short term if performed early. Nevertheless, the overall outcome for the long term remains disappointing, larger and longer prospective studies are urgently needed to investigate this issue.

The PRESSURE score to predict decompressive craniectomy after aneurysmal subarachnoid haemorrhage

The prognosis of patients with aneurysmal subarachnoid haemorrhage requiring decompressive craniectomy is usually poor. Proper selection and early performing of decompressive craniectomy might improve the patients’ outcome. We aimed at developing a risk score for prediction of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. All consecutive aneurysmal subarachnoid haemorrhage cases treated at the University Hospital of Essen between January 2003 and June 2016 (test cohort) and the University Medical Center Freiburg between January 2005 and December 2012 (validation cohort) were eligible for this study. Various parameters collected within 72 h after aneurysmal subarachnoid haemorrhage were evaluated through univariate and multivariate analyses to predict separately primary (PrimDC) and secondary decompressive craniectomy (SecDC). The final analysis included 1376 patients. The constructed risk score included the following parameters: intracerebral (‘Parenchymal’) haemorrhage (1 point), ‘Rapid’ vasospasm on angiography (1 point), Early cerebral infarction (1 point), aneurysm Sac > 5 mm (1 point), clipping (‘Surgery’, 1 point), age Under 55 years (2 points), Hunt and Hess grade ≥ 4 (‘Reduced consciousness’, 1 point) and External ventricular drain (1 point). The PRESSURE score (0–9 points) showed high diagnostic accuracy for the prediction of PrimDC and SecDC in the test (area under the curve = 0.842/0.818) and validation cohorts (area under the curve = 0.903/0.823), respectively. 63.7% of the patients scoring ≥6 points required decompressive craniectomy (versus 12% for the PRESSURE < 6 points, P < 0.0001). In the subgroup of the patients with the PRESSURE ≥6 points and absence of dilated/fixed pupils, PrimDC within 24 h after aneurysmal subarachnoid haemorrhage was independently associated with lower risk of unfavourable outcome (modified Rankin Scale >3 at 6 months) than in individuals with later or no decompressive craniectomy (P < 0.0001). Our risk score was successfully validated as reliable predictor of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. The PRESSURE score might present a background for a prospective randomized clinical trial addressing the utility of early prophylactic decompressive craniectomy in aneurysmal subarachnoid haemorrhage.

Bone Flap Changes after Cranioplasty Using Frozen Autologous Bone Flaps: A Three-Dimensional Volumetric Reconstruction Study

PURPOSE

Bone flap resorption (BFR) after cranioplasty with an autologous bone flap (ABF) is well known. However, the prevalences and degrees of BFR remain unclear. This study aimed to evaluate changes in ABFs following cranioplasty and to investigate factors related with BFR.

MATERIALS AND METHODS

We retrospectively reviewed 97 patients who underwent cranioplasty with frozen ABF between January 2007 and December 2016. Brain CT images of these patients were reconstructed to form three-dimensional (3D) images, and 3D images of ABF were separated using medical image editing software. ABF volumes on images were measured using 3D image editing software and were compared between images in the immediate postoperative period and at postoperative 12 months. Risk factors related with BFR were also analyzed.

RESULTS

The volumes of bone flaps calculated from CT images immediately after cranioplasty ranged from 55.3 cm³ to 175 cm³. Remnant bone flap volumes at postoperative 12 months ranged from 14.2% to 102.5% of the original volume. Seventy-five patients (77.3%) had a BFR rate exceeding 10% at 12 months after cranioplasty, and 26 patients (26.8%) presented severe BFR over 40%. Ten patients (10.3%) underwent repeated cranioplasty due to severe BFR. The use of a 5-mm burr for central tack-up sutures was significantly associated with BFR (p<0.001).

CONCLUSION

Most ABFs after cranioplasty are absorbed. Thus, when using frozen ABF, patients should be adequately informed. To prevent BFR, making holes must be kept to a minimum during ABF grafting.

Subcutaneous bone flap storage after emergency craniectomy: cost-effectiveness and rate of resorption

OBJECTIVEDecompressive craniectomy is used for uncontrolled intracranial pressure in traumatic brain injury and malignant hemispheric stroke. Subcutaneous preservation of the autologous bone flap in the abdomen is a simple, portable technique but has largely been abandoned due to perceived concerns of resorption. The authors sought to characterize their experience with subcutaneous preservation of the bone flap and cranioplasty.METHODSThe authors performed a retrospective single-institution review of subcutaneous preservation of the autologous bone flap after decompressive craniectomy from 2005 to 2015. The primary outcome was clinically significant bone resorption, defined as requiring a complete mesh implant at the time of cranioplasty, or delayed revision. The outcome also combined cases with any minor bone resorption to determine predictors of this outcome. Logistic regression modeling was used to determine the risk factors for predicting resorption. A cost comparison analysis was also used via the 2-sided t-test to compare the cost of cranioplasty using an autologous bone flap with standard custom implant costs.RESULTSA total of 193 patients with craniectomy were identified, 108 of whom received a cranioplasty. The mean time to cranioplasty was 104.31 days. Severe resorption occurred in 10 cases (9.26%): 4 were clinically significant (2 early and 2 late) and 6 demonstrated type II (severe) necrosis on CT, but did not require revision. Early resorption of any kind (mild or severe) occurred in 28 (25.93%) of 108 cases. Of the 108 patients, 26 (24.07%) required supplemental cranioplasty material. Late resorption of any kind (mild or severe) occurred in 6 (5.88%) of 102 cases. Of these, a clinically noticeable but nonoperative deformity was noted in 4 (3.92%) and minor (type I) necrosis on CT in 37 (37%) of 100. Bivariate analysis identified fragmentation of bone (OR 3.90, 95% CI 1.03-14.8), shunt-dependent hydrocephalus (OR 7.97, 95% CI 1.57-40.46), and presence of post-cranioplasty drain (OR 9.39, 95% CI 1.14-1000) to be significant risk factors for bone resorption. A binary logistic regression optimized using Fisher's scoring determined the optimal multivariable combination of factors. Fragmentation of bone (OR 5.84, 95% CI 1.38-28.78), diabetes (OR 7.61, 95% CI 1.37-44.56), and shunt-dependent hydrocephalus (OR 9.35, 95% CI 1.64-56.21) were found to be most predictive of resorption, with a C value of 0.78. Infections occurred in the subcutaneous pocket in 5 (2.60%) of the 193 cases and after cranioplasty in 10 (9.26%) of the 108 who underwent cranioplasty. The average cost of cranioplasty with autologous bone was $2156.28 ± $1144.60 (n = 15), and of a custom implant was $35,118.60 ± $2067.51 (3 different sizes; p < 0.0001).CONCLUSIONSCraniectomy with autologous bone cranioplasty using subcutaneous pocket storage is safe and compares favorably to cryopreservation in terms of resorption and favorably to a custom synthetic implant in terms of cost. While randomized data are required to definitively prove the superiority of one method, subcutaneous preservation has enough practical advantages with low risk to warrant routine use for most patients.

The 100-most Cited Articles About Craniectomy and Hemicraniectomy: A Bibliometric Analysis

Craniectomy is a life-saving procedure used in the setting of traumatic brain injury^, stroke and increased intracranial pressure. The purpose of this study was to analyze and determine the most influential articles and authors in the field of craniectomy. Our study presents an analysis of the articles that include the word "craniectomy" or "hemicraniectomy" in the title and a detailed analysis of the top 100-cited articles in that selection. This search provided insight into how this procedure was initially documented and how it has been utilized over the years. We used the SCOPUS database to search “craniectomy OR hemicraniectomy” in the article title. We then sorted the top 100 most-cited articles. Bibliometric analysis was performed. An H-index was presented with each author. The citation count ranged from 71 to 5310. The most published author was Werner Hacke, a German researcher (n=6). The highest quantity of influential work was published in 2006 and 2007 (n=9/yr). The United States published the most articles (n=42). The Journal of Neurosurgery published 21 of the top 100 most-cited articles. The chronological timeline shows the evolution of decompression as it related to both stroke and trauma. It demonstrated that well-cited articles acted as turning points to direct further scientific endeavors while highlighting the hard work of certain authors. There is, to the best of our knowledge, a shortage of literature on a bibliometric analysis regarding the term craniectomy. Thus, the current bibliometric study was undertaken to highlight the work of authors who have advanced knowledge about this procedure. It provides an analysis of the top 100-cited articles with craniectomy in the title with dates ranging from 1892 to 2016. A review of its publication history shows how interventions in this field have advanced over the last several decades.

Thick Clot in the Inferior Limiting Sulcus on Computed Tomography Image as an Indicator of Sylvian Subpial Hematoma in Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

Sylvian subpial hematoma (SSH) is occasionally observed in aneurysm subarachnoid hemorrhage (aSAH) when accompanied with the thick clot in the inferior limiting sulcus (ILS). We aimed to determine whether the thickness of the clot in the ILS (TCILS) was an indicator of SSH.

METHODS

Data from 150 consecutive patients with aSAH were retrospectively analyzed. The relationship between TCILS on axial computed tomography (CT) image and intraoperatively confirmed SSH was reviewed. In patients without SSH, the average of the clot thickness in the bilateral ILS was used. The primary outcome was SSH.

RESULTS

The median TCILS of the SSH group (n = 18, 12%) was larger than that of the non-SSH group (n = 132, 88%) (21 vs. 2.1 mm, respectively; P < 0.001). The intraclass correlation coefficients for clot thickness in the right and left ILS between 2 observers were 0.97 (P < 0.001) and 0.85 (P < 0.001). The TCILS threshold of ≥6.0 mm was associated with SSH, with a sensitivity of 89% and specificity of 99%. The unadjusted and adjusted odds ratios of the SSH of clot thickness in the affected ILS ≥6 mm relative to clot thickness in the affected ILS <6 mm were 263 (95% confidence interval [CI], 46-5063) and 137 (95% CI, 19-3029), respectively.

CONCLUSIONS

The clot thickness in the ILS on CT image was easily measured and could be a marker of SSH. SSH assessment could be useful in helping us predict the clinical course in patients with aSAH.

The Risk Factors of Subdural Hygroma after Decompressive Craniectomy

Objective

Subdural effusion, also known as subdural hygroma (SDG), is a secondary complication that can occur after decompressive craniectomy (DC). However, the pathogenesis of SDG is not fully understood. It is unclear whether SDG occurrence is related to preoperative patient status or surgical technique. The purpose of this study is to identify risk factors for SDG after DC.

Methods

Fifty-nine patients who underwent DC from January 2016 to December 2016 at the same institution were analyzed. We retrospectively reviewed the clinical and radiological features of the patients. We divided the patients into two groups based on the occurrence of SDG after DC. The risk factors for SDG were analyzed.

Results

The overall SDG rate after DC was 39% (23 patients). A statistically significant association was observed between preoperative diagnosis, e.g., subdural hemorrhage (SDH; odds ratio [OR], 4.99; 95% confidence interval [CI], 1.36–18.34) or subarachnoid hemorrhage (SAH; OR, 4.18; 95% CI, 1.07–16.32), and the occurrence of SDG after DC. Traumatic brain injury (OR, 4.91; 95% CI, 1.35–17.91) and preoperative cortical opening (OR, 4.77; 95% CI, 1.39–16.32) were important risk factors for SDG. Several surgical techniques did not show a statistically significant association with SDG. The occurrence of SDG after DC was related to the length of hospital stay (p=0.012), but not to prognosis.

Conclusion

After DC, SDG is not related to patients' prognosis but to the length of hospital stay. Therefore, it is necessary to study the occurrence of postoperative SDG by confirming the presence of preoperative SDH, SAH, and cortical opening.

Cranioplasty Using Autologous Bone versus Porous Polyethylene versus Custom-Made Titanium Mesh : A Retrospective Review of 108 Patients

Objective

The purpose of this study was to compare the cosmetic outcome and complications after cranioplasty (CP) due to three different implant materials, and analyze the mean implant survival and cumulative survival rate based on these results.

Methods

We reviewed 108 patients retrospectively who underwent CP between January 2014 and November 2016. Autologous bone (AB; 45 patients) and synthetic materials with porous polyethylene (PP; 32 patients) and custom-made 3-dimensional printed titanium mesh (CT; 31 patients) were used as implants.

Results

Regardless of implanted materials, more than 89.8% of the CP patients were satisfied with the cosmetic outcome. No statistically significant difference was observed among the three groups. The overall postoperative complication rates of each group were 31.1% in the AB group, 15.6% in the PP group and 3.2% in the CT group. The CT group showed lower complication rates compared with AB and PP groups (χ²-test : AB vs. PP, p=0.34; AB vs. CT, p=0.00; PP vs. CT, p=0.03). The AB and PP groups demonstrated a higher post-CP infection rate (11.1% and 6.3%) than the CT group (3.2%). However, no significant difference in the incidence of post-CP infection was observed among the three groups. The PP and CT groups demonstrated a higher mean implant survival time and cumulative survival rate than the AB group at the last follow-up (p<0.05).

Conclusion

In comparison with AB and PP, cranioplasty with CT shows benefits in terms of lower post-CP complication, less intraoperative bleeding loss, shorter operation time and in-hospital stay. The PP and CT groups showed higher implant survival time and cumulative survival rate compared with the AB group.

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.

A randomized controlled trial comparing autologous cranioplasty with custom-made titanium cranioplasty

OBJECTIVE Autologous bone is usually used to reconstruct skull defects following decompressive surgery. However, it is associated with a high failure rate due to infection and resorption. The aim of this study was to see whether it would be cost-effective to use titanium as a primary reconstructive material. METHODS Sixty-four patients were enrolled and randomized to receive either their own bone or a primary titanium cranioplasty. All surgical procedures were performed by the senior surgeon. Primary and secondary outcome measures were assessed at 1 year after cranioplasty. RESULTS There were no primary infections in either arm of the trial. There was one secondary infection of a titanium cranioplasty that had replaced a resorbed autologous cranioplasty. In the titanium group, no patient was considered to have partial or complete cranioplasty failure at 12 months of follow-up (p = 0.002) and none needed revision (p = 0.053). There were 2 deaths unrelated to the cranioplasty, one in each arm of the trial. Among the 31 patients who had an autologous cranioplasty, 7 patients (22%) had complete resorption of the autologous bone such that it was deemed a complete failure. Partial or complete autologous bone resorption appeared to be more common among young patients than older patients (32 vs 45 years old, p = 0.013). The total cumulative cost between the 2 groups was not significantly different (mean difference A$3281, 95% CI $-9869 to $3308; p = 0.327). CONCLUSIONS Primary titanium cranioplasty should be seriously considered for young patients who require reconstruction of the skull vault following decompressive craniectomy. Clinical trial registration no.: ACTRN12612000353897 ( anzctr.org.au ).

[Decompressive craniotomy in patients with intracranial aneurysmal hemorrhage]

Decompressive craniotomy (DCT) has been used for treatment of patients with acute aneurysmal subarachnoid hemorrhage (SAH) for more than 20 years. But so far, the attitude to this surgery is controversial, and the indications and contraindications for it are not clearly defined. The article reviews the domestic and foreign literature devoted to the issues of validity and efficacy of DCT in treatment of cerebral edema and intracranial hypertension in patients with aneurysmal SAH.

Intrasylvian hematoma caused by ruptured middle cerebral artery aneurysms predicts recovery from poor-grade subarachnoid hemorrhage

OBJECT

Intrasylvian hematoma (ISH) is a subtype of intracranial hematoma caused by aneurysmal rupture and often presents with a poor initial neurological grade; it is not well studied. The aim of this study was to elucidate outcomes of aneurysmal subarachnoid hemorrhage (SAH) with ISH.

METHODS

Data for 97 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grade IV or V) were retrospectively analyzed from a single-center, prospective, observational cohort database. Ultra-early surgical clipping, removal of hematoma, external decompression for brain swelling, and prevention of vasospasm by cisternal irrigation with milrinone were combined as an aggressive treatment. Characteristics and clinical courses of SAH with ISH were identified. The authors also evaluated any correlations between poor admission-grade SAH and ISH with good functional outcome.

RESULTS

Patients with poor admission-grade SAH and with ISH were more likely to have initial cerebral edema (p < 0.001, Mann-Whitney U-test), which significantly resolved overtime (p < 0.001, Mann-Whitney U-test). These patients had a better chance of functional survival (modified Rankin Scale scores of 1-3; OR 5.75; 95% CI 1.36-24.3; p = 0.017) at 6 months after hospital discharge, after adjustment for potential confounders such as younger age and better initial neurological grade by multivariable analysis.

CONCLUSIONS

ISH predicted good functional recovery from poor-grade aneurysmal SAH.

Decompressive Surgery in Patients with Poor-grade Aneurysmal Subarachnoid Hemorrhage: Clipping with Simultaneous Decompression Versus Coil Embolization Followed by Decompression

Objective

In addition to obliterating the aneurysm using clipping or coiling, decompressive surgery for control of rising intracranial pressure (ICP) is thought to be crucial to prevention of adverse outcomes in patients with poor grade aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the clinical characteristics of patients with poor-grade aSAH, and compared outcomes of aneurysmal clipping with simultaneous decompressive surgery to those of coil embolization followed by decompression.

Materials and Methods

In 591 patients with aSAH, 70 patients with H-H grade IV and V underwent decompressive surgery including craniectomy, lobectomy, and hematoma removal. We divided the patients into two groups according to clipping vs. coil embolization (clip group vs. coil group), and analyzed outcomes and mortality.

Results

Aneurysmal clipping was performed in 40 patients and coil embolization was performed in 30 patients. No significant differences in demographics were observed between the two groups. Middle cerebral artery and posterior circulation aneurysms were more frequent in the clip group. Among 70 patients, mortality occurred in 29 patients (41.4%) and 61 patients (87.1%) had a poor score on the Glasgow outcome scale (scores I-III). No significant difference in mortality was observed between the two groups, but a favorable outcome was more frequent in the coil group (p < 0.05).

Conclusion

In this study, despite aggressive surgical and endovascular management for elevated ICP, there were high rates of adverse outcomes and mortality in poor-grade aSAH. Despite poor outcomes overall, early coil embolization followed by decompression surgery could lead to more favorable outcomes in patients with poor-grade aSAH.

Cranioplasty with custom-made titanium plates--14 years experience

BACKGROUND

There is no consensus on which material is best suited for repair of cranial defects.

OBJECTIVE

To investigate the outcomes following custom-made titanium cranioplasty.

METHODS

The medical records for all patients who had titanium cranioplasty at 2 major neurosurgical centers in Western Australia were retrieved and analyzed for this retrospective cohort study.

RESULTS

Altogether, 127 custom-made titanium cranioplasties on 113 patients were included. Two patients had 3 titanium cranioplasties and 10 patients had 2. Infected bone flap (n = 61, 54%), either from previous craniotomy or autologous cranioplasty, and contaminated bone flap (n = 16, 14%) from the initial injury were the main reasons for requiring titanium cranioplasty. Complications attributed to titanium cranioplasty were common (n = 33, 29%), with infection being the most frequent complication (n = 18 patients, 16%). Complications were, on average, associated with an extra 7 days of hospital stay (interquartile range 2-17). The use of titanium as the material for the initial cranioplasty (P = .58), the presence of skull fracture(s) (P > .99) or scalp laceration(s) (P = .32) at the original surgery, and proven local infection before titanium cranioplasty (P = .78) were not significantly associated with an increased risk of infection. Infection was significantly more common after titanium cranioplasty for large defects (hemicraniectomy [39%] and bifrontal craniectomy [28%]) than after cranioplasty for small defects (P = .04).

CONCLUSION

Complications after using titanium plate for primary or secondary cranioplasty were common (29%) and associated with an increased length of hospital stay. Infection was a major complication (16%), and this suggested that more vigorous perioperative infection prophylaxis is needed for titanium plate cranioplasty.

Review and recommendations on management of refractory raised intracranial pressure in aneurysmal subarachnoid hemorrhage

Intracranial hypertension is commonly encountered in poor-grade aneurysmal subarachnoid hemorrhage patients. Refractory raised intracranial pressure is associated with poor prognosis. The management of raised intracranial pressure is commonly referenced to experiences in traumatic brain injury. However, pathophysiologically, aneurysmal subarachnoid hemorrhage is different from traumatic brain injury. Currently, there is a paucity of consensus on the management of refractory raised intracranial pressure in spontaneous subarachnoid hemorrhage. We discuss in this paper the role of hyperosmolar agents, hypothermia, barbiturates, and decompressive craniectomy in managing raised intracranial pressure refractory to first-line treatment, in which preliminary data supported the use of hypertonic saline and secondary decompressive craniectomy. Future clinical trials should be carried out to delineate better their roles in management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage patients.

Novel treatment targets for cerebral edema

Cerebral edema is a common finding in a variety of neurological conditions, including ischemic stroke, traumatic brain injury, ruptured cerebral aneurysm, and neoplasia. With the possible exception of neoplasia, most pathological processes leading to edema seem to share similar molecular mechanisms of edema formation. Challenges to brain-cell volume homeostasis can have dramatic consequences, given the fixed volume of the rigid skull and the effect of swelling on secondary neuronal injury. With even small changes in cellular and extracellular volume, cerebral edema can compromise regional or global cerebral blood flow and metabolism or result in compression of vital brain structures. Osmotherapy has been the mainstay of pharmacologic therapy and is typically administered as part of an escalating medical treatment algorithm that can include corticosteroids, diuretics, and pharmacological cerebral metabolic suppression. Novel treatment targets for cerebral edema include the Na(+)-K(+)-2Cl(-) co-transporter (NKCC1) and the SUR1-regulated NC(Ca-ATP) (SUR1/TRPM4) channel. These two ion channels have been demonstrated to be critical mediators of edema formation in brain-injured states. Their specific inhibitors, bumetanide and glibenclamide, respectively, are well-characterized Food and Drug Administration-approved drugs with excellent safety profiles. Directed inhibition of these ion transporters has the potential to reduce the development of cerebral edema and is currently being investigated in human clinical trials. Another class of treatment agents for cerebral edema is vasopressin receptor antagonists. Euvolemic hyponatremia is present in a myriad of neurological conditions resulting in cerebral edema. A specific antagonist of the vasopressin V1A- and V2-receptor, conivaptan, promotes water excretion while sparing electrolytes through a process known as aquaresis.

Decompressive craniectomy - operative technique and perioperative care

With improvements in neurocritical care advanced measures of treating raised intracranial pressure (ICP) are more frequently utilised. Decompressive craniectomy is an effective ICP-lowering procedure; however its benefits are maximised with optimal surgical technique and perioperative care, as well as by paying attention to possible complications. This article focuses on the current indications and rationale for decompressive craniectomy, and the surgical technique of bifrontal and unilateral decompression. The key surgical points include a large craniectomy window and opening of the dura, leaving it unsutured or performing a wide non-constricting duroplasty. Perioperative care and possible complications are also discussed.

Risk factors associated with subdural hygroma after decompressive craniectomy in patients with traumatic brain injury : a comparative study

OBJECTIVE

Subdural hygroma (SDG) is a complication occurring after head trauma that may occur secondary to decompressive craniectomy (DC). However, the mechanism underlying SDG formation is not fully understood. Also, the relationship between the operative technique of DC or the decompressive effect and the occurrence and pathophysiology of SDG has not been clarified. Purpose of this study was to investigate the risk factors of SDG after DC in our series.

METHODS

From January 2004 to December 2008, DC was performed in 85 patients who suffered from traumatic brain injury. We retrospectively reviewed the clinical and radiological features. For comparative analysis, we divided the patients into 2 groups : one group with SDG after craniectomy (19 patients; 28.4% of the total sample), the other group without SDG (48 patients; 71.6%). The risk factors for developing SDG were then analyzed.

RESULTS

The mean Glasgow Outcome Scale (GOS) scores at discharge of the groups with and without SDG were 2.8 and 3.1, respectively (p<0.0001). Analysis of radiological factors showed that a midline shift in excess of 5 mm on CT scans was present in 19 patients (100%) in the group with SDG and in 32 patients (66.7%) in the group without SDG (p<0.05). An accompanying subarachnoid hemorrhage (SAH) was seen in 17 patients (89.5%) in the group with SDG and in 29 patients (60.4%) in the group without SDG (p<0.05). Delayed hydrocephalus accompanied these findings in 10 patients (52.6%) in the group with SDG, versus 5 patients (10.4%) in the group without SDG (p<0.05). On CT, compression of basal cisterns was observed in 14 members (73.7%) in the group with SDG and in 18 members of the group without SDG (37.5%) (p<0.007). Furthermore, tearing of the arachnoid membrane, as observed on CT, was more common in all patients in the group with SDG (100%) than in the group without SDG (31 patients; 64.6%) (p<0.05).

CONCLUSION

GOS showed statistically significant difference in the clinical risk factors for SDG between the group with SDG and the group without SDG. Analysis of radiological factors indicated that a midline shifting exceeding 5 mm, SAH, delayed hydrocephalus, compression of basal cisterns, and tearing of the arachnoid membrane were significantly more common in patients with SDG.

Life-saving decompressive craniectomy for diffuse cerebral edema during an episode of new-onset diabetic ketoacidosis: case report and review of the literature

PURPOSE

Diabetic ketoacidosis (DKA), a well-known complication of diabetes mellitus, is associated with severe diffuse cerebral edema leading to brain herniation and death. Survival from an episode of symptomatic cerebral edema has been associated with debilitating neurological sequelae, including motor deficits, visual impairment, memory loss, seizures, and persistent vegetative states. A review of the literature reveals scant information regarding the potential surgical options for these cases. The authors present their case in which they used a craniectomy to treat this life-threatening condition.

METHODS

After reportedly suffering nausea and vomiting, a 12-year-old male presented to the emergency room with lethargy and was diagnosed with acute DKA. After appropriate treatment, the patient became comatose. A CT scan revealed diffuse cerebral edema. To decrease intracranial pressure and prevent further progression of brain herniation, a bifrontal decompressive craniectomy with duraplasty was performed.

RESULTS

The patient's neurological function gradually improved, and he returned to school and his regular activities with only minimal cognitive deficits.

CONCLUSION

Given the high mortality and morbidity associated with DKA-related edema, we believe decompressive craniectomy should be considered for malignant cerebral edema and herniation syndrome.

“In-window” craniotomy and “bridgelike” duraplasty: an alternative to decompressive hemicraniectomy

Object

The object of this study was to propose an alternative procedure to the classic decompressive hemicraniectomy using an “in-window” craniotomy and a “bridgelike” duraplasty.

Methods

The authors performed a large, almost rectangular craniotomy involving the frontal, temporal, and parietal bones and part of the occipital squama in 5 patients. The dura mater is opened and its area is enlarged using a rectangular dural patch of the surgeon's choice in the form of a bridge between the anterior and posterior dural edges. With a vertical cut, the bone flap is divided into 2 similarly sized pieces that function as “window lids.” The outer frontal and occipital sides of the bone are tied to the skull border at 2 points to function as a hinge joint. The angle of the bone cut must be beveled outward (inclination ~ 45° of the bone drill or saw) to allow the bone flap to rest on the adjacent skull and prevent its slippage toward the intracranial cavity.

Results

The above procedures were performed with effective control of intracranial hypertension due to cerebral venous sinus thrombosis, brain trauma, intracerebral hematoma, or malignant cerebral ischemia.

Conclusions

Decompressive surgery, which uses an in-window craniotomy that gradually opens according to the intracranial pressure, is an alternative solution for deploying autologous material. The procedure has the advantage of obviating the need for a second surgical procedure to close the bone defect, and thus preventing the metabolic cerebral impairment associated with the absence of an overlying skull.

Decompressive craniectomy for neurotrauma: the limitations of applying an outcome prediction model

BACKGROUND

There is currently much interest in the use of decompressive craniectomy for patients with severe head injury. A number of studies have demonstrated that not only can the technique lower intracranial pressure but can also improve outcome. Whilst many patients who would otherwise have died or had a poor outcome now go on to make a good recovery, there is little doubt that complications can have a very significant impact on long term outcome.

METHODS

By using the corticosteroid randomisation after significant head injury (CRASH) collaborators outcome prediction model, three patients were selected who had a similar outcome prediction. All three patients developed intracranial hypertension following trauma and had a decompressive craniectomy.

RESULTS

Despite having a similar outcome prediction only one patient made an uneventful recovery. The remaining two patients suffered significant complications.

CONCLUSIONS

This report illustrates the potential clinical applications and limitations of an outcome prediction model and demonstrates the impact that complications can have on eventual outcome.

The current status of decompressive craniectomy

Decompressive Craniectomy (DC) continues to be widely practiced but remains controversial. The procedure has its origins thousands of years ago, with early trepanation performed for a range of medical and religious reasons. We summarize the history, techniques, complications and pathophysiology and then explore in detail the recent evidence base for the most common indications for DC; Traumatic brain injury (TBI) and Cerebral infarction. An important consideration from the outset is the often forgotten issue of cranioplasty and we summarize advances in materials, technology and discuss the optimum timing. Outcomes of ongoing randomized trials in TBI are awaited with interest but the trend in the nonrandomized literature suggests timely intervention reduces mortality with acceptable morbidity. Level 1 evidence for early DC in young patients with malignant middle cerebral artery infarction has arrived and has implications for neurosurgical practice and rehabilitation services. Current European and North American practice recommends the judicious use of DC in traumatic brain injury and malignant middle cerebral artery infarction in select patients.

Emergent Clipping without Prophylactic Decompressive Craniectomy in Patients with a Large Aneurysmal Intracerebral Hematoma

OBJECTIVE

Many vascular neurosurgeons tend to remove bone flap in patients with large aneurysmal intracerebral hematomas (ICH). However, relatively little work has been done regarding the effectiveness of prophylactic decompressive craniectomy in a patient with a large aneurysmal ICH.

METHODS

Large ICH was defined as hematoma when its volume exceeded 25 mL, ipsilateral to aneurysms. The patients were divided into two groups; aneurysmal subarachnoid hemorrhage (SAH) associated with large ICH, January, 1994 - December, 1999 (Group A, 41 patients), aneurysmal SAH associated with large ICH, January, 2000 - May, 2005 (Group B, 27 patients). Demographic and clinical variables including age, sex, hypertension, vasospasm, rebleeding, Hunt-Hess grade, aneurysm location, aneurysm size, and outcome were compared between two groups, and also compared between craniotomy and craniectomy patients in Group A.

RESULTS

In Group A, 21 of 41 patients underwent prophylactic decompressive craniectomy. In Group B, only two patients underwent craniectomy. Surgical outcome in Group A (good 23, poor 18) was statistically not different from Group B (good 15, poor 12). Surgical outcomes between craniectomy (good 12, poor 9) and craniotomy cases (good 11, poor 9) in Group A were also comparable.

CONCLUSION

We recommend that a craniotomy can be carried out safely without prophylactic craniectomy in patients with a large aneurysmal ICH if intracranial pressure is controllable with hematoma evacuation.

Use of decompressive craniectomy in the treatment of hemispheric infarction

Decompressive craniectomy (DC) has demonstrated efficacy in reducing mortality in hemispheric infarction of the middle cerebral artery. The aim of our study was to compare the outcome of patients submitted to DC to patients treated in a conservative way. Eighteen patients were submitted to DC and 14 received conservative treatment. Neurological status was assessed by the Glasgow Coma Score and National Institutes of Health Stroke Scale score. Mortality, modified Rankin Scale and Barthel Index scores were assessed at 90 days to evaluate outcome. We did not observe reduction in overall mortality and functional outcome in patients submitted to DC. The differences between our group and previously published series are probably related to the neurological status of the patients at the time of therapeutic decision.

Decompressive Craniectomy

Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies is retrospective, the recent publication of several randomized prospective studies prompts a reevaluation of the utility of DC. We review the literature concerning the use of DC in TBI, MCA infarction, and SAH and address the evidence regarding common questions pertaining to the timing of and laterality of the procedure. We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.

Severe intracranial bleedings during endovascular procedures: outcome of surgically treated patients

OBJECTIVE

Severe intracranial bleedings (SIBs) during endovascular procedures (EPs) are accompanied by acute intracranial hypertension and brain herniation signs. The purpose of this study was to determine the effectiveness of urgent surgical management and its related patient outcome in cases with such a fatal complication.

METHOD

Medical records were reviewed retrospectively for the last 750 patients treated in our department in the past 12 years with acute non-traumatic intracranial bleeding, who underwent a diagnostic or therapeutic EP. Patients with a severe intra-procedural bleeding episode undergoing urgent surgical management (within 30 minutes after bleeding) were analysed.

RESULTS

Fourteen of 750 patients with ruptured vascular malformations presented a new SIB during EP. In nine patients, this occurred during initial angiography, two during aneurysm coiling, two during balloon angioplasty and one during arteriovenous malformation (AVM) embolization. The neurological condition 6 months later was good (independents patients) in seven cases with only a mild disability in two of them. Two patients showed a severe disability. Four patients died without recovering their consciousness. One patient presented a satisfactorily course but died weeks later owing to a pulmonary embolism.

CONCLUSION

Despite the fatal spontaneous prognosis of severe intracranial bleeding occurring during endovascular diagnostic or therapeutic procedures, a favorable outcome can be expected if an appropriated treatment was set within 30 minutes of the bleeding.

Decompressive hemicraniectomy for the treatment of intractable intracranial hypertension after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Decompressive hemicraniectomy and duroplasty (DHCD) can improve survival in patients with severe cerebral edema. We present our clinical experience with DHCD for the treatment of refractory elevated intracranial pressure (ICP) in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

DHCD was performed in 16 patients (11 female; median age, 49.5 years) with aSAH (11 Hunt-Hess grade 4 to 5) for sustained ICP >250 mm H(2)O refractory to maximal medical treatment and cerebrospinal fluid drainage at a median of 2 days from admission. Half of the patients were treated with endovascular coiling and the other half with surgical clipping.

RESULTS

DHCD (mean flap size, 8536 mm(2)) reduced ICP from 350+/-157 to 147+/-124 mm H(2)O. Eleven patients survived (69%), and at latest follow-up (median, 450 days), 7 (64%) had a modified Rankin score of 0 to 3 and 4 (36%) a score of 4 to 5. Peak herniated brain volume was inversely associated with good outcome (P<0.005). Early craniectomy performed within 48 hours after the aSAH was associated with better outcome: 6 of 8 patients had good outcomes (75%) compared with 1 of 8 patients in whom late decompression was performed (P<0.01). Midline shift, Hunt-Hess grade, presence of hemorrhage, hematoma volume, craniectomy area, peak ICP, and relative ICP reduction were not associated with outcome in this patient population.

CONCLUSIONS

DHCD is a useful adjunct modality for management of refractory intracranial hypertension in patients with high-grade aSAH, even in the absence of large intraparenchymal hemorrhage. In our series, long-term outcome was better in patients who underwent early intervention.

Decompressive hemicraniectomy in patients with subarachnoid hemorrhage and intractable intracranial hypertension

BACKGROUND AND PURPOSE

To evaluate the outcome of patients with aneurysmal subarachnoid hemorrhage (aSAH) developing intractable intracranial hypertension and treated by decompressive hemicraniectomy (DHC).

METHODS

Of 193 patients with aSAH 38 patients were treated with DHC after early aneurysm clipping. Indications for DHC were 1. Signs of brain swelling during aneurysm surgery (group 1: primary DHC). 2. Intracranial pressure- (ICP)-elevation and epidural, subdural or intracerebral hematoma after aneurysm surgery (group 2: secondary DHC due to hematoma) 3. Brain edema and elevated ICP without radiological signs of infarction (group 3: secondary DHC without infarction). 4. Brain edema and elevated ICP with radiological signs of infarction (group 4: secondary DHC with infarction).

RESULTS

Thirty-one patients (81.6%) suffered from high grade aSAH Hunt & Hess 4-5. 21 belonged to group 1, five to group 2, six to group 3 and six to group 4. Of a total of 38 patients a good functional outcome according to Glasgow Outcome Score (GOS 4 & 5) could be reached in 52.6% of the cases. 26.3% survived severely disabled (GOS 3), no case suffered from a vegetative state (GOS 2) but 21.1% died (GOS 1). After 12 months good functional outcome could be achieved in 52.4% of the cases in group 1, in 60% in group 2, in 83.3% in group 3 and in 16.7% in group 4.

CONCLUSIONS

In more than half of the patients with intractable intracranial hypertension after aSAH a good functional outcome could be achieved after DHC. Patients with progressive brain edema without radiological signs of infarction and those with hematoma may benefit most. The indication for DHC should be set restrictively if secondary infarcts are manifest.

Outcome after surgical decompression of severe traumatic brain injury

One of the factors that affects outcome following severe traumatic brain injury is development and progression of cerebral oedema with associated increase in intracranial pressure (ICP). Uncontrolled elevations of ICP may compromise energy metabolism of the injured brain and lead to secondary injury, affecting neurological outcome of the patient. Decompressive craniectomy has been used for over a century as a treatment of refractory brain swelling in a variety of neurological conditions. However, conclusive evidence of whether it has a beneficial or adverse affect on outcome is lacking. This article reviews the existing evidence on the role of decompressive craniectomy in management of patients with traumatic brain injury and stresses the need for randomised controlled trials.

Decompressive craniectomy in traumatic brain injury: outcome following protocol-driven therapy

Although decompressive craniectomy following traumatic brain injury is an option in patients with raised intracranial pressure (ICP) refractory to medical measures, its effect on clinical outcome remains unclear. The aim of this study was to evaluate the outcome of patients undergoing this procedure as part of protocol-driven therapy between 2000-2003. This was an observational study combining case note analysis and follow-up. Outcome was assessed at an interval of at least 6 months following injury using the Glasgow Outcome Scale (GOS) score and the SF-36 quality of life questionnaire. Forty-nine patients underwent decompressive craniectomy for raised and refractory ICP (41 [83.7%] bilateral craniectomy and 8 [16.3%] unilateral). Using the Glasgow Coma Scale (GCS), the presenting head injury grade was severe (GCS 3-8) in 40 (81.6%) patients, moderate (GCS 9-12) in 8 (16.3%) patients, and initially mild (GCS 13-15) in 1 (2.0%) patient. At follow-up, 30 (61.2%) patients had a favorable outcome (good recovery or moderate disability), 10 (20.48) remained severely disabled, and 9 (18.4%) died. No patients were left in a vegetative state. Overall the results demonstrated that decompressive craniectomy, when applied as part of protocol-driven therapy, yields a satisfactory rate of favorable outcome. Formal prospective randomized studies of decompressive craniectomy are now indicated.

Role of Decompressive Surgery in the Management of Severe Head Injuries: Prognostic Factors and Patient Selection

Decompressive surgery or craniectomy (DC) is a treatment option, which should be considered when the intracranial pressure (ICP) cannot be treated by conservative methods. The purpose of this study was to evaluate the benefits of decompressive craniectomy in patients with intractable posttraumatic intracranial hypertension and to evaluate the patient selection criteria for this management protocol. In this study, 100 patients with severe head injuries were involved. All patients were treated according to the European Brain Injury Consortium (EBIC) guidelines for severe head injuries and were assessed based on individual initial Glasgow Coma Scores (GCS), age, Glasgow Outcome Score (GOS), presence of systemic injury, changes in ICP, presence of mass lesion and the right timing for DC. All patients presented with a GCS of 8 or below. Based on their initial GCS, the patients were divided in two groups of 60 (group I with GCS 4-5) and 40 (group II with GCS 6-8) in each, respectively. Prognosis was evaluated according to the (GOS). After treatment with DC, 84 of the patients (84%) showed unfavorable and 16 (16%) showed favorable outcomes. In group I, 58 patients (96.6%) showed unfavorable and two (3.4%) showed favorable outcomes. In group II, 26 (65%) patients showed unfavorable and 14 (25%) showed favorable outcomes. The importance of initial GCS and age in patient outcomes were statistically significant. The presence of systemic injuries or mass lesions in outcomes were not statistically significant. Based on our findings, we conclude that patients with Glasgow Coma Scores of 6-8 are the best candidates for DC treatment.

The role of decompressive craniectomy in the management of traumatic brain injury: a critical review

Brain swelling and intracranial hypertension following severe head injury are known to contribute to secondary brain damage, and have been shown to adversely affect patient outcome. The use of unilateral craniectomy following the evacuation of a mass lesion, such as acute subdural haematoma or traumatic intracerebral haematoma, is accepted practice. The following review focuses on a bi-fronto-temporal decompressive craniectomy, used as an isolated operation for the control of intracranial hypertension, secondary to diffuse brain swelling refractory to medical management. Though the operation is being increasingly used, current opinion is still divided regarding its overall effects on outcome. This review examines the experimental and clinical evidence for and against the use of decompressive craniectomy, highlights the lack of class I evidence relevant to this topic and emphasises the necessity for well-designed prospective randomised controlled trials.

[Decompressive craniectomy in malignant infarction of the middle cerebral artery]

INTRODUCTION

Medically managed malignant infarction of the middle cerebral artery (MCA) is associated with an 80% mortality rate. However, several studies report a 40-50% increase in survival rates when decompressive craniectomy is performed. We present our experience with such surgical treatment and a literature review.

PATIENTS AND METHODS

Seven decompressive craniectomies were performed on five patients for spaceoccupying MCA infarctions. Age ranged from 33 to 57 years-old (three males and two females). Preoperative GCS score was 9-13. Cranial CT was performed within the first 12 hours. Intracranial pressure (ICP) was continuously measured in four patients. Two infarcts occurred in the dominant hemisphere and three in the non-dominant side. Wide fronto-parieto-temporal craniectomies were performed. The duramater was opened and a large heterologous dura graft was placed.

RESULTS

Surgery was performed on the second day after the onset of symptoms (median: 47 hours). Preoperative ICP ranged from 27 to 50 mmHg (median: 30.5 mmHg), with immediate postoperative ICP under 15 mmHg in all patients. Two patients (both non-dominant side) survived with good (after reoperation) and excellent functional outcome. They remain stable after ten and five months of follow-up. Three patients died five, five and thirteen days after admission due to uncontrollable high ICP. In our experience, bone removal itself was more relevant than dural opening for ICP control. Initial wide craniectomies may spare reoperations.

CONCLUSION

The significant mortality rate reduction, a wide therapeutic window (2-3 days) and a low incidence of intraoperative complications make decompressive craniectomy a relevant treatment in malignant cerebral MCA infarction.

Proposed use of prophylactic decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas

OBJECTIVE

As a group, patients who present in poor neurological grade after aneurysmal subarachnoid hemorrhage (SAH) often have poor outcomes. There may be subgroups of these patients, however, in which one pathological process predominates and for which the initiation of specific therapeutic interventions that target the predominant pathological process may result in improved outcome. We report the use of prophylactic decompressive craniectomy in patients presenting in poor neurological condition after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas. Craniectomy allowed significant parenchymal swelling in the posthemorrhagic period without increased intracranial pressure (ICP) or herniation syndrome.

METHODS

Eight patients (mean age, 56.5 yr; age range, 42-66 yr) presented comatose with SAH (five Hunt and Hess Grade IV, three Hunt and Hess Grade V). Radiographic evaluations demonstrated middle cerebral artery aneurysm and associated large sylvian fissure hematoma (mean clot volume, 121 ml; range, 30-175 ml). Patients were brought emergently to the operating room and treated with a modification of the pterional craniotomy and aneurysm clipping that included a planned craniectomy and duraplasty. A large, reverse question mark scalp flap was created, followed by bone removal with the following margins: anterior, frontal to the midpupillary line; posterior at least 2 cm behind the external auditory meatus; superior up to 2 cm lateral to the superior sagittal sinus; and inferior to the floor of the middle cranial fossa. Generous duraplasty was performed using either pericranium or suitable, commercially available dural substitutes.

RESULTS

All of the eight patients tolerated the craniectomy without operative complications. Postoperatively, all patients experienced immediate decreases in ICP to levels at or below 20 mm Hg (presentation mean ICP, 31.6 mm Hg; postoperative mean ICP, 13.1 mm Hg). ICP control was sustained in seven of eight patients, with the one exception being due to a massive hemispheric infarction secondary to refractory vasospasm. Follow-up (> or = 1 yr, except for one patient who died during the hospital stay) demonstrated that the craniectomy patients had a remarkably high number of good or excellent outcomes. The outcomes in the hemicraniectomy group were five good or excellent, one fair, and two poor or dead.

CONCLUSION

The data gathered in this study demonstrate that decompressive craniectomy can be performed safely as part of initial management for a subcategory of patients with SAH who present with large sylvian fissure hematomas. In addition, the performance of decompressive craniectomy in the patients described in this article seemed to be associated with rapid and sustained control of ICP. Although the number of patients in this study is small, the data lend support to the hypothesis that decompressive craniectomy may be associated with good or excellent outcome in a carefully selected subset of patients with SAH.