To Retain or Remove the Bone Flap During Evacuation of Acute Subdural Hematoma: Factors Associated with Perioperative Brain Edema

Decompressive Bone Flap Replacement (Decompressive Cranioplasty): A Novel Technique for Intracranial Hypertension-Initial Experience and Outcome

BACKGROUND

 Intracranial hypertension is a life-threatening condition that can be treated by decompressive craniectomy (DC), which involves removing a part of the skull and intracranial lesions. However, DC has many complications and requires a second surgery to repair the skull. Decompressive bone flap replacement (DBFR) or decompressive cranioplasty is a novel technique that replaces the bone flap with a titanium mesh, providing both decompression and skull integrity.

METHODS

 The materials and methods of DBFR are described in detail. A three-dimensional titanium mesh is fabricated based on the computed tomography (CT) data of previous DC patients. An appropriate titanium mesh is selected based on the preoperative and intraoperative assessments. After removing the intracranial lesions, the titanium mesh is fixed over the bone window.

RESULTS

 We successfully performed DBFR in three emergent cases. The postoperative CT scan showed adequate decompression in all cases. No reoperation for skull repair was needed, and there were no surgical complications. The cosmetic outcome was excellent. There were no relevant complications in the operative area.

CONCLUSIONS

 DBFR may be a safe and effective alternative to DC in a specific subgroup of patients, in whom complete removal of the bone flap is feasible. DBFR can reduce intracranial pressure while maintaining the integrity of the skull cavity, eliminating the need for additional surgery for skull repair. Possible improvements for DBFR in the future are suggested, such as using a greater curvature of the titanium mesh or a modified DBFR with a hinged titanium mesh.

Comparison of craniotomy and decompressive craniectomy for acute subdural hematoma: a meta-analysis of comparative study

BACKGROUND

Acute subdural hematoma (ASDH) necessitates urgent surgical intervention. Craniotomy (CO) and decompressive craniectomy (DC) are the two main surgical procedures for ASDH evacuation. This meta-analysis is to compare the clinical outcomes between the CO and DC procedures.

MATERIALS AND METHODS

The authors performed a meta-analysis according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA, Supplemental Digital Content 1, http://links.lww.com/JS9/C513 , Supplemental Digital Content 2, http://links.lww.com/JS9/C514 ) Statement protocol and assessing the methodological quality of systematic reviews (AMSTAR) (Supplemental Digital Content 3, http://links.lww.com/JS9/C515 ) guideline. The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched. Comparative studies reporting the outcomes of the CO and DC procedures in patients with ASDH were included.

RESULTS

A total of 15 articles with 4853 patients [2531 (52.2%) receiving CO and 2322 (47.8%) receiving DC] were included in this meta-analysis. DC was associated with higher mortality [31.5 vs. 40.6%, odds ratio (OR)=0.58, 95% CI: 0.43-0.77] and rate of patients with poorer neurological outcomes (54.3 vs. 72.7%; OR=0.43, 95% CI: 0.28-0.67) compared to CO. The meta-regression model identified the comparability of preoperative severity as the only potential source of heterogeneity. When the preoperative severity was comparable between the two procedures, the mortality (CO 35.5 vs. DC 38.1%, OR=0.80, 95% CI: 0.62-1.02) and the proportion of patients with poorer neurological outcomes (CO 64.8 vs. DC 66.0%; OR=0.82, 95% CI: 0.57-1.16) were both similar. Reoperation rates were similar between the two procedures (CO 16.1 vs. DC 16.0%; OR=0.95, 95% CI: 0.61-1.48).

CONCLUSION

Our meta-analysis reveals that DC is associated with higher mortality and poorer neurological outcomes in ASDH compared to CO. Notably, this difference in outcomes might be driven by baseline patient severity, as the significance of surgical choice diminishes after adjusting for this factor. Our findings challenge previous opinions regarding the superiority of CO over DC and underscore the importance of considering patient-specific characteristics when making surgical decisions. This insight offers guidance for surgeons in making decisions tailored to the specific conditions of their patients.

Comparative efficacy of craniotomy versus craniectomy in surgical management of acute subdural hematoma: A systematic review and meta-analysis

INTRODUCTION

Acute subdural hematoma (ASDH), a predominantly lethal neurosurgical emergency in the settings of traumatic brain injury, requires surgical evacuation of hematoma, via craniotomy or craniectomy. The clinical practices vary, with no consensus over the superiority of either procedure.

AIM

To evaluate whether craniotomy or craniectomy is the optimal approach for surgical evacuation of ASDH.

METHODS

After a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) up to January 2024, to identify relevant studies, a meta-analysis was performed using a random-effects model, and risk ratios were calculated with 95% confidence intervals (CIs). For quality assessment, the Cochrane risk of bias tool and Newcastle-Ottawa Scale were applied.

RESULTS

Out of 2143 potentially relevant studies, 1875 were deemed suitable for screening. Eighteen studies were included in the systematic review. Thirteen studies, in which 1589 patients underwent craniotomy and 1452 patients underwent craniectomy, allowed meta-analysis. Pooled estimates showed that there was no significant correlation of mortality at 6 months (RR 1.14;95 % CI; 0.94-1.38 P = 0.18) and 12 months (RR 1.17; 95 % CI; 0.84-1.63 P = 0.36) with the two surgical modalities. A positive association was observed between improved functional outcomes at 6-months and craniotomy (RR 0.76; 95 % CI; 0.62-0.93 P = 0.008), however, no significant difference was observed between the two treatment groups at 12 months follow-up (RR 0.89; 95 % CI; 0.72-1.09 P = 0.26). Craniotomy reported a significantly higher proportion of patients discharged to home (RR 0.63; 95 % CI; 0.49-0.83 P = 0.0007), whereas incidence of residual subdural hematoma was significantly lower in the craniectomy group (RR 0.70; 95 % CI; 0.52-0.94 P = 0.02).

CONCLUSION

Craniectomy is associated with poor clinical outcomes. However, with long-term follow-up, no difference in mortality and functional outcomes is observed in either of the patient populations. On account of equivocal evidence regarding the efficacy of craniectomy over craniotomy in the realm of long-term outcomes, utmost preference shall be directed toward craniotomy as it is less invasive and associated with fewer complications.

A comprehensive systematic review and meta-analysis study in comparing decompressive craniectomy versus craniotomy in patients with acute subdural hematoma

There are two controversial surgery methods which are traditionally used: craniotomy and decompressive craniectomy. The aim of this study was to evaluate the efficacy and complications of DC versus craniotomy for surgical management in patients with acute subdural hemorrhage (SDH) following traumatic brain injury (TBI). We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Embase up to July 30, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Relevant articles were reviewed, with a focus on studies comparing decompressive craniectomy to craniotomy techniques in patients with SDH following TBI. Ten studies in 2401 patients were reviewed. A total of 1170 patients had a craniotomy, and 1231 had decompressive craniectomy. The mortality rate was not significantly different between the two groups (OR: 0.46 [95% CI: 0.42-0.5] P-value: 0.07). The rate of revision surgery was insignificantly different between the two groups (OR: 0.59 [95% CI: 0.49-0.69] P-value: 0.08). No significant difference was found between craniotomy and decompressive craniectomy regarding unilateral mydriasis (OR: 0.46 [95% CI: 0.35-0.57] P-value < 0.001). However, the craniotomy group had significantly lower rates of non-pupil reactivity (OR: 0.27 [95% CI: 0.17-0.41] P-value < 0.001) and bilateral mydriasis (OR: 0.59 [95% CI: 0.5-0.66] P-value: 0.04). There was also no significant difference in extracranial injury between the two groups, although the odds ratio of significant extracranial injury was lower in the craniotomy group (OR: 0.58 [95% CI: 0.45-0.7] P-value: 0.22). Our findings showed that non-pupil and bilateral-pupil reactivity were significantly more present in decompressive craniectomy. However, there was no significant difference between the two groups regarding mortality rate, extracranial injury, revision surgery, and one-pupil reactivity.

Surgical application of endoscopic-assisted minimally-invasive neurosurgery to traumatic brain injury: Case series and review of literature

BACKGROUND/PURPOSE

Adequate decompression is the primary goal during surgical management of patients with traumatic brain injury (TBI). Therefore, it may seem counterintuitive to use minimally-invasive strategies to treat these patients. However, recent studies show that endoscopic-assisted minimally-invasive neurosurgery (MIN) can provide both adequate decompression (which is critical for preserving viable brain tissue) and maximize neurological recovery for patients with TBI. Hence, we reviewed the pertinent literature and shared our experiences on the use of MIN.

METHODS

This was a retrospective multi-center study. We collected data of 22 TBI patients receiving endoscopic-assisted MIN within 72 hours after the onset, with Glasgow Coma Scale (GCS) scores of 6-14 and whose hemorrhage volume ranging from 30 to 70 mL.

RESULTS

We have applied MIN techniques to a group of 22 patients with traumatic ICH (TICH), epidural hematoma (EDH), and subdural hematoma (SDH). The mean pre-operative GCS score was 7.5 (median 7), and mean hemorrhage volume was 57.14 cm³ Surgery time was shortened with MIN approaches to a mean of 59.6 min. At 6-month follow-up, the mean GCS score had improved to 12.3 (median 15). By preserving more normal brain tissue, MIN for patients with TBI can result in beneficial effects on recoveries and neurological outcomes.

CONCLUSION

Endoscopic-assisted MIN in TBI is safe and effective in a carefully selected group of patients.

Mortality Outcome of Emergency Decompressive Craniectomy and Craniotomy in the Management of Acute Subdural Hematoma: A National Data Analysis

BACKGROUND

The purpose of the study is to evaluate the in-hospital mortality of patients who presented with acute subdural hematoma (SDH) and underwent emergency decompressive craniectomy (DC) or craniotomy (CO) within 4 hours of hospital arrival.

METHOD

The National Trauma Data Bank (NTDB) dataset of the calendar year of 2007 through 2010 was accessed for the study. All blunt severe head injury patients who presented with acute SDH were included in the study. Severe head injury is defined as a head Abbreviated Injury Scale (AIS) score ≥3 and a Glasgow Coma Scale (GCS) score ≤8. Univariate followed by propensity-matched analyses were performed to compare the two procedure groups: DC and CO.

RESULTS

Out of 2370 patients, 518, (21.9%) patients underwent DC. There were significant differences found in the univariate analysis between the DC and CO groups for median age (38 (IQR: 22.0, 55.0) vs 49 (IQR: 27, 67), P < .001), mechanism of injury (fall: 33.2% vs 50.7%; motor vehicle crashes: 58.3% vs 40.9%, P < .001), and median injury severity score (ISS: 26.0 (IQR: 25, 38) vs 26 (IQR: 25.0, 33.0), P < .001). After propensity score matching and pair-matched analysis, no differences were found with any of the above characteristics. The pair-matched analysis also showed no significant difference in in-hospital mortality (42.7% vs 37.5%, P = .10) between the DC vs CO groups.

CONCLUSION

The overall in-hospital mortality for emergency CO or DC for the evacuation of SDH remains high. The preference of one operative procedure over the other did not impact overall mortality.

In-hospital mortality and length of hospital stay with craniotomy versus craniectomy for acute subdural hemorrhage: a multicenter, propensity score-matched analysis

OBJECTIVE

The optimal surgical treatment for acute subdural hemorrhage (ASDH) remains controversial. The purpose of this study was to compare outcomes in patients who underwent craniotomy with those in patients who underwent decompressive craniectomy for the treatment of ASDH.

METHODS

Using the Japan Trauma Data Bank, a nationwide trauma registry, the authors identified patients aged ≥ 18 years with ASDH who underwent surgical evacuation after blunt head trauma between 2004 and 2015. Logistic regression analysis was used to estimate a propensity score to predict decompressive craniectomy use. They then used propensity score-matched analysis to compare patients who underwent craniotomy with those who underwent decompressive craniectomy. To identify the potential benefits and disadvantages of decompressive craniectomy among different subgroups, they estimated the interactions between treatment and the subgroups using logistic regression analysis.

RESULTS

Of 236,698 patients who were registered in the database, 1788 were eligible for propensity score-matched analysis. The final analysis included 514 patients who underwent craniotomy and 514 patients who underwent decompressive craniectomy. The in-hospital mortality did not differ significantly between the groups (41.6% for the craniotomy group vs 39.1% for the decompressive craniectomy group; absolute difference -2.5%; 95% CI -8.5% to 3.5%). The length of hospital stay was significantly longer in patients who underwent decompressive craniectomy (median 23 days [IQR 4-52 days] vs 30 days [IQR 7-60 days], p = 0.005). Subgroup analyses demonstrated qualitative interactions between decompressive craniectomy and the patient subgroups, suggesting that patients who were more severely injured (Glasgow Coma Scale score < 9 and probability of survival < 0.64) and those involved in high-energy injuries may be good candidates for decompressive craniectomy.

CONCLUSIONS

The results of this study showed that overall, decompressive craniectomy did not appear to be superior to craniotomy in ASDH treatment in terms of in-hospital mortality. In contrast, there were significant differences in the effectiveness of decompressive craniectomy between the subgroups. Thus, future studies should prioritize the identification of a subset of patients who will possibly benefit from the performance of each of the procedures.

Using titanium mesh to replace the bone flap during decompressive craniectomy: A medical hypothesis

Decompressive craniectomy (DC) plays a significant role in treating refractory intracranial hypertension. During this surgical procedure, part of the skull is removed and the underlying dura mater is open, which can effectively release intracranial pressure. However, in some cases, the decision whether or not to remove the bone flap relies on the surgeon's personal experience. Positive decisions are usually made to avoid massive postoperative cerebral edema and infarction, which can lead to overtreatment. The procedure is related to many side-effects, which may affect the recovery of neurological function. Patients who have survived have to be anesthetized and undergo secondary cranioplasty 3 or 6 months later. Despite its technical simplicity, complications associated with cranioplasty are hard to ignore. Therefore, there is a need for a new surgical procedure combining decompressive craniectomy and cranioplasty. Acute expansion of the skin flap is limited, and the compensatory capacity of the skull after DC depends on the volume of the bone flap at the early stage. The titanium mesh is thin and strong, does not take up extra space provided by bone flap. Therefore, we put forward the concept of Decompressive Bone Flap Replacement. During this procedure, neurosurgeons resect the massive bone flap, open the dura mater, remove the hematoma in a similar manner to a standard craniotomy and then use titanium mesh shaped appropriately to replace the bone flap. Compared with traditional DC, it can ensure the integrity of the skull without affecting the effect of decompression. This paper presents 2 cases of DC and reviews the literature sustaining our hypothesis.

Twist drill craniostomy for traumatic acute subdural hematoma in the elderly: case series and literature review

Background

A large craniotomy is usually the first choice for removal of traumatic acute subdural hematoma (TASDH). To date, few studies have reported that TASDH could be successfully treated by twist drill craniostomy (TDC) alone or combined with instillation of urokinase. We aimed to define the TDC for the elderly with TASDH and performed literature review.

Case presentation

A total of 7 TASDH patients, who were presented and treated by TDC in this retrospective study between January 2009 and May 2017, consisted of 5 men and 2 women, ranging in age from 65 to 89 (average, 78.9) years. The patients’ baseline characteristics, including age, sex, medical history, received ventriculoperitoneal shunt for hydrocephalus or not, reason for avoiding or refusing large craniotomy, preoperative Glasgow Coma Scale (GCS), suffered from cerebral herniation or not, the location of TASDH, imaging characteristics of TASDH in CT scan, injury/surgery time interval, midline shift, preoperative neurologic deficit, operation time, and infusions of urokinase or not, were collected. The postoperative GCS, postoperative neurologic deficit, rebleeding or not, intracranial infection, and modified Rankin Scale (mRS) at 6 months after surgery were analyzed to access the safety and efficacy of evacuation with TDC. The results showed that the mean time interval from injury to TDC was 68.6 min (30–120 min). The mean distance of midline shift was 14.6 mm (10–20 mm). The preoperative GCS in all patients ranged from 4 to 13(median, 9). The mean duration of the operation was 14.4 min (6–19 min). Postoperative CT scan showed that hematoma evacuation rate was more than 70% in all cases. There were no cases of acute rebleeding and intracranial infection after TDC. No cases presented with chronic SDH at the ipsilateral side within 6 months after being treated by TDC alone or combined with instillation of urokinase. Favorable outcomes were shown in all cases (mRS scores 0–2) at 6 months after surgery.

Conclusions

TASDH in the elderly could be safely and effectively treated by TDC alone or combined with instillation of urokinase, which was a possible alternative for the elderly.

[Surgical techniques for severe brain injury : With special emphasis on polytrauma]

CLINICAL ISSUE

In Austria approximately 2000 people suffer from severe brain injury per year. Brain trauma is the most common cause of death under the age of 45 years. In polytrauma patients the treatment and management of severe brain injury is particularly challenging because the life-threatening injuries of other organ systems significantly influence the timing of surgery and the outcome. The sequence of the necessary surgery is an interdisciplinary decision already made in the emergency room. The evacuation of space-occupying intracranial hemorrhage can be of secondary importance.

STANDARD TREATMENT

The standard approach for acute subdural hematoma is a craniotomy using a large question mark-shaped incision (trauma flap) and decompression. In acute epidural hematoma and impression fractures the localization of the lesion determines the surgical approach and evacuation. A variety of access procedures are available. Frontobasal injuries are extremely rarely an indication for an emergency operation for life-threatening injuries. Decompressive craniotomy is performed as for craniotomy for acute subdural hematoma by the standard trauma flap.

DIAGNOSTIC WORK-UP

Emergency room computed tomography provides fast and accurate information about the localization and extent of brain injury.

PERFORMANCE

The mortality of acute subdural hematoma ranges between 50-90% despite an adequate evacuation. Outcome of epidural hematoma has a much better prognosis (10% mortality). The results of decompressive craniectomy versus conservative treatment for moderate disability and good recovery are quite similar according to the randomized evaluation of surgery with craniectomy for uncontrolled elevation of intracranial pressure (RESCUE-ICP) study.

PRACTICAL RECOMMENDATION

Interdisciplinary cooperation and communication and well-trained trauma surgeons with experience in brain trauma are key factors in the treatment of severe brain injury in polytrauma patients.

Severe Traumatic Brain Injury Requiring Surgical Decompression in the Young Adult: Factors Influencing Morbidity and Mortality - A Retrospective Analysis

INTRODUCTION

Severe traumatic brain injury (TBI) is a leading cause of morbidity and mortality among young adults. The clinical outcome may also be difficult to predict. We aim to identify the factors predictive of favorable and unfavorable clinical outcomes for youthful patients with severe TBI who have the option of surgical craniotomy or surgical craniectomy.

METHODS

A retrospective review at a single Level II trauma center was conducted, identifying patients aged 18 to 30 years with isolated severe TBI with a mass-occupying lesion requiring emergent (< 6 hours from time of arrival) surgical decompression. Glasgow Coma Scale (GCS) score on arrival, type of surgery performed, mechanism of injury, length of hospital stay, Glasgow Outcome Score (GOS), mortality, and radiographic findings were recorded. A favorable outcome was a GOS of four or five at 30 days post operation, while an unfavorable outcome was GOS of 1 to 3.

RESULTS

Fifty patients were included in the final analysis. Closed head injuries (skull and dura intact), effacement of basal cisterns, disproportional midline shift (MLS), and GCS 3-5 on arrival all correlated with statistically significant higher rate of mortality and poor 30-day functional outcome. All mortalities (6/50 patients) were positive for each of these findings.

CONCLUSIONS

Closed head injuries, the presenting GCS 3-5, the presence of MLS disproportional to the space occupying lesion (SOL), and effacement of basal cisterns on the initial computed tomography of the head all correlated with unfavorable 30-day outcome. Future prospective studies investigating a larger cohort may provide further insight into patients suffering from severe TBI.