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Kapapa T, Jesuthasan S, Schiller F, Schiller F, Oehmichen M, Woischneck D, Mayer B, Pala A. Outcome after Intracerebral Haemorrhage and Decompressive Craniectomy in Older Adults. Neurol Int 2024; 16:590-604. [PMID: 38804483 PMCID: PMC11130851 DOI: 10.3390/neurolint16030044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age). METHODS Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV-V) and unfavourable outcome (GOS I to III). RESULTS 56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years). CONCLUSION Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities.
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Affiliation(s)
- Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Stefanie Jesuthasan
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Frederike Schiller
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Franziska Schiller
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Marcel Oehmichen
- Department of Neurosurgery, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Dieter Woischneck
- Department of Neurosurgery, Hospital Landshut, Robert-Koch-Strasse 1, 84034 Landshut, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Schwabstrasse 13, 89075 Ulm, Germany
| | - Andrej Pala
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Decompressive Craniectomy in Severe Traumatic Brain Injury: The Intensivist's Point of View. Diseases 2023; 11:diseases11010022. [PMID: 36810536 PMCID: PMC9944486 DOI: 10.3390/diseases11010022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical-surgical consultation.
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Muacevic A, Adler JR, Dighe O, Iratwar S, Bisen G. Decompressive Craniectomy in the Management of Low Glasgow Coma Score Patients With Extradural Hematoma: A Review of Literature and Guidelines. Cureus 2023; 15:e33790. [PMID: 36819419 PMCID: PMC9927871 DOI: 10.7759/cureus.33790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/15/2023] [Indexed: 01/16/2023] Open
Abstract
An extradural hematoma (EDH), also known as an epidural hematoma, is a collection of blood between the inner skull table and the dura mater. It is restricted by the coronal, lambdoid, and sagittal sutures, as these are dural insertions. EDH most frequently occurs in 10- to 40-year-old patients. EDH is uncommon after age 60, as dura matter adheres firmly to the inner skull table. EDH is more common among men as compared to women. EDH most commonly occurs in the temporo-frontal regions and can also be seen in the parieto-occipital, parasagittal regions, and middle and posterior fossae. An EDH contributes approximately 2% of total head injuries and 15% of total fatal head injuries. In EDH, patients typically have a persistent, severe headache, and also, following a few hours of injury, they gradually lose consciousness. The primary bleeding vessels for EDH are the middle meningeal artery, middle meningeal vein, and torn dural venous sinuses. EDH is one of the many consequences of severe traumatic brain injuries that might lead to death. EDH is potentially a lethal condition that requires immediate intervention as, if left untreated, it can lead to growing transtentorial herniation, diminished consciousness, dilated pupils, and other neurological problems. Non-contrast computed tomography (NCCT) imaging is the gold standard of investigation for diagnosing EDH. For patients with surgical indications, early craniotomy and evacuation of acute extradural hematoma (AEDH) is the gold standard procedure and is predicted to have significant clinical results. Nevertheless, there is an ongoing debate regarding the best surgical operations for AEDH. Neurosurgeons must choose between a decompressive craniectomy (DC) or a craniotomy to manage EDH, especially in patients with low Glasgow coma scores, to have a better prognosis and clinical results. This is a consultant-based review article in which we have tried to contemplate various pieces of available literature. Here, the objective is to hypothesize DC as the primary surgical management for massive hematoma, which usually presents as a low Glasgow coma score. This is because DC was found to be beneficial in clinical practice.
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Comparative Study of Micro-Bone Window and Conventional Bone Window Microsurgery for Hypertensive Intracerebral Hemorrhage. J Craniofac Surg 2020; 31:1030-1033. [PMID: 32118662 DOI: 10.1097/scs.0000000000006259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To compare and analyze the efficacy and safety of traditional craniotomy and small bone window craniotomy in the treatment of hypertensive cerebral hemorrhage (HICH). PATIENTS AND METHODS Fifty-four patients with HICH treated with traditional craniotomy and small bone window craniotomy were retrospectively analyzed. The operation time, hospitalization time, preoperative, and postoperative CT analysis, Glasgow coma scale (GCS) score and Glasgow outcome scale (GOS) scores were analyzed. RESULTS There were no significant differences in gender, age, hematoma volume, GCS score and pre-operative time between the 2 groups (P > 0.05). The operation time and hospitalization time of the micro-bone window group were shorter than those of the traditional operation group (P < 0.05). The GCS and GOS scores of the small bone window group after 3 days and 6 months were higher than those of the traditional operation group (P < 0.05). However, there was no significant difference in hematoma clearance rate, re-bleeding rate and infection rate between the two groups (P > 0.05). CONCLUSION For patients with GCS 8-12 HICH, micro-bone window not only has the same effect as traditional bone window, but also has the advantages of shorter operation time and less trauma.
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Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Chaudhary PK, Tripathi M, Deora H, Mohindra S, Buddhiraja M. Megacraniectomy for Malignant Intracranial Hypertension: No Time for Caution. J Neurosci Rural Pract 2019; 10:555-558. [PMID: 31595135 PMCID: PMC6779548 DOI: 10.1055/s-0039-1698284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Malignant intracranial hypertension (IHT) intracranial tension (ICT) is a surgical emergency. Routine decompressive craniectomy may not be sufficient in reducing the malignant IHT. At present, we do not have the exact solution to this ominous situation. Authors came across a similar scenario where we had to go forward with modification of a previously known described procedure, removing bifrontal, temporal, and parietal bones including midline bone strip over a superior sagittal sinus in a case of resistant malignant ICT, following coiling of an anterior communicating artery aneurysm. This radical technique, named as megacraniectomy, was used as a last resort in a rapidly deteriorating patient. The patient survived the stormy phase of malignant ICT and showed significant improvement in neurological status. Authors here describe this approach as a novel idea to be explored in resource-stricken situations.
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Affiliation(s)
- Prashant K Chaudhary
- Department of Neurosurgery, Sri Balaji Action Medical Institute and Action Cancer Hospital, New Delhi, India
| | - Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Harsh Deora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sandeep Mohindra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Manish Buddhiraja
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
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Hemoglobin Concentration Affects Hypertensive Basal Ganglia Hemorrhage After Surgery: Correlation Analysis in a High-Altitude Region. World Neurosurg 2019; 127:e835-e842. [PMID: 30954736 DOI: 10.1016/j.wneu.2019.03.281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Hypertensive cerebral hemorrhage leads to greater mortality and worse functional outcomes at high altitudes. Experimental studies have suggested that hemoglobin can lead to increased perihemorrhagic edema after intracerebral hemorrhage. METHODS Patients were divided into a high-hemoglobin (H-H) group (>180 g/L) and a low-hemoglobin (L-H) group (≤180 g/L). The distance from the cortex to the midline was used to indicate the degree of edema. At 1, 7, 14, and 21 days, the patients' status was scored using the Glasgow coma scale, and survival was plotted using Kaplan-Meier survival curves. Pearson correlation analysis showed that the difference between the postoperative and preoperative Glasgow coma scale score correlated with the hemoglobin concentration. The Glasgow outcome scale was used to assess neurological recovery after 6 months. RESULTS On days 7, 14, and 21, the edema of the H-H group was significantly greater than that of the L-H group (P < 0.01 and P < 0.001, respectively). The edema of the H-H group peaked at 14 and 21 days, but that of the L-H group peaked at 7 days. The hemoglobin concentration and postoperative neurological recovery had a linear relationship in the H-H group. The L-H group had greater survival compared with the H-H group (P < 0.05). The L-H group had higher Glasgow outcome scale scores compared with the H-H group (P < 0.05). CONCLUSION The hemoglobin concentration affects the mortality and morbidity from hypertensive cerebral hemorrhage in high-altitude regions, and a linear relationship exists between hemoglobin concentration and neurological recovery in the H-H group.
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Barzaghi LR, Parisi V, Gigliotti CR, Giudice L, Snider S, Dell'Acqua A, Del Vecchio A, Mortini P. Bone resorption in autologous cryopreserved cranioplasty: quantitative evaluation, semiquantitative score and clinical significance. Acta Neurochir (Wien) 2019; 161:483-491. [PMID: 30617716 DOI: 10.1007/s00701-018-03789-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/24/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Changes after reimplantation of the autologous bone have been largely described. However, the rate and the extent of resorption in cranial grafts have not been clearly defined. Aim of our study is to evaluate the bone flap resorption (BFR) after cryopreservation. METHODS We retrospectively reviewed 27 patients, aged 18 years or older, subjected to cranioplasty (CP) adopting autologous cryopreserved flap. The BFR was derived from the percentage of decrease in flap volume (BFR%), comparing the first post-operative computed tomography (CT) and the last one available (performed at least 1 year after surgery). We also proposed a semiquantitative scoring system, based on CT, to define a clinically workable BFR classification. RESULTS After a mean ± SE follow-up of 32.5 ± 2.4 months, the bone flap volume decreased significantly (p < 0.0001). The mean BFR% was 31.7 ± 3.8% and correlated with CT-score (p < 0.001). Three BFR classes were described: mild (14.8% of cases) consisting in minimal bone remodelling, CT-score ≤ 6, mean BFR% = 3.5 ± 0.7%; moderate (51.9% of cases) corresponding to satisfactory cerebral protection, CT-score < 13, mean BFR% = 25.6 ± 2.2%; severe (33.3% of cases) consisting in loss of cerebral protection, CT-score ≥ 13, mean BFR% = 54.2 ± 3.9%. Females had higher BFR% than males (p = 0.022). BFR classes and new reconstructive surgery were not related (p = 0.58). CONCLUSIONS BFR was moderate or severe in 85.2% of re-implanted cryopreserved flaps. The proposed CT-score is an easy and reproducible tool to define resorption extent.
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Affiliation(s)
- Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy.
| | - Veronica Parisi
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Carmen Rosaria Gigliotti
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lodoviga Giudice
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Silvia Snider
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Dell'Acqua
- Department of Neurocritical Care, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
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Huh J, Yang SY, Huh HY, Ahn JK, Cho KW, Kim YW, Kim SL, Kim JT, Yoo DS, Park HK, Ji C. Compare the Intracranial Pressure Trend after the Decompressive Craniectomy between Massive Intracerebral Hemorrhagic and Major Ischemic Stroke Patients. J Korean Neurosurg Soc 2018; 61:42-50. [PMID: 29354235 PMCID: PMC5769847 DOI: 10.3340/jkns.2017.0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/03/2017] [Accepted: 09/06/2017] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Joon Huh
- Department of Neurosurgery, Myungji St. Mary's Hospital, Seoul, Korea
| | - Seo-Yeon Yang
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Han-Yong Huh
- Department of Neurosurgery, St. Paul's Hospital, Seoul, Korea
| | - Jae-Kun Ahn
- Department of Neurosurgery, St. Paul's Hospital, Seoul, Korea
| | - Kwang-Wook Cho
- Department of Neurosurgery, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Young-Woo Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Sung-Lim Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Jong-Tae Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital, Incheon, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea.,Department of Neurosurgery, St. Paul's Hospital, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Cheol Ji
- Department of Neurosurgery, St. Paul's Hospital, Seoul, Korea
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Goedemans T, Verbaan D, Coert BA, Sprengers MES, van den Berg R, Vandertop WP, van den Munckhof P. Decompressive craniectomy in aneurysmal subarachnoid haemorrhage for hematoma or oedema versus secondary infarction. Br J Neurosurg 2017; 32:149-156. [PMID: 29172712 DOI: 10.1080/02688697.2017.1406453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Decompressive craniectomy (DC) has been proposed as lifesaving treatment in aneurysmal subarachnoid haemorrhage (aSAH) patients with elevated intracranial pressure (ICP). However, data is sparse and controversy exists whether the underlying cause of elevated ICP influences neurological outcome. The purpose of this study is to clarify the role of the underlying cause of elevated ICP on outcome after DC. MATERIALS AND METHODS We retrospectively studied the one-year neurological outcome in a single-centre cohort to identify predictors of favourable (Glasgow Outcome Scale (GOS) 4-5) and unfavourable (GOS 1-3) outcome. Additionally, available individual patient data in the literature was reviewed with a special emphasis on the underlying reason for DC. RESULTS From 2006-2015, 53 consecutive aSAH patients underwent DC. Nine (17%) achieved favourable, 44 (83%) unfavourable outcome (31 patients died). One fourth of the patients undergoing DC for hematoma or (hematoma-related) oedema survived favourably (increasing to 46% for patients aged <51 years), versus none of the patients undergoing DC for secondary infarction. Analysis of individual data of 105 literature patients showed a similar trend, although overall outcome was much better: half of the patients undergoing DC for hematoma/oedema regained independence, versus less than one-fourth of patients undergoing DC for secondary infarction. CONCLUSIONS DC in aSAH patients is associated with high rates of unfavourable outcome and mortality, but hematoma or oedema as underlying reason for DC is associated with better outcome profiles compared to secondary infarction. Future observational cohort studies are needed to further explore the different outcome profiles among subpopulations of aSAH patients requiring DC.
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Affiliation(s)
- Taco Goedemans
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | - Dagmar Verbaan
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | - Bert A Coert
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | | | - René van den Berg
- b Department of Radiology , Academic Medical Centre , Amsterdam , The Netherlands
| | - W Peter Vandertop
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
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11
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Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate. Stroke Res Treat 2017; 2017:2507834. [PMID: 28409051 PMCID: PMC5376465 DOI: 10.1155/2017/2507834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/22/2017] [Indexed: 11/25/2022] Open
Abstract
Objective and Methods. The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 48 hours using the modified Rankin scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4 at three months. Results. In total, 137 patients underwent DHC. Functional outcome analyzed as mRS 0–4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [P = 0.140] and mortality [P = 0.975]. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the “best” multivariate model, second infarct growth rate [IGR2] >7.5 ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] and second infarct growth rate [IGR2] were nearly double [P < 0.001] in patients with early surgery [under 48 hours]. Conclusions. The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery.
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Brown DA, Wijdicks EFM. Decompressive craniectomy in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:299-318. [PMID: 28187804 DOI: 10.1016/b978-0-444-63600-3.00016-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- D A Brown
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
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13
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Moussa WMM, Khedr W. Decompressive craniectomy and expansive duraplasty with evacuation of hypertensive intracerebral hematoma, a randomized controlled trial. Neurosurg Rev 2016; 40:115-127. [PMID: 27235128 DOI: 10.1007/s10143-016-0743-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/22/2016] [Accepted: 05/05/2016] [Indexed: 12/25/2022]
Abstract
Hypertensive intracerebral hemorrhage (ICH) has high morbidity and mortality rates. Decompressive craniectomy (DC) is generally used for the treatment of cases associated with refractory increased intracranial pressure (ICP). In this study, we investigated the beneficial effects of adding DC and expansive duraplasty (ED) to hematoma evacuation in patients who underwent surgery for large hypertensive ICH. A prospective randomized controlled clinical trial where 40 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B, each comprised 20 patients. Group A patients, the treatment group, were submitted to hematoma evacuation together with DC and ED, whereas group B patients, the control group, were submitted only to hematoma evacuation. Twenty-three (57.5 %) of the patients were males, with an overall age range of 34-79 years (mean 59.3 years). Preoperative Glasgow Coma Scale (GCS) scores in group A ranged from 4 to 13 (mean 7.1), while in group B it ranged from 4 to 12 (mean 6.8). Postoperative hydrocephalus occurred in 3 (15 %) patients in group A and in 4 (20 %) patients in group B, whereas meningitis occurred in one patient (5 %) in group A. The mortality rate was 2 (10 %) patients in group A as compared to 5 (25 %) patients in group B (p = 0.407). High admission GCS (p = 0.0032), younger age (p = 0.0023), smaller hematoma volume (p = 0.044), subcortical hematoma location (p = 0.041), absent or minimal preoperative (p = 0.0068), and postoperative (p = 0.0031) midline shift as well as absent intraventricular extension of the hematoma (p = 0.036) contributed significantly to a better outcome. Selected patients' subgroups who benefited from adding DC and ED to ICH evacuation were age category of 30 to less than 50 (p = 0.0015) and from 50 to less than 70 (p = 0.00619) as well as immediate preoperative GCS from 6 to 8 (p = 0.000436) and from 9 to 12 (p = 0.00774). At 6 months' follow-up, 14 (70 %) patients of group A had favorable outcome as compared to 4 (20 %) patients of group B (p = 0.0015). Adding DC with ED to evacuation of a large hypertensive hemispheric ICH might improve the outcome in selected group of patients.
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Affiliation(s)
- Wael Mohamed Mohamed Moussa
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Champolion Street, Khartoum Square, Azareeta, Alexandria, Egypt.
| | - Wael Khedr
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Champolion Street, Khartoum Square, Azareeta, Alexandria, Egypt
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Oh CH, Shim YS, Yoon SH, Hyun D, Park H, Kim E. Early Decompression of Acute Subdural Hematoma for Postoperative Neurological Improvement: A Single Center Retrospective Review of 10 Years. Korean J Neurotrauma 2016; 12:11-7. [PMID: 27182496 PMCID: PMC4866559 DOI: 10.13004/kjnt.2016.12.1.11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 01/06/2016] [Accepted: 02/10/2016] [Indexed: 11/15/2022] Open
Abstract
Objective This study was conducted to investigate survival related factors, as well as to evaluate the effects of early decompression on acute subdural hematoma (ASDH). Methods We retrospectively reviewed cases of decompressive craniectomy (DC) for decade. In total, 198 cases of DC involved ASDH were available for review, and 65 cases were excluded due to missing data on onset time and a delayed operation after closed observation with medical care. Finally, 133 cases of DC with ASDH were included in this study, and various factors including the time interval between trauma onset and operation were evaluated. Results In the present study, survival rate after DC in patients with ASDH was shown to be related to patient age (50 years old, p=0.012), brain compression ratio (p=0.042) and brain stem compression (p=0.020). Sex, preoperative mental status, and time interval between trauma onset and operation were not related with survival rate. Among those that survived (n=78), improvements in Glasgow Coma Scale (GCS) score of more than three points, compared to preoperative measurement, were more frequently observed among the early (less than 3 hours between trauma onset and operation) decompressed cases (p=0.013). However, improvements of more than 4 or 5 points on the GCS were not affected by early decompression. Conclusion Early decompression of ASDH was not correlated with survival rate, but was related with neurological improvement (more than three points on the GCS). Accordingly, early decompression in ASDH, if indicated, may be of particular benefit.
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Affiliation(s)
- Chang Hyun Oh
- Department of Neurosurgery, Guro Teun Teun Research Institute, Seoul, Korea
| | - Yu Shik Shim
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Dongkeun Hyun
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Hyeonseon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Eunyoung Kim
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Fotakopoulos G, Tsianaka E, Vagkopoulos K, Fountas KN. According to which factors in severe traumatic brain injury craniectomy could be beneficial. Surg Neurol Int 2016; 7:19. [PMID: 26981320 PMCID: PMC4774169 DOI: 10.4103/2152-7806.176671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 12/31/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To investigate the clinical outcome at 101 patients undergoing decompressive craniectomy (DC) after severe traumatic brain injury (TBI). METHODS Age, Glasgow Coma Scale (GCS) at the time of intubation, and the intraoperative intracranial pressure (ICP) were recorded. Formal DC was performed in all cases and the square surface of bone flap was calculated in cm(2) based on the length and the width from computed tomography scan. RESULTS The difference of good neurological recovery (Glasgow outcome score 4-5), between patients with ICP ≤20 mmHg, GCS ≥5, age ≤60 years, and bone flap ≥130 cm(2) and those with ICP >20 mmHg, GCS <5, age >60 years, and bone flap <130 cm(2), was statistically significant. CONCLUSION Although the application of DC in severe TBI is controversial and the population in this study is small, our study demonstrates the threshold of the specific factors (patient age, ICP and GCS on the day of the surgery and the size of the bone flap) which may help in the decision of performing DC. Furthermore, this study proves that the different combinations and mainly at the same time involvement of all prognostic parameters (age <60, GCS <5, bone flap ≥130 cm(2), and ICP ≤20 at time of DC surgery) allow a better outcome.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece,Corresponding author
| | - Eleni Tsianaka
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Konstantinos Vagkopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece,Center for Research and Technology of Thessaly, 38500 Larissa, Greece
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Karnatovskaia LV, Lee AS, Festic E, Kramer CL, Freeman WD. Effect of prolonged therapeutic hypothermia on intracranial pressure, organ function, and hospital outcomes among patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2015; 21:451-61. [PMID: 24865270 DOI: 10.1007/s12028-014-9989-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Global cerebral edema (GCE) with subsequent refractory intracranial hypertension complicates some cases of aneurysmal subarachnoid hemorrhage (aSAH), and typically is associated with poorer outcome. Treatment options for refractory intracranial pressure (ICP) cases are limited to decompressive hemicraniectomy (DHC) and targeted temperature management (TTM) with induced hypothermia (32-34 °C). No outcomes comparison between patients treated with either or both forms of refractory ICP therapy exists, and data on the effect of prolonged hypothermia on ICP and organ function among patients with aSAH are limited. METHODS This is a retrospective study of aSAH patients who underwent DHC and/or prolonged hypothermia (greater than 48 h) for refractory ICP (i.e., ICP >20 mmHg after osmotherapy) in the intensive care unit of a single, tertiary-care academic center. RESULTS Nineteen individuals with aSAH underwent TTM with or without DHC; sixteen patients underwent DHC alone. The patients in TTM group were younger (median age 44 years) than the DHC without TTM population (median age 60 years). TTM was started on median day 2 with a median duration of 7 days. There were no significant group differences in survival to discharge (59 % vs. 69 %) or in the mean modified Rankin score on follow-up (3.6 vs. 3.7), despite the TTM group having longer hospital length of stay (24 vs. 19 days, p = 0.03), longer duration of mechanical ventilation (20 vs. 9 days, p = 0.04), a higher cumulative fluid balance (12.8 vs. 5.1 L, p = 0.01), and higher APACHEII scores. The median maximal ICP decreased from 23.5 to 21 mmHg within 24 h of hypothermia initiation. There were no significant differences in other markers of end-organ function (respiratory, hematologic, renal, liver, and cardiac), infection rate, or adverse events between groups. CONCLUSIONS Use of prolonged TTM among aSAH patients with GCE and refractory ICP elevations is associated with a longer duration of mechanical ventilation but is not different in terms of neurological outcomes measured by modified Rankin score or organ function outcomes compared to patients who received DHC alone.
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Affiliation(s)
- Lioudmila V Karnatovskaia
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Davis Building E-7A, Jacksonville, FL, 32224, USA,
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Wang QP, Ma JP, Zhou ZM, Yang M, You C. Hydrocephalus after decompressive craniectomy for malignant hemispheric cerebral infarction. Int J Neurosci 2015; 126:707-12. [DOI: 10.3109/00207454.2015.1055357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Rastogi V, Lamb DG, Williamson JB, Stead TS, Penumudi R, Bidari S, Ganti L, Heilman KM, Hedna VS. Hemispheric differences in malignant middle cerebral artery stroke. J Neurol Sci 2015; 353:20-7. [PMID: 25959980 DOI: 10.1016/j.jns.2015.04.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/21/2015] [Accepted: 04/23/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND We recently reported that left versus right hemisphere cerebral infarctions patients more frequently have worse outcomes. However our clinical experience led us to suspect that the incidence of malignant middle cerebral artery infarctions (MMCA) was higher in the right compared to the left hemispheric strokes. OBJECTIVE To determine whether laterality in MMCA stroke is an important determinant of stroke sequelae. METHODS A systematic search was performed for publications in PubMed using "malignant middle cerebral artery and infarction". A total of 73 relevant studies were abstracted. RESULTS MMCA laterality data were available for 2673 patients, with 1687 (63%) right hemispheric involvement, thus right being more commonly associated with MMCA (binomial test, p<0.05). While mortality rates were similar, right hemispheric MMCA (n=271) had mortality of 31% (n=85) whereas left hemispheric MMCA (n=144) had mortality of 36% (n=53), morbidity rates were worse on the right. CONCLUSION MMCA stroke appears to be more common on the right, and this laterality is also associated with significantly higher morbidity. Further prospective studies are needed to more completely understand the nature of this laterality as well as test possible new treatments to reduce mortality and morbidity associated with MMCA.
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Affiliation(s)
- Vaibhav Rastogi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Damon G Lamb
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - John B Williamson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - Thor S Stead
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Rachel Penumudi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Sharathchandra Bidari
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL 32611, United States
| | - Latha Ganti
- Lake City VAMC, NF/SGVHS, Lake City, FL 32025-5808, United States
| | - Kenneth M Heilman
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States; Malcom Randall VAMC, Gainesville, FL 32608, United States
| | - Vishnumurthy S Hedna
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32611, United States.
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Bae DH, Choi KS, Yi HJ, Chun HJ, Ko Y, Bak KH. Cerebral Infarction after Traumatic Brain Injury: Incidence and Risk Factors. Korean J Neurotrauma 2014; 10:35-40. [PMID: 27169031 PMCID: PMC4852621 DOI: 10.13004/kjnt.2014.10.2.35] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 07/25/2014] [Accepted: 08/16/2014] [Indexed: 11/16/2022] Open
Abstract
Objective Post-traumatic cerebral infarction (PTCI) is one of the most severe secondary insults after traumatic brain injury (TBI), and is known to be associated with poor outcome and high mortality rate. We assessed the practical incidence and risk factors for the development of PTCI. Methods We conducted retrospective study on 986 consecutive patients with TBI from the period May 2005 to November 2012 at our institution. The definition of PTCI was made on non-enhanced CT scan based on a well-demarcated or fairly discernible region of low attenuation following specific vascular territory with normal initial CT. Clinical and radiological findings that related to patients' outcome were reviewed and statistically compared. Results PTCI was observed in 21 (2.1%) patients. Of various parameters, age (p=0.037), initial Glasgow coma scale score (p<0.01), brain herniation (p=0.044), and decompressive craniectomy (p=0.012) were significantly higher in patients with PTCI than patients who do not have PTCI. Duration between accident and PTCI, patterns of TBI and vascular territory of PTCI were not specific. The mortality rates were significantly higher in patients with PTCI than without PTCI. Conclusion The development of PTCI is rare after TBI, but it usually results in serious outcome and high mortality. Early recognition for risks and aggressive managements is mandatory to prevent PTCI.
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Affiliation(s)
- Dong-Hyeon Bae
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Yong Ko
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Koang Hum Bak
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
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20
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El Ghoul W, Harrisson S, Belli A. Autologous cranioplasty following decompressive craniectomy in the trauma setting. Br J Neurosurg 2014; 29:64-69. [PMID: 25284308 DOI: 10.3109/02688697.2014.957157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) is an option for the treatment of increased intracranial pressure resulting from an acute neurological insult, including insults caused by trauma. When the brain swelling has receded, the skull is reconstructed with a wide choice of materials, each with its own advantages and disadvantages in terms of cost, cosmetic appearance, biocompatibility, implant strength and complication rate. Autologous cranioplasty (AC), where the patient's own bone flap is stored and reutilised, is common in many countries. No outcome studies have, however, been published on this technique for traumatic injuries. METHODS A retrospective study was conducted including all AC operations performed following DC due to traumatic brain injury. All operations were performed in one institution during a 4-year time period. Results were analysed for complication rates. RESULTS 44 cases were included. The mean time from craniotomy to cranioplasty was 86 (95% CI: 63-109) days. Complications severe enough to warrant readmission or further surgery were found in 13 cases (30%). No statistically significant predictor of complication from cranioplasty was detected. The complication rate was similar to published data on cranioplasty using artificial prosthetic materials. CONCLUSIONS AC in the trauma setting is a valid treatment option with a complication rate that seems no worse than other alternatives.
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Affiliation(s)
- Wessam El Ghoul
- a Department of Neurosurgery , Skane University Hospital , Lund , Sweden
| | - Stuart Harrisson
- b Department of Neurosurgery , Wessex Neurological Centre, Southampton Hospital University Trust , Southampton , UK
| | - Antonio Belli
- c NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham , Birmingham , UK
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Rahmanian A, Seifzadeh B, Razmkon A, Petramfar P, Kivelev J, Alibai EA, Hernesniemi J. Outcome of decompressive craniectomy in comparison to nonsurgical treatment in patients with malignant MCA infarction. SPRINGERPLUS 2014; 3:115. [PMID: 24711983 PMCID: PMC3977016 DOI: 10.1186/2193-1801-3-115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/13/2014] [Indexed: 11/17/2022]
Abstract
Background Malignant cerebral infarction is a well-recognized disease, comprising 10-15% of all cases with cerebral infarction and causing herniation and death in 80% of cases. In this study, we compare the effects of decompressive craniectomy versus conventional medical treatment on mortality rate and functional and neurological outcome in patients with malignant MCA infarction. Methods We performed a prospective case–control study on 60 patients younger than 80years of age suffering malignant MCA cerebral infarction. The case group underwent decompressive craniectomy in addition to routine aggressive medical care; while the control group received routine medical treatment. Patient outcome was assessed using Glasgow outcome scale and modified Rankin scale within three months of follow-up. The data were analyzed by SPSS version 16.0 software using Chi Square, One-way ANOVA and Mann–Whitney tests. Results There were 27 male and 33 female patients with a mean age of 60.6 years (SD = 12.3). Glasgow outcome scale score averaged 2.93 in the surgical versus 1.53 in the medical group; this difference was significant (p = 0.001). Outcome in modified Rankin scale was also significantly lower in the surgical (3.27) versus medical (5.27) group (p < 0.001). Surgery could decrease the mortality rate about 47%. Conclusion In this study, decompressive craniectomy could decrease mortality rate, and improve neurological and functional outcome, and decrease long-term disability in patients with malignant MCA infarction.
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Affiliation(s)
- Abdolkarim Rahmanian
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Babak Seifzadeh
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Ali Razmkon
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran ; Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Petramfar
- Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
| | - Ehsan-Ali Alibai
- Department of Neurosurgery, Shiraz University of Medical Sciences, Nemazee Hospital, P.O. Box: 71937-11351, Shiraz, Iran
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
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El Ahmadieh TY, Adel JG, El Tecle NE, Daou MR, Aoun SG, Nanney AD, Bendok BR. Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring. Neurosurg Clin N Am 2013; 24:375-91. [PMID: 23809032 DOI: 10.1016/j.nec.2013.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.
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Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, McGaw Medical Center, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 2210, Chicago, IL 60611, USA
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Ventriculomegaly after decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage. Clin Neurol Neurosurg 2013; 115:317-22. [DOI: 10.1016/j.clineuro.2012.05.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 05/19/2012] [Accepted: 05/27/2012] [Indexed: 11/24/2022]
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Li Q, Yang CH, Xu JG, Li H, You C. Surgical treatment for large spontaneous basal ganglia hemorrhage: retrospective analysis of 253 cases. Br J Neurosurg 2013; 27:617-21. [DOI: 10.3109/02688697.2013.765938] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Piedra MP, Ragel BT, Dogan A, Coppa ND, Delashaw JB. Timing of cranioplasty after decompressive craniectomy for ischemic or hemorrhagic stroke. J Neurosurg 2013; 118:109-14. [DOI: 10.3171/2012.10.jns121037] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The optimal timing of cranioplasty after decompressive craniectomy for stroke is not known. Case series suggest that early cranioplasty is associated with higher rates of infection while delaying cranioplasty may be associated with higher rates of bone resorption. The authors examined whether the timing of cranioplasty after decompressive craniectomy for stroke affects postoperative complication rates.
Methods
A retrospective cohort study was undertaken to evaluate complication rates in patients undergoing cranioplasty at early (within 10 weeks of craniectomy) or late (≥ 10 weeks) stages. Multivariate logistic regression analysis was used to determine characteristics that would predict complications in patients undergoing cranioplasty after decompressive craniectomy for stroke.
Results
While the overall complication rate was higher in the early cranioplasty cohort (22% vs 16% in the late cranioplasty cohort), the difference was not statistically significant (p = 0.5541). Patients in the early cranioplasty cohort had lower rates of postoperative hematoma but higher rates of infection. Presence of a CSF shunt was the only significant predictor of complications (OR 8.96, 95% CI 1.84–43.6).
Conclusions
Complications rates for early cranioplasty (within 10 weeks of craniectomy) are similar to those encountered when cranioplasty is delayed, although the cohort size in this study was too small to state equivalence. Patients with a ventriculoperitoneal shunt are at higher risk for complications after cranioplasty.
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McKenna A, Wilson CF, Caldwell SB, Curran D. Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review. Br J Neurosurg 2012; 26:310-5. [DOI: 10.3109/02688697.2012.654835] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Rogers SJ, Browne AL, Vidovich M, Honeybul S. Defining meaningful outcomes after decompressive craniectomy for traumatic brain injury: Existing challenges and future targets. Brain Inj 2011; 25:651-63. [DOI: 10.3109/02699052.2011.580316] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Intiso D, Lombardi T, Grimaldi G, Iarossi A, Tolfa M, Russo M, Di Rienzo F. Long-term outcome and health status in decompressive craniectomized patients with intractable intracranial pressure after severe brain injury. Brain Inj 2011; 25:379-86. [DOI: 10.3109/02699052.2011.558046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Eberle BM, Schnüriger B, Inaba K, Gruen JP, Demetriades D, Belzberg H. Decompressive craniectomy: surgical control of traumatic intracranial hypertension may improve outcome. Injury 2010; 41:894-8. [PMID: 21574279 DOI: 10.1016/j.injury.2010.02.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to assess the role of decompressive craniectomy (DC) inpatients with post-traumatic intractable intracranial hypertension (ICH) in the absence of an evacuable intracerebral haemorrhage. METHODS Retrospective study at LAC+USC Medical Centre including patients who underwent DC for post-traumatic malignant brain swelling or ICH without space occupying haemorrhage, during the period 01/2004 to 12/2008. The analysis included the effect of DC on intracranial pressure (ICP) and timing of DC on functional outcomes and survival. RESULTS Of 106 patients who underwent DC, 43 patients met inclusion criteria. Of those, 34 were operated within the first 24 h from admission. DC decreased the ICP significantly from 37.8 ± 12.1 mmHg to 12.7 ± 8.2 mmHg in survivors and from 52.8 ± 13.0 to 32.0 ± 17.3 mmHg in non-survivors. Overall 25.6%died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). No tendency towards either increased or decreased incidence in favourable outcome was found relative to the time from admission to DC.Six of the 18 patients (33.3%) with favourable outcome were operated on within the first 6 h. CONCLUSIONS DC lowers ICP and raises CPP to high normal levels in survivors compared to non-survivors.The timing of DC showed no clear trend, for either good neurological outcome or death. Overall, the survival rate of 74.4% is promising and 41.9% had favourable neurological outcome.
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Affiliation(s)
- Barbara M Eberle
- Department of Surgery, Division of Acute Care Surgery (Trauma, Emergency Surgery and Surgical Critical Care), Los Angeles County and University of Southern California Medical Center, United States
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Steiner T, Vincent C, Morris S, Davis S, Vallejo-Torres L, Christensen MC. Neurosurgical outcomes after intracerebral hemorrhage: results of the Factor Seven for Acute Hemorrhagic Stroke Trial (FAST). J Stroke Cerebrovasc Dis 2010; 20:287-94. [PMID: 20452785 DOI: 10.1016/j.jstrokecerebrovasdis.2009.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 12/14/2009] [Accepted: 12/21/2009] [Indexed: 11/17/2022] Open
Abstract
The value of neurosurgical interventions after spontaneous intracerebral hemorrhage (SICH) is uncertain. We evaluated clinical outcomes in patients diagnosed with SICH within 3 hours of symptom onset who underwent hematoma evacuation or external ventricular drainage (EVD) of the hematoma in the Factor Seven for Acute Hemorrhagic Stroke Trial (FAST). FAST was a randomized, multicenter, double-blind, placebo-controlled trial conducted between May 2005 and February 2007 at 122 sites in 22 countries. Neurosurgical procedures (hematoma evacuation and external ventricular drainage) performed at any point after hospital admission were prospectively recorded. Clinical outcomes evaluated were post-SICH disability, as assessed by the modified Rankin Scale; neurologic impairment, as assessed by the National Institutes of Health Stroke Scale; and mortality at 90 days after SICH onset. The impact of neurosurgical procedures on clinical outcomes was evaluated using multivariate logistic regression analysis, controlling for relevant baseline characteristics. Fifty-five of 821 patients underwent neurosurgery. Patients who underwent hematoma evacuation or EVD were on average younger, had greater baseline neurologic impairment, and lower levels of consciousness compared with patients who did not undergo neurosurgery. After adjusting for these differences and other relevant baseline characteristics, we found that neurosurgery was generally associated with unfavorable outcomes at day 90. Among the patients who underwent hematoma evacuation, those with lobar ICH had less ICH expansion than those with deep gray matter ICH, and the smaller expansion was associated with lower mortality. ICH volume was substantially decreased in patients who underwent hematoma evacuation between 24 and 72 hours after hospital admission, and this was associated with better clinical outcome. In conclusion, a small number of patients who underwent neurosurgery in FAST exhibited no overall clinical benefit from neurosurgical intervention, although outcomes varied by type of surgery, time of surgery, and hematoma location. Our findings support the need for further research into the value of neurosurgery in patients with SICH.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Cerebral hemodynamic changes in severe head injury patients undergoing decompressive craniectomy. J Neurosurg Anesthesiol 2010; 21:339-45. [PMID: 19955897 DOI: 10.1097/ana.0b013e3181b1dbba] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the intracranial hemodynamic modifications induced by a decompressive craniectomy (DC) after severe traumatic brain injury (TBI), using transcranial Doppler (TCD) ultrasonography and intracranial pressure (ICP) sensor. Mortality rate and neurological outcomes were also evaluated after this procedure. DESIGN A prospective study was carried out on 26 TBI patients, measuring transcranial Doppler and ICP before, immediately after, and 48 hours after the DC, allowing for statistical analysis of hemodynamic changes. The mortality rate and the neurological outcomes were assessed. MEASUREMENTS AND RESULTS After DC, ICP decreased from 37+/-17 to 20+/-13 mm Hg (P=0.0003). The global cerebral blood flow was modified with diastolic velocities rising from 23+/-15 to 31+/-13 cm/s (P=0.0038) and a pulsatility index decreasing from 1.70+/-0.66 to 1.18+/-0.37 (P=0.0012). This normalization of the global cerebral hemodynamics after the DC was immediate, symmetric, and constant during the first 48 hours. Outcome was evaluated at 6 months: good recovery or moderate disability was observed in 11 patients (42%), persistent vegetative state in 7 patients (27%), and 8 patients died (31%). CONCLUSIONS The DC results in a significant, immediate, and durable improvement of ICP associated with a normalization of cerebral blood flow velocities in most TBI patients with refractory intracranial hypertension.
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Bao YH, Liang YM, Gao GY, Pan YH, Luo QZ, Jiang JY. Bilateral Decompressive Craniectomy for Patients with Malignant Diffuse Brain Swelling after Severe Traumatic Brain Injury: A 37-Case Study. J Neurotrauma 2010; 27:341-7. [PMID: 19715392 DOI: 10.1089/neu.2009.1040] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ying-Hui Bao
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University/School of Medicine, Shanghai, People's Republic of China
| | - Yu-Min Liang
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University/School of Medicine, Shanghai, People's Republic of China
| | - Guo-Yi Gao
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University/School of Medicine, Shanghai, People's Republic of China
| | - Yao-Hua Pan
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University/School of Medicine, Shanghai, People's Republic of China
| | - Qi-Zhong Luo
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University/School of Medicine, Shanghai, People's Republic of China
| | - Ji-Yao Jiang
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University/School of Medicine, Shanghai, People's Republic of China
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Eghwrudjakpor PO, Allison AB. Decompressive craniectomy following brain injury: factors important to patient outcome. Libyan J Med 2010; 5:10.4176/091104. [PMID: 21483545 PMCID: PMC3066780 DOI: 10.4176/091104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 10/20/2009] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is often performed as an empirical lifesaving measure to protect the injured brain from the damaging effects of propagating oedema and intracranial hypertension. However, there are no clearly defined indications or specified guidelines for patient selection for the procedure. AIMS To evaluate outcome determinants and factors important in patient selection for the procedure. METHODS We reviewed the literature on DC, including single case reports and reported case series, to identify factors affecting outcome following the procedure, as well as its pitfalls and associated complications. RESULTS Glasgow coma score of 8 and above, age less than 50 years and early intervention were found to be among the most significant determinants of prognosis. CONCLUSION Improving patient selection for DC may be expected to further improve the outcome following the procedure in severely brain-injured patients.
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Affiliation(s)
- Patrick O. Eghwrudjakpor
- Patrick O. Eghwrudjakpor, Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria.
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Eghwrudjakpor PO, Allison AB. Decompressive craniectomy following brain injury: factors important to patient outcome. Libyan J Med 2010; 5:4620. [PMID: 28156293 PMCID: PMC3066780 DOI: 10.3402/ljm.v5i0.4620] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 10/20/2009] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is often performed as an empirical lifesaving measure to protect the injured brain from the damaging effects of propagating oedema and intracranial hypertension. However, there are no clearly defined indications or specified guidelines for patient selection for the procedure. AIMS To evaluate outcome determinants and factors important in patient selection for the procedure. METHODS We reviewed the literature on DC, including single case reports and reported case series, to identify factors affecting outcome following the procedure, as well as its pitfalls and associated complications. RESULTS Glasgow coma score of 8 and above, age less than 50 years and early intervention were found to be among the most significant determinants of prognosis. CONCLUSION Improving patient selection for DC may be expected to further improve the outcome following the procedure in severely brain-injured patients.
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Affiliation(s)
| | - Akaribari B. Allison
- Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
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Surgical Outcome Following a Decompressive Craniectomy for Acute Epidural Hematoma Patients Presenting with Associated Massive Brain Swelling. BRAIN EDEMA XIV 2010; 106:261-4. [DOI: 10.1007/978-3-211-98811-4_49] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Nagel A, Graetz D, Vajkoczy P, Sarrafzadeh AS. Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: relation to cerebral perfusion pressure and metabolism. Neurocrit Care 2009; 11:384-94. [PMID: 19714498 DOI: 10.1007/s12028-009-9269-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 08/13/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Outcome is poor in aneurysmal subarachnoid hemorrhage (SAH) patients with intracranial hypertension. As one treatment option for increased intracranial pressure (ICP), decompressive craniectomy (DC) is discussed. Its impact on cerebral metabolism and outcome in SAH patients is evaluated in this pilot study. METHODS A prospectively collected database of cerebral metabolism in SAH patients was analyzed retrospectively for individuals developing high ICP (>20 mmHg > 6 h/day, n = 18). Patients with intracranial hypertension were classified into groups with (n = 7) and without DC (n = 11). An age-matched control group was established (n = 89). Cerebral perfusion pressure (CPP) and high ICP treatment were analyzed for 7 days after SAH (or 72 h after craniectomy, respectively). Cerebral microdialysates were analyzed hourly. Twelve-month outcome was evaluated. RESULTS Groups were comparable for age, WFNS grade, and outcome. ICP was significantly reduced by DC (P < 0.01), however, in 43% of patients the effect was transient. An increase in the lactate/pyruvate ratio (P < 0.001) and glycerol levels (>200 muM) was observed before DC. In the DC group, glucose (P = 0.005) and pyruvate (P = 0.04) were higher, while glycerol levels were lower (P = 0.007) compared to the non-DC group, reflecting better aerobic glucose utilization and reduced cellular stress. CONCLUSION Outcome was poor in all SAH patients with intracranial hypertension. Although glucose utilization was improved after DC, no improvement in outcome could be shown for this small patient population. Future studies will have to demonstrate whether markers of cerebral crisis may support the decision for DC in aneurysmal SAH patients.
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Affiliation(s)
- Alexandra Nagel
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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Impact of Decompressive Craniectomy on Functional Outcome After Severe Traumatic Brain Injury. ACTA ACUST UNITED AC 2009; 66:1570-4; discussion 1574-6. [PMID: 19509616 DOI: 10.1097/ta.0b013e3181a594c4] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Decompressive Hemicraniectomy in Large Putaminal Hematomas: An Indian Experience. J Stroke Cerebrovasc Dis 2009; 18:1-10. [DOI: 10.1016/j.jstrokecerebrovasdis.2008.09.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Accepted: 06/09/2008] [Indexed: 11/20/2022] Open
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Kim KT, Park JK, Kang SG, Cho KS, Yoo DS, Jang DK, Huh PW, Kim DS. Comparison of the effect of decompressive craniectomy on different neurosurgical diseases. Acta Neurochir (Wien) 2009; 151:21-30. [PMID: 19096757 DOI: 10.1007/s00701-008-0164-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Accepted: 07/09/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many previous studies have reported that decompressive craniectomy has improved clinical outcomes in patients with intractable increased intracranial pressure (ICP) caused by various neurosurgical diseases. However there is no report that compares the effectiveness of the procedure in the different conditions. The authors performed decompressive craniectomy following a constant surgical indication and compared the clinical outcomes in different neurosurgical diseases. MATERIALS AND METHODS Seventy five patients who underwent decompressive craniectomy were analysed retrospectively. There were 28 with severe traumatic brain injury (TBI), 24 cases with massive intracerebral haemorrhage (ICH), and 23 cases with major infarction (MI). The surgical indications were GCS score less than 8 and/or a midline shift more than 6 mm on CT. The clinical outcomes were assessed on the basis of mortality and Glasgow Outcome Scale (GOS) scores. The changes of ventricular pressure related to the surgical intervention were also compared between the different disease groups. FINDINGS Clinical outcomes were evaluated 6 months after decompressive craniectomy. The mortality was 21.4% in patients with TBI, 25% in those with ICH and 60.9% in MI. A favourable outcome, i.e. GOS 4-5 (moderate disability or better) was observed in 16 (57.1%) patients with TBI, 12 (50%) with ICH and 7 (30.4%) with MI. The change of ventricular pressure after craniectomy and was 53.2 (reductions of 17.4%) and further reduced by 14.9% (with dural opening) and (24.8%) after returning to its recovery room, regardless of the diseases group. CONCLUSIONS According to the mortality and GOS scores, decompressive craniectomy with dural expansion was found to be more effective in patients with ICH or TBI than in the MI group. However, the ventricular pressure change during the decompressive craniectomy was similar in the different disease groups. The authors thought that decompressive craniectomy should be performed earlier for the major infarction patients.
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Affiliation(s)
- Ki-Tae Kim
- Department of Radiology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, South Korea
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Morgalla MH, Will BE, Roser F, Tatagiba M. Do long-term results justify decompressive craniectomy after severe traumatic brain injury? J Neurosurg 2008; 109:685-90. [PMID: 18826356 DOI: 10.3171/jns/2008/109/10/0685] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT A decompressive craniectomy can be a life-saving procedure to relieve critically increased intracranial pressure. The survival of a patient is important as well as the subsequent and long-term quality of life. In this paper the authors' goal was to investigate whether long-term clinical results justify the use of a decompressive craniectomy. METHODS Thirty-three patients (20 males and 13 females) with a mean age of 36.3 years (range 13-60 years) with severe traumatic brain injury (Grades III and IV) and subsequent massive brain swelling were examined. For postoperative assessment the Barthel Index was used. A surgical intervention was based on the following criteria: 1) The intracranial pressure could not be controlled by conservative treatment and constantly exceeded 30 mm Hg (cerebral perfusion pressure<50 mm Hg). 2) Transcranial Doppler ultrasonography revealed only a systolic flow pattern or systolic peaks. 3) There were no other major injuries. 4) The patient was not older than 60 years. RESULTS One-fifth of all patients died and one-fifth remained in a vegetative state. Mild deficits were seen in 6 of 33 patients. A full rehabilitation (Barthel Index 90-100) was achieved in 13 patients (39.4%). Five patients could resume their former occupation, and another 4 had to change jobs. CONCLUSIONS Age remains to be one of the most important exclusion factors. Decompressive craniectomy provided good clinical results in nearly 40% of patients who were otherwise most likely to die. Therefore, long-term results justify the use of decompressive craniectomy in this case series.
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Abstract
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.
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Risk factors for posttraumatic cerebral infarction in patients with moderate or severe head trauma. Neurosurg Rev 2008; 31:431-6; discussion 436-7. [DOI: 10.1007/s10143-008-0153-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2007] [Revised: 04/30/2008] [Accepted: 06/29/2008] [Indexed: 10/21/2022]
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Outcome After Decompressive Craniectomy for the Treatment of Severe Traumatic Brain Injury. ACTA ACUST UNITED AC 2008; 65:380-5; discussion 385-6. [DOI: 10.1097/ta.0b013e31817c50d4] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cooper DJ, Rosenfeld JV, Murray L, Wolfe R, Ponsford J, Davies A, D'Urso P, Pellegrino V, Malham G, Kossmann T. Early decompressive craniectomy for patients with severe traumatic brain injury and refractory intracranial hypertension--a pilot randomized trial. J Crit Care 2007; 23:387-93. [PMID: 18725045 DOI: 10.1016/j.jcrc.2007.05.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Revised: 04/04/2007] [Accepted: 05/04/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE The aims of this study were to test the feasibility and to assess potential recruitment rates in a pilot study preliminary to a phase III randomized trial of decompressive craniectomy surgery in patients with diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. MATERIALS AND METHODS A study protocol was developed, inclusion and exclusion criteria were defined, and a standardized surgical technique was established. Neurologic outcomes were assessed 6 months after injury with a validated structured questionnaire and a single trained assessor blind to treatment group. RESULTS During the 8-month pilot study at a level 1 trauma center in Melbourne, Australia, 69 intensive care patients with severe TBI were assessed for inclusion. Six patients were eligible, and 5 (8%) were randomized. Six months after injury, 100% of patients received outcome assessments. Key improvements to the multicenter Decompressive Craniectomy study protocol were enabled by the pilot study. CONCLUSIONS In patients with severe TBI and refractory intracranial hypertension, the frequency of favorable neurologic outcomes (independent living) was low and similar to predicted values (40% favorable). A future multicenter phase III trial involving 18 neurotrauma centers with most sites conservatively recruiting at just 25% of the pilot study rate would require at least 5 years to achieve an estimated 210-patient sample size. Collaboration with neurotrauma centers in countries other than Australia and New Zealand would be required for such a phase III trial to be successful.
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Affiliation(s)
- D James Cooper
- Department of Intensive Care, Alfred Hospital, Monash University, Melbourne 3004, Australia
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Schmidt JH, Reyes BJ, Fischer R, Flaherty SK. Use of hinge craniotomy for cerebral decompression. J Neurosurg 2007; 107:678-82. [PMID: 17886572 DOI: 10.3171/jns-07/09/0678] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓Decompressive craniectomy to relieve cerebral edema and intracranial hypertension due to traumatic brain injury is a generally accepted practice; however, the procedure remains controversial because of its uncertain effects on outcome, specific complications such as the syndrome of the sinking skin flap, and the need for subsequent cranioplasty. The authors developed a novel craniotomy technique using titanium bone plates in a hinged fashion, which maintains cerebral protection while reducing postoperative complications and eliminating subsequent cranioplasty procedures.
The authors conducted a retrospective review of data obtained in all consecutive patients who had undergone post-traumatic cerebral decompression craniotomy using the hinge technique at a Level I trauma facility between 1990 and 2004.
Twenty-five patients, most of whom were male (88%) and Caucasian (88%) with a mean age of 38.2 ± 16.1 years, underwent the hinge craniotomy. The in-hospital mortality rate was 48%, and good cerebral decompression was achieved. None of the patients required surgery for flap replacement. Long-term follow-up data showed that one patient required subsequent cranioplasty due to infection and one patient presented with cranial deformities. None of the patients presented with bone resorption or sinking flap syndrome.
The hinge technique effectively prevents procedure-related morbidity and the need for subsequent surgical bone replacement otherwise introduced by traditional decompressive craniectomy. A randomized controlled trial is required to substantiate these findings.
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Affiliation(s)
- John H Schmidt
- Department of Surgery, School of Medicine, West Virginia University Health Sciences Center, Charleston Division, USA
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Brain edema after intracerebral hemorrhage: mechanisms, treatment options, management strategies, and operative indications. Neurosurg Focus 2007; 22:E6. [PMID: 17613237 DOI: 10.3171/foc.2007.22.5.7] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Primary intracerebral hemorrhage (ICH) is associated with a high mortality rate and severe morbidity. The treatment of choice is still controversial, given that data from several clinical trials have not provided convincing evidence to support the efficacy of surgical clot removal. Favoring early clot removal is evidence that the limited release of specific neurotoxins associated with the breakdown products of hemoglobin underlies secondary brain injury. Attention has therefore shifted to perilesional brain injury, especially brain edema, as a potential target for therapeutic intervention in patients with ICH. In this review the authors address current understanding of the causes of edema formation following ICH and the treatment options, which are mostly supportive in nature.
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Abstract
Brain edema is a common pathophysiological process seen in many neurosurgical conditions. It can be localized in relation to focal lesions or generalized in diffuse types of brain injury. In addition to local adverse effects occurring at a cellular level, brain edema is associated with raised intracranial pressure (ICP), and both phenomena contribute to poor outcome in patients. One of the goals in treating patients with acute neurosurgical conditions in intensive care is to control brain edema and maintain ICP below target levels. The mainstay of treatment is medical therapy to reduce edema, but in certain patients--for example, those with diffuse severe traumatic brain injury (TBI) and malignant middle cerebral artery infarction--such treatment is not effective. In these patients, opening the skull (decompressive craniectomy) to reduce ICP is a potential option. In this review the authors discuss the role of decompressive craniectomy as a surgical option in patients with brain edema in the context of a variety of pathological entities. They also address the current evidence for the technique (predominantly observational series) and the ongoing randomized studies of decompressive craniectomy in TBI and ischemic stroke.
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Affiliation(s)
- Peter Hutchinson
- University of Cambridge Academic Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom.
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