Pseudohypoxic Brain Swelling: A Newly Defined Complication after Uneventful Brain Surgery, Probably Related to Suction Drainage

Wernicke Encephalopathy: Typical and Atypical Findings in Alcoholics and Non-Alcoholics and Correlation with Clinical Symptoms

PURPOSE

Clinical diagnosis of Wernicke encephalopathy (WE) can be challenging due to incomplete presentation of the classical triad. The aim was to provide an update on the relevance of standard MRI and to put typical and atypical imaging findings into context with clinical features.

METHODS

In this two-center retrospective observational study, the local radiology information system was searched for consecutive patients with clinical or imaging suspicion of WE. Two independent raters evaluated T2-weighted imaging (WI), fluid-attenuation inversion recovery (FLAIR), diffusion WI (DWI), T2*WI and/or susceptibility WI (SWI), and contrast-enhanced (CE)-T1WI, and noted the involvement of typical (i.e., mammillary bodies (MB), periaqueductal grey (PAG), thalamus, hypothalamus, tectal plate) and atypical (all others) lesion sites. Unusual signal patterns like hemorrhages were also documented. Reported clinical features together with the diagnostic criteria of the latest guidelines of the European Federation of Neurological Societies (EFNS) were used to test for relationships with MRI biomarkers.

RESULTS

47 patients with clinically confirmed WE were included (Jan '99-Apr '23; mean age, 53 yrs; 70% males). Interrater reliability for imaging findings was substantial (κ = 0.71), with lowest agreements for T2WI (κ = 0.85) compared to all other sequences and for PAG (κ = 0.65) compared to all other typical regions. In consensus, 77% (n = 36/47) of WE cases were rated MRI positive, with FLAIR (n = 36/47, 77%) showing the strongest relation (χ2 = 47.0; P < 0.001) compared to all other sequences. Microbleeds in the MB were detected in four out of ten patients who received SWI, not visible on corresponding T2*WI. Atypical findings were observed in 23% (n = 11/47) of cases, always alongside typical findings, in both alcoholics (n = 9/44, 21%) and non-alcoholics (n = 2/3, 67%). Isolated involvement of structures, explicitly PAG (n = 4/36; 11%) or MB (n = 1/36; 3%), was present but observed less frequently than combined lesions (n = 31/36; 86%). A cut-off width of 2.5 mm for the PAG on 2D axial FLAIR was established between cases and age- and sex-matched controls. An independent association was demonstrated only between short-term memory loss and changes in the MB (OR = 2.2 [95% CI: 1.1-4.5]; P = 0.024). In retrospect, EFNS criteria were positive (≥ 2 out of 4) in every case, but its count (range, 2-4) showed no significant (P = 0.427) relationship with signal changes on standard MRI.

CONCLUSION

The proposed sequence protocol (FLAIR, DWI, SWI and T1WI + CE) yielded good detection rates for neuroradiological findings in WE, with SWI showing microbleeds in the MB with superior detectability. However, false negative results in about a quarter of cases underline the importance of neurological alertness for the diagnosis. Awareness of atypical MRI findings should be raised, not only in non-alcoholics. There is limited correlation between clinical signs and standard MRI biomarkers.

Pseudohypoxic brain swelling following cerebrospinal fluid leakage: a case report on rapid identification and multidisciplinary management

This report delineates the intricate diagnostic journey and therapeutic conundrum presented by a 61-year-old male who exhibited atypical neurological deterioration shortly after lumbar fusion surgery, manifesting clinical and radiological features suggestive of pseudohypoxic encephalopathy, an entity characterized by symptoms mimicking cerebral hypoxia in the absence of a discernible hypoxic insult. Following an initially unremarkable recovery from an elaborate spinal surgery, the patient's postoperative condition was confounded by a perplexing decline in consciousness, unresponsive to conventional therapeutic interventions and devoid of clear etiological indicators on standard neuroimaging. The subsequent diagnostic odyssey unraveled a cerebrospinal fluid leak as the putative reason, positing a nuanced clinical paradigm wherein the cerebrospinal fluid leak engendered a state mimicking pseudohypoxic brain swelling. This report underscores the clinical challenges and emphasizes the need for an astute diagnostic approach in postoperative patients with unexplained neurological symptoms advocating for a comprehensive evaluation to identify underlying cerebrospinal fluid leaks and mitigate potential morbidity.

Pseudohypoxic brain swelling and secondary hydrocephalus with pseudomeningocele after lumbar surgery: a case report

BACKGROUND

Postoperative intracranial complications are rare in spine surgery not including cranial procedures. We describe an uncommon case of pseudohypoxic brain swelling (PHBS) and secondary hydrocephalus after transforaminal lumbar interbody fusion (TLIF) presenting as impaired consciousness and repeated seizures.

CASE PRESENTATION

A 65-year-old man underwent L4-5 TLIF for lumbar spondylolisthesis and began experiencing generalized seizures immediately postoperatively. Computed tomography (CT) revealed diffuse cerebral edema-like hypoxic ischemic encephalopathy. He was transported to our hospital, at which time epidural drainage was halted and anti-edema therapy was commenced. His impaired consciousness improved. However, he suffered secondary hydrocephalus due to continuous bleeding from a dural defect and spinal epidural fluid collection 3 months later. Following the completion of dural repair and insertion of a ventriculoperitoneal shunt, his neurologic symptoms and neuroimaging findings improved significantly.

CONCLUSIONS

PHBS can be considered in patients with unexpected neurological deterioration following lumbar spine surgery even with the absence of documented durotomy. This might be due to postoperative intracranial hypotension-associated venous congestion, and to be distinguished from the more common postoperative cerebral ischemic events-caused by arterial or venous occlusions-or anesthetics complications.

Pseudohypoxic brain swelling following elective lumbar laminectomy: A rare case report and review of literature

Pseudohypoxic brain swelling, also known as postoperative intracranial hypotension-associated venous congestion, is an intriguing complication following routine neurosurgical interventions. We report a case of a 73-year-old female patient who exhibited this rare complication following an elective L4-L5 laminectomy, without evidence of intraoperative cerebrospinal fluid leakage. Initially presenting with clinical features suggestive of anoxic/hypoxic brain injury, the case deviated from typical pseudohypoxic ischemic venous hypertension (PIHV) patterns, leading to a challenging diagnostic process. The patient's remarkable recovery, contrary to the initial grim prognosis, emphasizes the critical need for considering PIHV in differential diagnoses when postoperative symptoms mimic anoxic/hypoxic brain injuries. This case contributes to the evolving understanding of PIHV, particularly in scenarios lacking conventional risk factors like cerebral spinal fluid (CSF) leakage, and underscores the importance of comprehensive postoperative surveillance and management. It also highlights the imperative for continued research into the pathophysiology and treatment strategies of PIHV to enhance patient outcomes in complex surgical contexts.

Sudden death associated with the use of suction drains - a report of 2 cases following uneventful cranioplasty and literature review. Is the use of suction drains safe?

BACKGROUND AND IMPORTANCE

The use of drains, including suction drains in neurosurgery is individual preference-based, rather than scientific evidence-based. Furthermore, the use of suction drains has been associated with significant risks to patients, including sudden death.

CLINICAL PRESENTATION

We present 2 cases of unfortunate sudden deaths following uneventful cranioplasty procedures, both of which were associated with the use of a suction drain. We also review the literature focusing on the benefits and risks in the use of suction drains, and discuss pathophysiological mechanisms underlying sudden death associated with their use.

CONCLUSION

There is no substantial evidence to support the use of suction drains in neurosurgery. Furthermore, they have been associated with significant complications, including risk to life. Our experience and literature review suggest that the risk of sudden death is disproportionately higher following cranioplasty. We do not recommend the use of suction drains in cranial neurosurgery, and we strongly recommend against their use in cranioplasty procedures.

Postoperative Intracranial Hypotension-Associated Venous Congestion after Spinal Surgery Managed with Multiple Blood Patches: Case Report

BACKGROUND

 Postoperative intracranial hypotension-associated venous congestion (PIHV) is a rare event. The authors report the case of a patient presenting with PIHV after spinal surgery following the sudden loss of cerebrospinal fluid (CSF) induced by suction drainage.

METHODS

 A 69-year-old patient underwent uneventful revision surgery for wound dehiscence after lumbar surgery with placement of a subfascial suction drain.

RESULTS

 Postoperatively, the patient presented with fluctuating consciousness and a generalized tonic-clonic seizure. Computed tomography (CT) and serial magnetic resonance imaging (MRI) were performed showing convexity subarachnoid hemorrhages (SAHs), diffuse swelling of the brain and thalami and striatum bilaterally without diffusion restriction, and signs of intracranial hypertension resulting in pseudohypoxic brain swelling in PIHV. A dural leak at L3-L4 was treated with several CT-guided patches combining autologous blood and fibrin glue injections. The patient recovered without neurologic deficit and follow-up MRI revealed progressive complete reversal of brain swelling, and re-expansion of CSF spaces.

CONCLUSION

 PIHV is a rare but potentially fatal entity. Awareness of PIHV after cranial or spinal surgery leads to early treatment of CSF hypovolemia and possibly better clinical outcome. Following acute CSF volume loss, an acute elevation of cerebral blood volume overcoming autoregulatory mechanisms seems a likely explanation for diffuse cerebral vasogenic edema and SAH in PIHV.

Malignant bihemispheric cerebral edema after cranioplasty - An extension of the Monro-Kellie doctrine and predictive factors

Background

Several changes in normal pressure dynamics on the brain occur with a decompressive craniectomy and subsequent cranioplasty. Dead space volume is an important factor contributing to intracranial volume postcranioplasty. A decrease in this volume due to negative suction drain along with relative negative pressure on the brain with the loss of external atmospheric pressure may lead to fatal cerebral edema.

Case Description

A 52-year-old gentleman with a 210 mL volume and middle cerebral artery territory infarction underwent an emergency craniectomy and 6 months later a titanium mold cranioplasty. Precranioplasty computed tomography (CT) scan evaluation revealed a sunken skin flap with a 9 mm contralateral midline shift. Immediately following an uneventful surgery, the patient had sudden fall in blood pressure to 60/40 mmHg and over a few min had dilated fixed pupils. CT revealed severe diffuse cerebral edema in bilateral hemispheres with microhemorrhages and expansion of the sunken right gliotic brain along with ipsilateral ventricular dilatation. Despite undergoing a contralateral decompressive craniectomy due to the midline shift toward the right, the outcome was fatal.

Conclusion

Careful preoperative risk assessment in cranioplasty and close monitoring postprocedure is crucial, especially in malnourished, poststroke cases, with a sinking skin flap syndrome, and a long interval between decompressive craniectomy and cranioplasty. Elective preventive measures and a low threshold for CT scanning and removal of the bone flap or titanium mold are recommended.

Surgical drain induced subgaleal hematomas and skin necrosis in pediatrics: a case report

INTRODUCTION

Subgaleal drainage is often being used in craniotomy procedures. It's not only offers advantages but also carries a risk of life-threatening complications. Here, we present a rare case of subgaleal hematoma and skin necrosis caused by placement of subgaleal drainage in a pediatric patient after a craniotomy procedure.

CASE REPORT

We reported a 6-months-old child who came to our institution complaining of uncontrolled eye movements which occurred 4 months earlier. From the CT scan and MRI, it was found that the patient had a mass in his suprasellar region, which suggested a suprasellar tumor. She underwent a mass resection procedure, but unfortunately, 3 days after the surgical procedure, the wound appeared necrotic, with a blackish color around the drain. The necrotic wound was suspected due to vacuum subgaleal drain placement. The wound was cleaned and the suture removed, but the necrotic area was still there. Four days after the surgery, the patient clinical condition got worse. After 17 days of treatment with no significant improvement, unfortunately, the patient died.

DISCUSSION

The mechanism of subgaleal hematoma and skin necrosis induced by the Redon drain possibly related to mechanical compression by the drain, which damage perforating vessels and subsequently disrupt skin vascularization, combined with vascular stasis as given by negative pressure of the drain. This induced skin ischemia lesion which later contributes the necrotic formation.

CONCLUSION

The subgaleal hematoma and skin necrosis as a complication of subgaleal redon drain in pediatric are rare phenomenon and likely under reported. The possible underlying mechanism was that drain's negative pressure disrupt subgaleal tissue and induce necrotic formation. Even the complication is rare compared to older children, yet it has been linked to an increased risk for infection, morbidity, and mortality.

Malignant cerebral edema after cranioplasty: a case report and literature review

BACKGROUND

Cranioplasty is a common surgery in the neurosurgery for patients with skull defects following decompression craniectomy. Concomitant rare complications are increasingly reported, such as malignant cerebral edema after cranioplasty.

CASE REPORT

A 45-year-old man underwent decompression craniectomy due to traumatic brain injury. At 3 months after the decompression craniectomy, the patient developed refractory subdural hydrogen and received ipsilateral refractory subdural effusion capsule resection, but no significant relief was seen. Therefore, the cranioplasty was decided to treat subdural hydrogen and restore the normal appearance of the skull. After the successful cranioplasty surgery and the expected anesthesia recovery period, the pupils of the patients were continued to be dilated and fixed, without light reflection and spontaneous breathing. The Computed Tomography of the patient 1 hour after surgery showed malignant cerebral edema.

CONCLUSIONS

Malignant cerebral edema is a rare and lethal complication after cranioplasty. Negative pressure drainage and deregulation of cerebral blood flow at the end of cranioplasty may partially explain the malignant cerebral after cranioplasty. In addition, patients with epileptic seizures, no spontaneous breathing, dilated pupils without reflection, and hypotension within a short period after cranioplasty may show the occurrence of malignant cerebral.

Pseudohypoxic Brain Swelling after Unilateral Burr Hole Drainage: A Novel Case Report

An 85-year-old man underwent emergency right trepanation and drainage for a symptomatic chronic subdural hematoma. Pseudohypoxic brain swelling (PHBS) was suspected because magnetic resonance imaging revealed diffuse brain swelling. Although cerebrospinal fluid (CSF) leakage was not obvious during or after surgery, most of the reported PHBS cases have leaked CSF during craniotomy or spine surgery. PHBS has not been previously reported in patients without obvious CSF leakage or after unilateral burr hole drainage. Herein, we report an extremely rare case with a literature review investigating its pathogenesis and clinical features.

Multiple Cerebral Hemorrhages Caused by Paradoxical Reperfusion Injury After Cranioplasty

Cranioplasty-related reperfusion injury has rarely been reported. Although there are several hypotheses, particularly regarding the mechanisms of the event, clear evidence is lacking. Here, we report the case of an 84-year-old man with traumatic intracranial hemorrhage and subdural hematoma who underwent decompressive craniectomy and hematoma evacuation in the right hemisphere. After 45 days, cranioplasty was performed using titanium. A preoperative perfusion study with 99m-Tc-HMPAO brain single-photon emission tomography revealed diffuse hypoperfusion in the left cerebral hemisphere with decreased vascular reserve. After cranioplasty, multiple cerebral hemorrhages were observed on immediate postoperative computed tomography. Cerebral hemorrhage eventually improved without surgery. Here, we report a case with findings revealed through perfusion studies before and after surgery.

Increase in Brain Volume After Aneurysmal Subarachnoid Hemorrhage Leads to Unfavorable Outcome: A Retrospective Study Quantified by CT Scan

Background and Purpose: Primary brain swelling occurs in aneurysmal subarachnoid hemorrhage (aSAH) patients. The absence of a dynamic quantitative method restricts further study of primary brain swelling. This study compared differences in the change rate of brain volume (CRBV) between patients with and without primary brain swelling in the early stage of aSAH. Moreover, the relationship between CRBV and clinical outcomes was evaluated.

Methods: Patients hospitalized within 24 h after aSAH were included in this retrospective study. Utilizing a qualitative standard established before the study to recognize primary brain swelling through brain CT after aSAH, clinical outcomes after 3 months of SAH were evaluated with a modified Rankin scale (mRS). The brain volume (BV) of each patient was calculated with a semiautomatic threshold algorithm of 3D-slicer, and the change in brain volume (CIBV) was obtained by subtracting the two extreme values (CIBV = BV_max – BV_min). The CRBV was obtained by CIBV/BV_min × 100%. The CRBV values that predicted unfavorable prognoses were estimated.

Results: In total, 130 subjects were enrolled in the study. The mean CRBV in the non-swelling group and swelling group were 4.37% (±4.77) and 11.87% (±6.84), respectively (p < 0.05). CRBV was positively correlated with the length of hospital stay, blood in the ambient cistern, blood in the lateral ventricle, and lateral ventricular volume (Spearman ρ = 0.334; p < 0.001; Pearson ρ = 0.269, p = 0.002; Pearson ρ = 0.278, p = 0.001; Pearson ρ = 0.233, p = 0.008, respectively). Analysis of variance showed significant differences in CIBV, CRBV, blood in the ambient cistern, blood in the lateral ventricle, and lateral ventricular volume among varying modified Fisher scale (mFisher), with higher admission mFisher scale, indicating larger values of these variables. After adjusting for risk factors, the model showed that for every 1% increase in the CRBV, the probability of poor clinical prognosis increased by a factor of 1.236 (95% CI = 1.056–1.446). In the stratified analysis, the odds of worse clinical outcomes increased with increases in the CRBV. Receiver operating characteristic curve analysis showed that HH grade, mFisher scale, and score of CRBV (SCRBV) had diagnostic performance for predicting unfavorable clinical outcomes.

Conclusion: Primary brain swelling increases brain volume after aSAH. The CRBV quantified by 3D-Slicer can be used as a volumetric representation of the degree of brain swelling. A larger CRBV in the early stage of aSAH is associated with poor prognosis. The CRBV can be used as a neuroimaging biomarker of early brain injury after bleeding and may be an effective predictor of patients' clinical prognoses.

Vacuum Drains versus Passive Drains versus No Drains in Decompressive Craniectomies-A Randomized Controlled Trial on Subgaleal Drain Complication Rates (VADER Trial)

OBJECTIVE

Subgaleal drains are generally deemed necessary for cranial surgeries including decompressive craniectomies (DCs) to avoid excessive postoperative subgaleal hematoma (SGH) formation. Many surgeries have moved away from routine prophylactic drainage but the role of subgaleal drainage in cranial surgeries has not been addressed.

METHODS

This was a randomized controlled trial at 2 centers. A total of 78 patients requiring DC were randomized in a 1:1:1 ratio into 3 groups: vacuum drains (VD), passive drains (PD), and no drains (ND). Complications studied were need for surgical revision, SGH amount, new remote hematomas, postcraniectomy hydrocephalus (PCH), functional outcomes, and mortality.

RESULTS

Only 1 VD patient required surgical revision to evacuate SGH. There was no difference in SGH thickness and volume among the 3 drain types (P = 0.171 and P = 0.320, respectively). Rate of new remote hematoma and PCH was not significantly different (P = 0.647 and P = 0.083, respectively), but the ND group did not have any patient with PCH. In the subgroup analysis of 49 patients with traumatic brain injury, the SGH amount of the PD and ND group was significantly higher than that of the VD group. However, these higher amounts did not translate as a significant risk factor for poor functional outcome or mortality. VD may have better functional outcome and mortality.

CONCLUSIONS

In terms of complication rates, VD, PD, and ND may be used safely in DC. A higher amount of SGH was not associated with poorer outcomes. Further studies are needed to clarify the advantage of VD regarding functional outcome and mortality, and if ND reduces PCH rates.

Placement of Wound Drain After Anterior Circulation Aneurysm Clipping: A Single-Center Retrospective Study

OBJECTIVE

Wound drain used to be a routine procedure after craniotomy for aneurysm clipping, although this was not based on clinical evidence. The purpose of our study was to determine the necessity of wound drain placement after anterior circulation aneurysm surgery.

METHODS

Retrospective analysis of patients with anterior circulation aneurysms treated by clipping in the Department of Neurosurgery, Wuhan University Zhongnan hospital from January 2019 to December 2019 was carried out. Demographic and clinical data, including age, sex, body mass index, disease history, results of the laboratory and imaging examinations, and surgical logs, were reviewed.

RESULTS

A total of 236 patients (90 male and 146 female) were included in the analysis and were divided into a Drain group and a No Drain group according to whether postoperative wound drainage was applied. There was no statistical difference in the incidence of a postoperative extradural hematoma between patients in the 2 groups. However, the incidence of postoperative meningitis was higher in the Drain group than in the No Drain group (9.09% vs. 1.59%, P = 0.009), and the total length of stay and postoperative length of stay in the Drain group were also more extended than in the No Drain group (17.32 ± 6.45 vs. 14.43 ± 5.75, P = 0.005; 12.83 ± 5.07 vs. 9.82 ± 4.50, P = 0.007, respectively).

CONCLUSIONS

Postoperative wound drain did not significantly reduce the incidence of an extradural hematoma after anterior circulation aneurysm surgery. On the contrary, it may be associated with an increased incidence of postoperative meningitis and length of stay. Given these findings, the postoperative drain should be maintained cautiously and meet more rigorous application criteria.

Postoperative Treatment of Intracranial Hypotension Venous Congestion-Associated Brain Injury With Zolpidem

ABSTRACT

A previously independent 75-yr-old man developed postoperative intracranial hypotension-associated venous congestion after an elective T10-pelvis fusion, which was complicated by durotomy. Postoperative day 0 magnetic resonance imaging noted symmetric edema of the basal ganglia, thalami, and cerebellar cortex as well as smooth diffuse pachymeningeal enhancement and dural thickening, consistent with postoperative intracranial hypotension-associated venous congestion. On postoperative day 0, patient developed tonic clonic seizures, and on postoperative day 2, patient was unable to follow commands or blink to visual threat, able to track eyes to sound only, and spontaneously moved all limbs. Patient was started on zolpidem 2.5 mg on postoperative day 2, and 12 hrs later, he had significantly improved motor function, arousal, verbalization, and followed simple commands. After three doses, patient was fully alert and oriented with improved mobility and comprehension. Six zolpidem doses were administered in total, and repeat magnetic resonance imaging on postoperative day 16 showed markedly improved regional edema. The patient was admitted to a brain injury inpatient rehabilitation unit and was discharged to home 9 days later with Functional Independence Measure gain of 17. Intracranial hypotension can adversely affect primary mesocircuit structures supporting arousal. Zolpidem, a selective α-1-subunit GABA-A agonist, supports GABAergic tone in these regions. This patient's clinical presentation and recovery paralleled selective basal ganglial-thalamic edema development and resolution.

Hyperperfusion and intracranial hemorrhage after burr hole surgery of chronic subdural hematoma

Background:

Chronic subdural hematomas (CSDHs) mainly occur in elderly people and usually develop after minor head injuries. CSDH can be cured by a relatively simple burr hole surgery. Rarely reported, hemorrhagic postsurgical complications include subarachnoid, intracerebral, intraventricular, and remote cerebellar hemorrhages. The causes of such uncommon complications are difficult to explain and remain poorly understood.

Case Description:

We report the case study of an 89-year-old man with CSDH who presented with the right hemiparesis. He underwent burr hole surgery with a closed-drainage system. A computed tomography (CT) scan conducted the following day demonstrated an acute intraventricular hemorrhage and hyperperfusion of the ipsilateral hemisphere.

Conclusion:

This is a rare case of an acute hematoma in the ventricle following drainage of a CSDH. The likely mechanism of this intraventricular hemorrhage could be that the drainage of the hematoma produced a movement of the ventricle and hemisphere accompanied by hyperperfusion.

Fatal postoperative intracranial hypotension-associated venous congestion after elective laminectomy

Postoperative intracranial hypotension-associated venous congestion is a rare complication that features radiologic characteristics suggestive of hypoxic ischaemic encephalopathy without systemic hypoxia or hypotension actually occurring. This makes the condition prone to being misidentified as a complication of anaesthesia. In this case, a patient undergoing emergency haematoma evacuation after a previous lumbar laminectomy lost cerebrospinal fluid rapidly and accidentally via a wound drain. She subsequently developed postoperative seizures and eventually died some days later having never regained consciousness. A magnetic resonance imaging scan acquired after the event showed signs initially thought to be indicative of hypoxic ischaemic encephalopathy but was later identified to be postoperative intracranial hypotension-associated venous congestion due to temporary obstruction of the great cerebral vein, resulting in local rather than systemic hypoxia. Anaesthetists should be aware of this rare condition and be familiar with its pathophysiology and presentation.

Consensus statement from the international consensus meeting on post-traumatic cranioplasty

Background

Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach.

Methods

The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP.

Results

The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations.

Conclusions

This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Pseudohypoxic Brain Swelling after Drilling and Drainage for Chronic Subdural Hematoma

Pseudohypoxic brain swelling (PHBS) is a rare and potentially fatal complication that may occur in patients following uneventful brain surgery. We present a case of PHBS that developed after drilling and drainage of a chronic subdural hematoma. Neuroimaging findings, pathogenic factors, and therapy are also discussed.

Advantages of using a prophylactic epidural closed drain and non-watertight dura suture in a craniotomy near the "parietal site"

Background

In neurosurgery, the necessity of having a drainage tube is controversial. Subgaleal fluid collection (SFC) often occurs, especially in a craniotomy near the "parietal site".This study aimed to reassess the benefit of using a prophylactic epidural drainage (ED) and non-watertight dura suture in a craniotomy near the parietal site.

Methods

A retrospective review was conducted on 63 consecutive patients who underwent a craniotomy near the parietal site. The patients were divided into two groups according to different period. The deal group received ED and a non-watertight dura suture (drain group, DG), the control group that did not (non-drain group, NDG). Complications and patient recovery were evaluated and analysed.

Results

Three patients (11.5%, 26) in DG and 20 patients (54.1%, 37) in NDG presented with SFC (p < 0.05). One patient (3.8%) in DG and three patients (8.1%) in NDG presented with subdural tensile hydrops (STH) (p > 0.05). Six developed an infection in NDG (four intracranial infections, one abscess, one pulmonary infection), while none in DG (p > 0.05) developed infection. Three (11.5%) cases in DG and one (2.7%) case in NDG had muscle strength that improved postoperatively (p > 0.05). Fifteen (57.7%) in DG and 14 (37.8%) in NDG had epileptic seizures less frequently postoperatively (p < 0.05). The average temperature (37.4 °C vs 37.6 °C, p > 0.05), the maximum temperature (37.9 °C vs 38.1 °C, p > 0.05) on 3 PODs, the postoperative hospital stay day (7.5 days vs 8.0 days, p > 0.05), and the postoperative medicine fee (¥29762.0 vs ¥28321.0, p > 0.05) were analysed.

Conclusion

In patients who undergo a craniotomy near the parietal site, the prophylactic use of ED and a non-watertight dura suture helps reduce SFC, infection, and control epilepsy.

Risk factors of postoperative remote intracerebral hemorrhage after craniotomy for ruptured cerebral aneurysms

Objective

We aimed to identify the relation between perioperative cerebrospinal fluid (CSF) drain through lumbar drainage (LD) and development of postoperative (POP) remote intracerebral hemorrhage (rICH) in craniotomy to treat ruptured intracranial aneurysms.

Methods

We retrospectively reviewed consecutive patients who underwent craniotomy for ruptured cerebral aneurysms at the authors’ institution between 1998 and 2004. We subsequently compared the incidence and characteristics of POP rICH between the patients who had a perioperative LD and those who did not. All statistical analyses were conducted using the software package SPSS 19.0 (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant.

Results

We enrolled 688 patients, of which 80 patients (11.6%) received perioperative LD, and 608 did not. LD and non-LD groups were comparable because although clinical characteristics of the two groups were significantly different considering history of hypertension, timing of surgery, and closed system negative pressure suction drain (SD) placement, none of these three variables was an independent risk factor associated with POP rICH in multivariate analysis. POP rICH incidence was significantly higher in the LD goup (12.5%) than non-LD group (0.8%) (p=0.000) in univariate analysis. LD placement was the only independent risk factor associated with the development of rICH in multivariate logistic regression analysis.

Conclusions

POP rICH incidence was significantly higher in patients who were managed with perioperative LD than in those who did not. LD insertion in craniotomy for ruptured intracranial aneurysm, should be closely monitored to address the occurrence of POP rICH.

Surgical nuances and placement of subgaleal drains for supratentorial procedures-a prospective analysis of efficacy and outcome in 150 craniotomies

Background

For supratentorial craniotomy, surgical access, and closure technique, including placement of subgaleal drains, may vary considerably. The influence of surgical nuances on postoperative complications such as cerebrospinal fluid leakage or impaired wound healing overall remains largely unclear. With this study, we are reporting our experiences and the impact of our clinical routines on outcome in a prospectively collected data set.

Method

We prospectively observed 150 consecutive patients undergoing supratentorial craniotomy and recorded technical variables (type/length of incision, size of craniotomy, technique of dural and skin closure, type of dressing, and placement of subgaleal drains). Outcome variables (subgaleal hematoma/CSF collection, periorbital edema, impairment of wound healing, infection, and need for operative revision) were recorded at time of discharge and at late follow-up.

Results

Early subgaleal fluid collection was observed in 36.7% (2.8% at the late follow-up), and impaired wound healing was recorded in 3.3% of all cases, with an overall need for operative revision of 6.7%. Neither usage of dural sealants, lack of watertight dural closure, and presence of subgaleal drains, nor type of skin closure or dressing influenced outcome. Curved incisions, larger craniotomy, and tumor size, however, were associated with an increase in early CSF or hematoma collection (p < 0.0001, p = 0.001, p < 0.01 resp.), and larger craniotomy size was associated with longer persistence of subgaleal fluid collections (p < 0.05).

Conclusions

Based on our setting, individual surgical nuances such as the type of dural closure and the use of subgaleal drains resulted in a comparable complication rate and outcome. Subgaleal fluid collections were frequently observed after supratentorial procedures, irrespective of the closing technique employed, and resolve spontaneously in the majority of cases without significant sequelae. Our results are limited due to the observational nature in our single-center study and need to be validated by supportive prospective randomized design.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04196-6) contains supplementary material, which is available to authorized users.

Pseudohypoxic Brain Swelling After Uncomplicated Lumbar Decompression and Fusion for Spondylolisthesis

BACKGROUND

Pseudohypoxic brain swelling (PHBS), also known as postoperative intracranial hypotension-associated venous congestion, is a rare complication after neurosurgery characterized by rapid and often severe postoperative deterioration in consciousness and distinct imaging findings on brain magnetic resonance imaging. Imaging findings associated with PHBS include computed tomography and magnetic resonance imaging findings that resemble hypoxic changes and intracranial hypotensive changes in basal ganglia and thalamus, telencephalic, and infratentorial regions without notable changes in intracranial vasculature.

CASE DESCRIPTION

This report describes the case of an L4-5 microdiskectomy with posterior decompression and fusion complicated by clinical and radiographic findings resembling PHBS without a known intraoperative durotomy.

CONCLUSIONS

Spine surgeons should be alerted to the possibility that PHBS may occur in patients even after an operation without known durotomy or cerebrospinal fluid leakage and with spontaneous clinical resolution unrelated to suction drainage changes or epidural blood patches.

Craniocerebral disproportion after decompressive craniectomy in infants: The hidden enemy of cranial repair?

INTRODUCTION

Cranioplasty aims at restoring the physiological integrity and volume of the skull. Any disproportion between the intracranial content and the volume of the container may favor the occurrence of complications. A classification of volume mismatches is proposed. A negative mismatch, consisting of intracranial content minor to skull volume, is well represented by the sinking flap. On the other side, a positive mismatch, consisting of intracranial content higher than skull volume, usually depends on CSF collection or hydrocephalus once the brain edema is regressed. Though, in children, this condition may result from physiological brain growth after decompressive craniectomy. Treatment algorithm based on this classification is presented.

ILLUSTRATIVE CASE

A 1-year-old boy with a severe traumatic brain injury underwent right decompressive craniectomy, evacuation of subdural hematoma, and dural expansion at another institution. After failure of autologous bone-assisted cranioplasty for infection, a helmet was recommended in order to postpone the cranial repair. Patient was admitted to our institution 3 years later. CT scan showed brain herniation through the cranial defect, associated to a condition of acquired craniocerebral disproportion, due to the condition of "open skull". Augmented hydroxyapatite cranioplasty (CustomBone, Finceramica, Faenza, Italy) was performed in order to manage this rare condition of positive volume mismatch. Subsequent course was uneventful and no complication was recorded at 30-month follow-up.

CONCLUSIONS

This illustrative case highlights the possible occurrence of a positive structural mismatch between the skull and the intracranial content after decompressive craniectomy, thus configuring a condition of acquired craniocerebral disproportion, aside of other brain or CSF complications. We firstly recognize this condition in the literature and propose it as a possible factor affecting the outcome of cranioplasty in infants and young children.

Postoperative Drain Use in Cranial Vault Remodeling: A Survey of Craniofacial Surgeon Practices and a Review of the Literature

BACKGROUND

The use of subgaleal drains following primary cranioplasty for craniosynostosis has undergone limited investigation. Proposed benefits include prevention of seroma, detection of postoperative bleeding, and cerebrospinal fluid leak. We conducted a systematic review of the literature and surveyed craniofacial surgeons to ascertain the current evidence pertaining to drain use following primary cranioplasty for craniosynostosis and to determine surgical practice patterns.

METHODS

PubMed and Embase databases were searched to identify relevant articles. Abstracts were reviewed by 2 investigators, and a Cohen κ statistic was calculated. Patient demographic and outcome data were extracted and compared. A 9-question survey was e-mailed to active and associate members of the American Society of Craniofacial Surgeons.

RESULTS

A total of 7395 unique citations were identified. Only 2 retrospective chart reviews met inclusion criteria. All objective parameters demonstrated no difference between patients with and without drains. A subjective benefit of limiting facial swelling was proposed without objective analysis. Fifty (32.5%) of the 154 craniofacial surgeons responded to the survey. Forty-two percent used postoperative drains. A significant association (P = .01) was found between the belief that drains limited facial swelling and their use.

CONCLUSIONS

The literature examining postoperative drain use in primary cranioplasty for craniosynostosis is restricted. The current studies show no definite benefit to drain use but are limited in their assessment of key outcomes. There is wide variability among surgeons regarding drain use, and this seems to be motivated by belief and tradition.

The "Negative" Impact of a Subgaleal Drain: Post-cranioplasty Negative Pressure Subgaleal Drain-induced Ascending Transtentorial Herniation

One commonly practiced procedural step to reduce the risk of postoperative hematoma accumulation when performing cranioplasties is to place a closed negative-pressure subgaleal drain. We present a patient with sinking skin flap syndrome that underwent such a procedure and subsequently experienced immediate postoperative ascending transtentorial herniation and intracranial hemorrhage remote from the surgical site. On determining that the subgaleal drain was the responsible cause, it was immediate removed, and the patient had neurological recovery. Fewer than 30 cases of life-threatening subgaleal drain-related complications have been documented, and this is the first reported case of ascending herniation occurring after cranioplasty. This report illustrates the potential risks of subgaleal drainage, the importance of early recognition of this rare phenomenon and that intervention can be potentially life-saving.

Pseudohypoxic Brain Swelling After Elective Lumbar Spinal Surgery: Case Report

Pseudohypoxic brain swelling (or the more recent term, postoperative intracranial hypotension-associated venous congestion) is a rare and potentially deadly complication that can occur after routine spine or brain surgery. The mechanism of this injury has been described as a rapid cerebral spinal fluid drainage leading to venous cerebral congestion. The clinical and radiographic findings mimic those found in a patient who has suffered an anoxic brain injury. We present the third reported case of postoperative intracranial hypotension-associated venous congestion following spinal surgery.

Early post-operative cerebrospinal fluid hypovolemia: Report of 7 cases

Cerebrospinal fluid (CSF) hypovolemia is a common neurosurgical condition, which may be spontaneous or iatrogenic. At our institution, a substantial number of the reported cases of early post-operative CSF hypovolemia were identified to have unintentional or unrecognized post-operative continuous excessive CSF leakage. Cases who presented with post-operative CSF hypovolemia several days after uneventful intracranial surgeries without continuous CSF leakage were rarely reported. A retrospective review of the medical records of these patients was performed to identify those patients who developed early post-operative CSF hypovolemia without the presence of post-operative continuous CSF leakage. A total of 7 patients, 5 of which were males, were identified in this retrospective study. They experienced CSF hypovolemia between days 1 and 7 after emergency or scheduled intracranial surgeries. Ventricular collapse, cisternal effacement and midline shift are the most common radiological observations. With early diagnosis and management, 4 of the patients achieved a Glasgow Outcome Scale (GOS) score of 5, 1 achieved a GOS score of 4 and the remaining 2 had a GOS score of 3. No mortality was noted in this series. Although rare in incidence, early post-operative CSF hypovolemia may occur without the existence of post-operative continuous CSF leakage. When the diagnosis of CSF hypovolemia is reached, factors that may exacerbate CSF compensation should be promptly terminated. Trendelenburg position and sufficient intravenous hydration are practical and effective managements, and CSF hypovolemia may thereby be reversed in a substantial number of patients.

Compression of a giant pseudomeningocele causing transient anoxic seizures-a case report

Transient anoxic seizure upon application of pressure on a giant pseudomeningocele has never been reported in the literature; such abrupt changes in intracranial pressure due to large volume of cerebrospinal fluid (CSF) translocation, if left untreated may lead to permanent cerebral hypoxic injury and death. Here we describe a case of a 26-year-old woman who had undergone lumbar disc surgery in another unit few months ago and developed a large lump around her back. Any pressure on the lump resulted in headaches and at times episodes of seizures. Clinical examination revealed a very large fluid-filled lump consistent with a giant pseudomeningocele, confirmed by an MRI. A video EEG while applying pressure on the lump was recorded. The patient developed a typical seizure attack with a characteristic pattern of cerebral anoxia, and a paired ECG showed irregular rhythm with junctional and ventricular ectopic beats during the latter part of the attack, raising a suspicion of asystole. Upon relieving the pressure off the lump, the patient gradually regained consciousness with no permanent neurological deficit. We then discuss the pathophysiology of anoxic seizures and highlight the need to be vigilant in managing patients with such lesions in order to prevent permanent cerebral hypoxic injury and death.

Massive Brain Swelling and Death After Cranioplasty: A Systematic Review

BACKGROUND

Although cranioplasty is a common procedure, it may cause a variety of complications. Massive brain swelling after cranioplasty (MBSC) is an unusual complication that has been reported more frequently in recent years. Most of the existing information about this condition is speculative and the cause remains unclear.

METHODS

A PubMed and Scopus search adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed to include studies reporting patients with MBSC. Different information was analyzed in these cases to describe the characteristics and identify risk factors for MBSC.

RESULTS

The search yielded 19 articles with a total of 26 patients. All studies were case reports and small case series. In most patients, preoperative intracranial hypotension and a considerable degree of sinking of skin flap were identified; this was the only constant finding observed in these cases. In addition, we propose a grading system to estimate the degree of preoperative sinking of skin flap and an algorithm with recommendations to decrease the incidence of MBSC.

CONCLUSIONS

MBSC is an unusual, highly lethal, and probably underreported condition. The information gathered in this review indicates that MBSC occurs secondary to a cascade of pathologic events triggered by the bone flap implantation. This evidence suggests that the primary pathologic change is a sudden increase in the intracranial pressure acting on a brain chronically exposed to intracranial hypotension.

Intracranial Hypotension-associated Cerebral Swelling following Cranioplasty: Report of Two Cases

Cranioplasty is a comparatively simple neurosurgical procedure, and fatal complications are rare. This report describes two cases of critical brain swelling after otherwise uneventful cranioplasty. Both cases had subarachnoid hemorrhage and extremely similar clinical courses. They underwent decompressive craniotomy and clipping in the acute phase and had cranioplasty in the chronic phase, resulting in serious cerebral swelling and death. Deep venous sinus thrombosis was revealed in the autopsy for one case. Although no venous occlusion was identified in the other case, radiological findings suggested venous congestion. In both cases, intraoperative cerebrospinal fluid leakage was massive and was prolonged by a drain; therefore, we hypothesized that intracranial hypotension (IH) caused stagnation of venous flow. Neurosurgeons should be aware that fatal venous congestion induced by IH may occur after cranioplasty. To avoid this, tight dural closure should be obtained, and avoidance of the use of subcutaneous drains should be considered.

Malignant Cerebral Swelling After Cranioplasty: Case Report and Literature Review

BACKGROUND

Cranioplasty is considered a low-risk operation in the field of neurosurgery following decompression craniectomy. Well-known complications after cranioplasty, such as infection, seizure, and titanium plate exposure, may not threaten the lives of patients. Unfortunately, there are many fatal complications that are underreported. In this study, we report a case and perform a literature review to introduce malignant cerebral swelling, which is regarded as a devastating complication.

CASE DESCRIPTION

A 51-year-old man who was a victim of traumatic brain injury underwent emergency clot removal and decompression craniectomy. His neurologic condition improved with subsequent rehabilitation therapy, and he had left sinking skin flap syndrome where the skull was defective. Six months after the initial surgery, he underwent a cranioplasty; however, he did not recover from the uneventful anesthesia. A vacuum suction drain showed 300 mL of flow outflow had drained when his pupils dilated and fixed. An immediate computed tomography scan showed ipsilateral diffuse cerebral swelling with diffuse cerebral hemorrhage. Despite all approaches that were considered, the cerebral swelling continued to worsen until death.

CONCLUSION

Cranioplasty is a high-risk procedure in some cases. Sinking skin flap syndrome and vacuum suction drain may be the main risks of a postoperative venous congestion and stasis, which may result in diffuse cerebral swelling. Once the computed tomography scan shows malignant cerebral swelling, the patient is expected to have a poor prognosis.

Prompt Recognition and Management of Postoperative Intracranial Hypotension-Associated Venous Congestion: A Case Report

BACKGROUND

Postoperative intracranial hypotension-associated venous congestion (PIHV) is an uncommon cause of clinical deterioration after a neurosurgical procedure that is often unrecognized until late in its course. Functional outcomes range from remarkable neurological recovery to death. Little is understood about the reason for deterioration in certain patients compared with improvement in others. A 68-year-old man with a progressive cervical myelopathy underwent an uncomplicated cervical decompression and alignment restoration at our hospital and suffered violent generalized tonic-clonic seizures intraoperatively and postoperatively. A postoperative head CT showed a right parietal hematoma, but no other cranial findings. A subsequent MRI demonstrated what we describe as early PIHV with symmetric T2 signal changes in the bilateral deep gray structures. No diffusion restriction corresponded to these areas. A CT myelogram revealed a considerable CSF collection within the operative bed. Upon returning to the operating room to localize the source of the leak, a large dural tear was identified off of midline with a bone chip alongside the defect. The defect was repaired, and the patient remained comatose for over a week postoperatively. He made a remarkable gradual recovery, and after a month in the hospital and rehabilitation, he returned home with relatively minimal neurological deficits.

CONCLUSIONS

We postulate that if caught early and treated aggressively, neurologic injury resulting from PIHV may be reversible despite initially ominous imaging. Neurosurgeons and neurointensivists should therefore be compelled to search for dural defects and return to the operating room for immediate repair.

Jackson-Pratt drainage in pediatric craniofacial reconstructive surgery: is it helping or hurting?

OBJECTIVE Jackson-Pratt drains (JPDs) are commonly employed in pediatric craniofacial reconstructive surgery (CRFS) to reduce postoperative wound complications, but their risk profile remains unknown. Perioperative blood loss and volume shifts are major risks of CFRS. The goal of this study was to evaluate the risks of JPD usage in CFRS, particularly with regard to perioperative blood loss, hyponatremia, intensive care unit (ICU) length of stay, and postoperative wound complications. METHODS The authors performed a retrospective review of data obtained in pediatric patients who underwent CFRS at a single institution, as performed by multiple surgeons between January 2010 and December 2014. Data were gathered from patients who did and did not receive JPDs at the time of surgery. Outcome measures were compared between the JPD and no-JPD groups. RESULTS The overall population 179 pediatric patients: 128 who received JPDs and 51 who did not. In their analysis, the authors found no significant differences in baseline patient characteristics between the two groups. The average JPD output over the first 48 hours was 222 ± 142 ml. When examining the immediate preoperative to immediate postoperative time period, no significant differences were noted between the groups with regard to the need for blood transfusion or changes in hemoglobin, hematocrit, or serum sodium levels. These differences were also not significant when examining the 48-hour postoperative period. Finally, no significant differences in hospital length of stay, ICU length of stay, or emergency department visits at 60 days were noted between the two groups. CONCLUSIONS In this retrospective study, the use of JPDs in pediatric CFRS was not associated with an increased risk of serious perioperative complications, although the benefits of this practice remain unclear.

Malignant Cerebral Swelling After Cranioplasty due to Ipsilateral Intracranial Vasculopathy: Case Report and Literature Review

BACKGROUND

Cranioplasty is a well-established surgical operation that is used worldwide for patients with skull defects following decompressive craniectomy (DC). However, in some cases, potentially fatal complications may occur, such as malignant cerebral swelling after uneventful cranioplasty.

CASE DESCRIPTION

We present a rare case of massive malignant ipsilateral cerebral swelling following uneventful titanium mesh cranioplasty due to rare ipsilateral intracranial vasculopathy confirmed by magnetic resonance angiography (MRA) and magnetic resonance venography (MRV). Fortunately, we performed titanium mesh explantation and extended DC in time, and the patient survived. Malignant cerebral swelling after uneventful cranioplasty is an unpredictable but fatal complication. Most reported cases have had an unfavorable prognosis. To the best of our knowledge, the mechanism was first confirmed by MRA and MRV, which demonstrated that the cerebral swelling was due to unilateral intracranial vasculopathy, including a rare ipsilateral intracranial internal carotid artery occlusion, as well as extremely thin lateral and sigmoid sinuses.

CONCLUSIONS

Our case demonstrates for the first time that ipsilateral intracranial vasculopathy is a risk factor for malignant cerebral swelling after cranioplasty. Patients with traumatic brain injury with suspected intracranial vasculopathy should undergo a comprehensive vascular evaluation before cranioplasty to help prevent malignant cerebral swelling.

Unexpected complications immediately after cranioplasty

Case

An 84-year-old man with subarachnoid hemorrhage underwent craniotomy and clipping with external decompression. Perfusion magnetic resonance imaging showed subclinical sinking skin flap syndrome, and he underwent cranioplasty on postoperative day 58. No problems occurred during the operation, but cerebral edema and hemorrhage were recognized on immediate postoperative computed tomography. Edema continued to progress, but edema and bleeding eventually improved without additional surgery.

Outcome

Neurological symptoms improved to presurgical baseline and stabilized.

Conclusion

Causes of cerebral edema and hemorrhage immediately after cranioplasty include reperfusion, reduction of automatic adjustment function, sinking skin flap syndrome, negative pressure due to s.c. drain, venous stasis, vascular damage following restoration of midline shift, and allergic reaction. Although cranioplasty itself is a relatively minor surgery, the fatality rate for this complication is high. Most complications are due to infection, convulsions, or epidural hematoma, but brain edema and hemorrhage also occur. It is necessary to elucidate the etiology before corrective surgery.

Cerebral venous overdrainage: an under-recognized complication of cerebrospinal fluid diversion

Understanding the altered physiology following cerebrospinal fluid (CSF) diversion in the setting of adult hydrocephalus is important for optimizing patient care and avoiding complications. There is mounting evidence that the cerebral venous system plays a major role in intracranial pressure (ICP) dynamics especially when one takes into account the effects of postural changes, atmospheric pressure, and gravity on the craniospinal axis as a whole. An evolved mechanism acting at the cortical bridging veins, known as the “Starling resistor,” prevents overdrainage of cranial venous blood with upright positioning. This protective mechanism can become nonfunctional after CSF diversion, which can result in posture-related cerebral venous overdrainage through the cranial venous outflow tracts, leading to pathological states. This review article summarizes the relevant anatomical and physiological bases of the relationship between the craniospinal venous and CSF compartments and surveys complications that may be explained by the cerebral venous overdrainage phenomenon. It is hoped that this article adds a new dimension to our therapeutic methods, stimulates further research into this field, and ultimately improves our care of these patients.

Cardiac arrest due to intracranial hypotension following pseudohypoxic brain swelling induced by negative suction drainage in a cranioplasty patient: a case report

Pseudohypoxic brain swelling (PHBS) is known to be an uncommon event that may occur during and following an uneventful brain surgery, when negative suction drainage is used. The cerebrospinal fluid loss related to suction drainage can evoke intracranial hypotension that progress to PHBS. The main presentations of PHBS are sudden unexpected circulatory collapses, such as severe bradycardia, hypotension, cardiac arrest, consciousness deterioration and diffuse brain swelling as seen with brain computerized tomography (CT). We present a stuporous 22-year-old patient who underwent cranioplasty under general anesthesia. The entire course of the general anesthesia and operation progressed favorably. However, the time of scalp suture completion, sudden bradycardia and hypotension occurred, followed by cardiac arrest immediately after initiation of subgaleal and epidural suction drainage. After successful resuscitation, the comatose patient was transferred to the neurosurgical intensive care unit and PHBS was confirmed using brain CT.

Massive cerebral swelling immediately after cranioplasty, a fatal and unpredictable complication: report of 4 cases

Cranioplasty after decompressive craniectomy (DC) is associated with increased morbidity, but the reported mortality rate is low. Recently, some authors have reported a rare unexplained complication of sudden death in association with massive cerebral edema immediately after cranioplasty.

The author reports on 4 patients who underwent cranioplasty after DC between January 2005 and August 2010 at his department and died because of massive cerebral edema immediately after uneventful surgery and anesthesia. All 4 of the new cases reported involved young male patients who underwent decompressive hemicraniectomy after traumatic brain injury. They developed massive cerebral swelling immediately after uneventful cranioplasty (3 patients) or after removal of an epidural hematoma several hours after surgery (1 patient). All 4 patients had a large skull defect and significantly sunken craniotomy site, and all were treated with a closed vacuum suction system that was placed under the scalp and kept open at the end of the cranioplasty procedure. After surgery, the patients' pupils became fixed and dilated, and brain CT scans showed massive brain edema. Despite emergency DC, the patients did not recover, and all 4 died. A MEDLINE search showed 8 similar cases that were reported previously.

Fatal cerebral swelling after uneventful cranioplasty is a distinct clinical entity, although it is unpredictable. It is postulated that a negative pressure difference from the elimination of atmospheric pressure that had been chronically applied on the injured sinking brain in combination with the negative pressure applied by the closed subgaleal suction drain may lead to a massive brain shift toward the cranioplasty site and initiate a fatal vasomotor reaction.

Necessity of Surgical Site Closed Suction Drain for Pterional Craniotomy

Objective

The aim of this study was to assess the benefit of using a prophylactic surgical site closed suction drain in pterional craniotomy.

Materials and Methods

A retrospective review was conducted on 607 consecutive patients who underwent a pterional craniotomy for treatment of intracranial anterior circulation aneurysms over a 5-year period. Between January 2000 and December 2004, 607 patients were divided into two groups, those who had a prophylactic suction drain during closure of the surgical site (drain group, DG) and those who did not (non-drain group, NDG). Head computed tomography (CT) was taken routinely on postoperative day (POD) 1, 7, and 14. Patients' demographics, incidence of surgical site complications, and courses of surgical site healing which were evaluated radiologically by the thickness of the surgical site myocutaneous layer, were analyzed between DG and NDG.

Results

Patients' demographics and characteristics did not differ significantly between the two groups. The head CT showed that the degree of changes in the postoperative surgical site thickness was 148% at POD 1, 209% at POD 7, and 198% at POD 14 in DG, and 118% at POD 1, 152% at POD 7, and 158% at POD 14 in NDG compared to the preoperative value. Postoperative surgical site hematoma was 7.9% (22/274) in DG and 2.4% (8/333) in NDG.

Conclusion

Prophylactic use of an epidural and/or subgaleal closed suction drain does not appear to be necessary for prevention of postoperative surgical site hematoma as well as for promotion of surgical site healing in pterional craniotomy.

Infrequent Hemorrhagic Complications Following Surgical Drainage of Chronic Subdural Hematomas

Chronic subdural hematomas mainly occur amongst elderly people and usually develop after minor head injuries. In younger patients, subdural collections may be related to hypertension, coagulopathies, vascular abnormalities, and substance abuse. Different techniques can be used for the surgical treatment of symptomatic chronic subdural hematomas : single or double burr-hole evacuation, with or without subdural drainage, twist-drill craniostomies and classical craniotomies. Failure of the brain to re-expand, pneumocephalus, incomplete evacuation, and recurrence of the fluid collection are common complications following these procedures. Acute subdural hematomas may also occur. Rarely reported hemorrhagic complications include subarachnoid, intracerebral, intraventricular, and remote cerebellar hemorrhages. The causes of such uncommon complications are difficult to explain and remain poorly understood. Overdrainage and intracranial hypotension, rapid brain decompression and shift of the intracranial contents, cerebrospinal fluid loss, vascular dysregulation and impairment of venous outflow are the main mechanisms discussed in the literature. In this article we report three cases of different post-operative intracranial bleeding and review the related literature.

Intracranial hypotension: clinical presentation, imaging findings, and imaging-guided therapy

PURPOSE OF REVIEW

To illustrate clinical presentations, imaging findings, and diagnostic and therapeutic approaches associated with various conditions of intracranial hypotension.

RECENT FINDINGS

Intracranial hypotension occurs spontaneously, following (lumbar) dural puncture, accidental dural opening, or excessive surgical cerebrospinal fluid drainage. The typical clinical manifestation - orthostatic headache - may be masqueraded by atypical clinical findings, including coma, frontotemporal dementia, leptomeningeal hemosiderosis-associated symptoms, and others. MRI signs are highly specific, but the imaging strategy to search for spinal cerebrospinal fluid leaks (none, computed tomography myelography, magnetic resonance myelography with gadolinium, digital subtraction myelography) is a matter of debate. The same is true for the mode of treatment (bed rest, blind, fluoroscopy or computed tomography-guided epidural blood patching, fibrin patching, surgery).

SUMMARY

Clinical presentation as well as diagnostic and therapeutic approaches in intracranial hypotension are very heterogenous.