[Decompression craniotomy in acute brain edema. Apropos of 30 operated cases]

Cerebral hemodynamic changes gauged by transcranial Doppler ultrasonography in patients with posttraumatic brain swelling treated by surgical decompression

Object

The use of decompressive craniectomy has experienced a revival in the previous decade, although its actual benefit on patients’ neurological outcome remains the subject of debate. A better understanding of the intracranial pressure dynamics, as well as of the metabolic and hemodynamic brain processes, may be useful in assessing the effect of this surgery on the pathophysiology of the swollen brain. The aim of this study was to use transcranial Doppler (TCD) ultrasonography to examine the hemodynamic changes in the brain after decompressive craniectomy in patients with head injury, in addition to examining the relationship between such hemodynamic changes and the patient’s neurological outcome.

Methods

Nineteen patients presenting with traumatic brain swelling and cerebral herniation syndrome who had undergone decompressive craniectomy with dural expansion were studied prospectively. The TCD ultrasonography measurements were performed bilaterally in both the middle cerebral artery (MCA) and in the distal portion of the cervical internal carotid artery (ICA) immediately prior to and after surgical decompression.

After surgery, the mean blood flow velocity (BFV) rose to 175 ± 209% of preoperative values in the MCA of the operated side, while rising to 132 ± 183% in the contralateral side; the difference between the mean BFV increase in in the MCA of both the decompressed and the opposite side reached statistical significance (p < 0.05). The mean BFV of the extracranial ICA increased to 91 ± 119% in the surgical side and 45 ± 60% in the opposite side. Conversely, the MCA pulsatility index (PI) values decreased, on average, to 33 ± 36% of the preoperative value in the operated side and to 30 ± 34% on the opposite side; the MCA PI value reductions were significantly greater in the decompressed side when compared with the contralateral side (p < 0.05). The PI of the extracranial ICA reduced, on average, to 37 ± 23% of the initial values in the operated side and to 24 ± 34%, contralaterally. No correlation was verified between the neurological outcome and cerebral hemodynamic changes seen on TCD ultrasonography.

Conclusions

Decompressive craniectomy results in a significant elevation of cerebral BFV in most patients with traumatic brain swelling and transtentorial herniation syndrome. The increase in cerebral BFV may also occur in the side opposite the decompressed hemisphere; the cerebral BFV increase is significantly greater in the operated hemisphere than contralaterally. Concomitantly, PI values decrease significantly postoperatively, mainly in the decompressed cerebral hemisphere, indicating reduction in cerebrovascular resistance.

Craniotomia descompressiva para tratamento precoce da hipertensão intracraniana traumática

O papel da craniotomia descompressiva (CD) no tratamento da hipertensão intracraniana (HIC) refratária ainda não está estabelecido na literatura. Atualmente é recomendada como opção, pois há deficiência de trabalhos classe I ou II que suportem seu emprego. Trabalhos recentes têm avaliado a eficácia da CD quando aplicada precocemente no tratamento da HIC pós traumática. No presente trabalho analisam-se 21 pacientes nos quais a CD foi realizada precocemente. A maioria dos pacientes apresentava traumatismo cranioencefálico grave (Escala de coma glasgow <9) e tomografia de crânio evidenciando tumefação cerebral (brain swelling) ou hematoma subdural agudo. A principal complicação inerente à técnica foi a hidrocefalia (28,5%). Boa reabilitação social ocorreu em 11 pacientes (52,5%). Parece que a CD, quando realizada precocemente, é eficaz no tratamento da HIC refratária, ressaltando-se ainda a necessidade de estudos classe I e II que suportem esta opinião.

[Penetrating brain injury due to a large asbestos fragment treated by decompressive craniectomy: case report]

We report the case of a 22-year-old man victim of penetrating brain injury due to a 15 x 12 asbestos fragment and a successfully treatment via decompressive craniectomy. Unlike gunshot wounds to the head, penetrating brain injury from low energy objects are unusual. Most cases reported involve cranio-orbitary injuries as well as self inflicted lesions in mentally ill patients. The reported case is noteworthy due to the large dimensions of the foreign body, the treatment via decompressive craniectomy and the good patient functional outcome.

Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury

BACKGROUND

Decompressive craniectomy has historically served as a salvage procedure to control intracranial pressure after severe traumatic brain injury. We assessed the safety and feasibility of performing craniectomy as the initial surgical intervention.

METHODS

Of 29 consecutive patients undergoing emergent decompression for severe traumatic brain injury with horizontal midline shift greater than explained by a removable hematoma, 17 had traditional craniotomy with or without brain resection and 12 underwent craniectomy.

RESULTS

The craniectomy group had lower Glasgow Coma Scale scores at surgery (median, 4 vs. 7; p = 0.04) and more severe radiographic injuries (using specific measures). Mortality, Glasgow Outcome Scale scores, Functional Independence Measures, and length of stay in both the acute care setting and the rehabilitation phase were similar between the surgical groups.

CONCLUSION

Despite more severe injury severity, patients undergoing initial craniectomy had outcomes similar to those undergoing traditional surgery. A randomized evaluation of the effect of early craniectomy on outcome is warranted.

Surgical decompression for traumatic brain swelling: indications and results

OBJECT

Decompressive craniectomy has been performed since 1977 in patients with traumatic brain injury. The authors assess the efficacy of this treatment and the indications for its use.

METHODS

The clinical status of the 57 patients, their computerized tomography (CT) scans, and intracranial pressure (ICP) levels were documented prospectively in a standard protocol. At the beginning of the study, all patients older than 30 years were excluded. As of 1989 patients older than 40 years were excluded until 1991; since that time patients older than 50 years have been excluded. Primary brain or brainstem injury with fully developed bulbar brain syndrome, loss of auditory evoked potentials (AEPs), and/or oscillation flow in a transcranial Doppler ultrasound examination were contraindications to decompressive craniectomy. A positive indication for decompression was given in the case of progressive therapy-resistant intracranial hypertension in correlation with clinical (Glasgow Coma Scale [GCS] score, decerebrate posturing, dilating of pupils) and electrophysiological (electroencephalography, somatosensory evoked potentials, and AEPs) parameters and with findings on CT scans. Unilateral decompressive craniectomy was performed in 31 patients and bilateral craniectomy in 26 patients. In all cases, a wide frontotemporoparietal craniectomy was followed by a dura enlargement covered with temporal muscle fascia. The outcomes of the treatment were surprisingly good. Only 11 patients (19%) died, three of whom died of acute respiratory disease syndrome. Five patients (9%) survived, but remained in a persistent vegetative state; six patients (11%) survived with a severe permanent neurological deficit, and 33 patients (58%) attained social rehabilitation. Two patients (3.5%) did not have a follow-up examination. The GCS score on the 1st day posttrauma and the mean ICP turned out to be the best predictors for a good prognosis. The results demonstrate the importance of decompressive craniectomy in the treatment of traumatic brain swelling.

CONCLUSIONS

Surgical decompression should be routinely performed when indicated before irreversible ischemic brain damage occurs.

Impressão basilar e malformação de Arnold-Chiari: considerações técnico-cirúrgicas a propósito de 13 casos

Os autores empregaram detalhes técnicos pessoais para descompressão da fossa posterior em casos de impressão basilar e/ou maliormação de Arnold-Chiari, consistente em intuoação endotraqueal sem retroflexão da cabeça do paciente, sendo o mesmo operado em posição sentada e com a cabeça ereta. Foi realizada plástica da paquimeninge da fossa posterior com dura-mater de cadáver conservada em glicerina.

[Bifrontal decompressive craniotomy as the treatment for severe cerebral edema]

The authors present the results observed with large bifrontal decompressive craniotomy performed on 12 patients with severe cerebral edema, 10 of them related to cerebral contusion, which did not respond to conventional methods of therapy. All patients had before surgery very bad prognosis, with severe neurological signs of higher brain stem compression. Bilateral carotid angiography was sistematically performed before and after surgery, constituting as a matter of fact the decisive element indicating cerebral decompression. Six patients (50 per cent) survived and 5 of them (41.6 per cent) had an excellent neurological and mental improvement. Considering these results, we think that a large bifrontal decompressive craniotomy is the best method of treatment in such cases, specially when performed precociously. These patients, however, need very special care after surgery, if possible in units of intensive therapy, owing to the large incidence of complications.