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O'Donohoe TJ, Ovenden C, Bouras G, Chidambaram S, Plummer S, Davidson AS, Kleinig T, Abou-Hamden A. The role of decompressive craniectomy following microsurgical repair of a ruptured aneurysm: Analysis of a South Australian cerebrovascular registry. J Clin Neurosci 2024; 121:67-74. [PMID: 38364728 DOI: 10.1016/j.jocn.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Decompressive craniectomy (DC) remains a controversial intervention for intracranial hypertension among patients with aneurysmal subarachnoid haemorrhage (aSAH). METHODS We identified aSAH patients who underwent DC following microsurgical aneurysm repair from a prospectively maintained registry and compared their outcomes with a propensity-matched cohort who did not. Logistic regression was used to identify predictors of undergoing decompressive surgery and post-operative outcome. Outcomes of interest were inpatient mortality, unfavourable outcome, NIS-Subarachnoid Hemorrhage Outcome Measure and modified Rankin Score (mRS). RESULTS A total of 246 patients with aSAH underwent clipping of the culprit aneurysm between 01/09/2011 and 20/07/2020. Of these, 46 underwent DC and were included in the final analysis. Unsurprisingly, DC patients had a greater chance of unfavourable outcome (p < 0.001) and higher median mRS (p < 0.001) at final follow-up. Despite this, almost two-thirds (64.1 %) of DC patients had a favourable outcome at this time-point. When compared with a propensity-matched cohort who did not, patients treated with DC fared worse at all endpoints. Multivariable logistic regression revealed that the presence of intracerebral haemorrhage and increased pre-operative mid-line shift were predictive of undergoing DC, and WFNS grade ≥ 4 and a delayed ischaemic neurological deficit requiring endovascular angioplasty were associated with an unfavourable outcome. CONCLUSIONS Our data suggest that DC can be performed with acceptable rates of morbidity and mortality. Further research is required to determine the superiority, or otherwise, of DC compared with structured medical management of intracranial hypertension in this context, and to identify predictors of requiring decompressive surgery and patient outcome.
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Affiliation(s)
- Tom J O'Donohoe
- Department of Neurosurgery, Royal Adelaide Hospital, South Australia, Australia; University of Adelaide, South Australia, Australia.
| | - Christopher Ovenden
- Department of Neurosurgery, Royal Adelaide Hospital, South Australia, Australia
| | | | | | - Stephanie Plummer
- Department of Neurosurgery, Royal Adelaide Hospital, South Australia, Australia
| | - Andrew S Davidson
- Department of Neurosurgery, Royal Melbourne Hospital, Victoria, Australia
| | - Timothy Kleinig
- University of Adelaide, South Australia, Australia; Stroke Unit, Royal Adelaide Hospital, South Australia, Australia
| | - Amal Abou-Hamden
- Department of Neurosurgery, Royal Adelaide Hospital, South Australia, Australia; University of Adelaide, South Australia, Australia
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Siddiqi MM, Khawar WI, Donnelly BM, Lim J, Kuo CC, Monteiro A, Baig AA, Waqas M, Soliman MAR, Davies JM, Snyder KV, Levy EI, Siddiqui AH, Vakharia K. Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 175:e925-e939. [PMID: 37075897 DOI: 10.1016/j.wneu.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel preoperative and postoperative risk factors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis. METHODS A systematic search was conducted using PubMed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC was reported by >4 studies and could be extracted separately for patients who did or did not develop SDHC. RESULTS Thirty-seven studies were included, comprising 12,667 patients with aSAH (SDHC 2214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH, including high World Federation of Neurological Surgeons grades (odds ratio [OR], 2.43), hypertension (OR, 1.33), anterior cerebral artery (OR, 1.36), middle cerebral artery (OR, 0.65), and vertebrobasilar artery (2.21) involvement, decompressive craniectomy (OR, 3.27), delayed cerebral ischemia (OR, 1.65), and intracerebral hematoma (OR, 3.91). CONCLUSIONS Several new factors associated with increased odds of developing SDHC after aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of preoperative and postoperative prognosticators that may influence how surgeons recognize, treat, and manage patients with aSAH at high risk for developing SDHC.
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Affiliation(s)
- Manhal M Siddiqi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
| | - Wasiq I Khawar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Brianna M Donnelly
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Mohammed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Neurosurgery Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
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Size of Craniectomy Predicts Approach-Related Shear Bleeding in Poor-Grade Subarachnoid Hemorrhage. Brain Sci 2023; 13:brainsci13030371. [PMID: 36979181 PMCID: PMC10046376 DOI: 10.3390/brainsci13030371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Decompressive craniectomy is an option to decrease elevated intracranial pressure in poor-grade aneurysmal subarachnoid hemorrhage (SAH) patients. The aim of the present study was to analyze the size of the bone flap according to approach-related complications in patients with poor-grade SAH. We retrospectively analyzed poor-grade SAH patients (WFNS 4 and 5) who underwent aneurysm clipping and craniectomy (DC or ommitance of bone flap reinsertion). Postoperative CT scans were analyzed for approach-related tissue injury at the margin of the craniectomy (shear bleeding). The size of the bone flap was calculated using the De Bonis equation. Between 01/2012 and 01/2020, 67 poor-grade SAH patients underwent clipping and craniectomy at our institution. We found 14 patients with new shear bleeding lesion in postoperative CT scan. In patients with shear bleeding, the size of the bone flap was significantly smaller compared to patients without shear bleeding (102.1 ± 45.2 cm2 vs. 150.8 ± 37.43 cm2, p > 0.0001). However, we found no difference in mortality rates (10/14 vs. 23/53, p = 0.07) or number of implanted VP shunts (2/14 vs. 18/53, p = 0.2). We found no difference regarding modified Rankin Scale (mRS) 6 months postoperatively. In poor-grade aneurysmal SAH, the initial planning of DC—if deemed necessary —and enlargement of the flap size seems to decrease the rate of postoperatively developed shear bleeding lesions.
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Güresir E, Lampmann T, Brandecker S, Czabanka M, Fimmers R, Gempt J, Haas P, Haj A, Jabbarli R, Kalasauskas D, König R, Mielke D, Németh R, Oppong MD, Pala A, Prinz V, Ringel F, Roder C, Rohde V, Schebesch KM, Wagner A, Coch C, Vatter H. PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial. Trials 2022; 23:1027. [PMID: 36539817 PMCID: PMC9764529 DOI: 10.1186/s13063-022-06969-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is associated with poor neurological outcome and high mortality. A major factor influencing morbidity and mortality is brain swelling in the acute phase. Decompressive craniectomy (DC) is currently used as an option in order to reduce intractably elevated intracranial pressure (ICP). However, execution and optimal timing of DC remain unclear. METHODS PICASSO resembles a multicentric, prospective, 1:1 randomized standard treatment-controlled trial which analyzes whether primary DC (pDC) performed within 24 h combined with the best medical treatment in patients with poor-grade SAH reduces mortality and severe disability in comparison to best medical treatment alone and secondary craniectomy as ultima ratio therapy for elevated ICP. Consecutive patients presenting with poor-grade SAH, defined as grade 4-5 according to the World Federation of Neurosurgical Societies (WFNS), will be screened for eligibility. Two hundred sixteen patients will be randomized to receive either pDC additional to best medical treatment or best medical treatment alone. The primary outcome is the clinical outcome according to the modified Rankin Scale (mRS) at 12 months, which is dichotomized to favorable (mRS 0-4) and unfavorable (mRS 5-6). Secondary outcomes include morbidity and mortality, time to death, length of intensive care unit (ICU) stay and hospital stay, quality of life, rate of secondary DC due to intractably elevated ICP, effect of size of DC on outcome, use of duraplasty, and complications of DC. DISCUSSION This multicenter trial aims to generate the first confirmatory data in a controlled randomized fashion that pDC improves the outcome in a clinically relevant endpoint in poor-grade SAH patients. TRIAL REGISTRATION DRKS DRKS00017650. Registered on 09 June 2019.
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Affiliation(s)
- Erdem Güresir
- grid.15090.3d0000 0000 8786 803XDepartment of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Tim Lampmann
- grid.15090.3d0000 0000 8786 803XDepartment of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Simon Brandecker
- grid.15090.3d0000 0000 8786 803XDepartment of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Marcus Czabanka
- grid.7839.50000 0004 1936 9721Department of Neurosurgery, Johann Wolfgang Goethe-University of Frankfurt, Schleusenweg 2-16, D-60529 Frankfurt, Germany
| | - Rolf Fimmers
- grid.15090.3d0000 0000 8786 803XInstitute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Jens Gempt
- grid.6936.a0000000123222966Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Patrick Haas
- grid.10392.390000 0001 2190 1447Department of Neurosurgery, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, D-72076 Tübingen, Germany
| | - Amer Haj
- grid.411941.80000 0000 9194 7179Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss Allee 11, D-93053 Regensburg, Germany
| | - Ramazan Jabbarli
- grid.410718.b0000 0001 0262 7331Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Hufelandstraße 55, D-45147 Essen, Germany
| | - Darius Kalasauskas
- grid.410607.4Department of Neurosurgery, Mainz University Hospital, Langenbeckstraße 1, D-55131 Mainz, Germany
| | - Ralph König
- grid.6582.90000 0004 1936 9748Department of Neurosurgery, University of Ulm/BKH Günzburg, Lindenallee 2, D-89312 Günzburg, Germany
| | - Dorothee Mielke
- grid.7450.60000 0001 2364 4210Department of Neurosurgery, Georg-August-University Göttingen, Robert-Koch-Straße 40, D-37075 Göttingen, Germany
| | - Robert Németh
- grid.15090.3d0000 0000 8786 803XInstitute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Marvin Darkwah Oppong
- grid.410718.b0000 0001 0262 7331Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Hufelandstraße 55, D-45147 Essen, Germany
| | - Andrej Pala
- grid.6582.90000 0004 1936 9748Department of Neurosurgery, University of Ulm/BKH Günzburg, Lindenallee 2, D-89312 Günzburg, Germany
| | - Vincent Prinz
- grid.7839.50000 0004 1936 9721Department of Neurosurgery, Johann Wolfgang Goethe-University of Frankfurt, Schleusenweg 2-16, D-60529 Frankfurt, Germany
| | - Florian Ringel
- grid.410607.4Department of Neurosurgery, Mainz University Hospital, Langenbeckstraße 1, D-55131 Mainz, Germany
| | - Constantin Roder
- grid.10392.390000 0001 2190 1447Department of Neurosurgery, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, D-72076 Tübingen, Germany
| | - Veit Rohde
- grid.7450.60000 0001 2364 4210Department of Neurosurgery, Georg-August-University Göttingen, Robert-Koch-Straße 40, D-37075 Göttingen, Germany
| | - Karl-Michael Schebesch
- grid.411941.80000 0000 9194 7179Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss Allee 11, D-93053 Regensburg, Germany
| | - Arthur Wagner
- grid.6936.a0000000123222966Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Christoph Coch
- grid.15090.3d0000 0000 8786 803XClinical Study Core Unit, Study Center Bonn (SZB), University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Hartmut Vatter
- grid.15090.3d0000 0000 8786 803XDepartment of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
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Efficacy of autogenous bone grafts preserved in 80% ethanol solution for preventing surgical site infection after cranioplasty: A retrospective cohort study. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Decompressive Craniectomy for Infarction and Intracranial Hemorrhages. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tawk RG, Hasan TF, D'Souza CE, Peel JB, Freeman WD. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. Mayo Clin Proc 2021; 96:1970-2000. [PMID: 33992453 DOI: 10.1016/j.mayocp.2021.01.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/27/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.
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Affiliation(s)
- Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport
| | | | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Critical Care, Mayo Clinic, Jacksonville, FL
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Jabbarli R, He SQ, Darkwah Oppong M, Herten A, Chihi M, Pierscianek D, Dammann P, Sure U, Wrede KH. Size does matter: The role of decompressive craniectomy extent for outcome after aneurysmal subarachnoid hemorrhage. Eur J Neurol 2021; 28:2200-2207. [PMID: 33760316 DOI: 10.1111/ene.14835] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE In previous studies in patients with traumatic brain injury and ischemic stroke, the size of decompressive craniectomy (DC) was reported to be paramount with regard to patient outcomes. We aimed to identify the impact of DC size on treatment results in individuals with aneurysmal subarachnoid hemorrhage (SAH). METHODS The extent of DC in 232 patients with SAH who underwent bifrontal or hemicraniectomy between January 2003 and December 2015 was analyzed using semi-automated surface measurements. The study endpoints were course of intracranial pressure (ICP) treatment after DC, occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6 months (defined as modified Rankin scale score >3). The associations of DC size with the study endpoints were adjusted for DC timing, patient age, clinical and radiographic severity of SAH, aneurysm location, and treatment modality. RESULTS The mean DC surface area was 100.9 (±45.8) cm2 . In multivariate analysis, a large DC (>105 cm2 ) was independently associated with a lower risk of cerebral infarcts (adjusted odds ratio [aOR] 0.30, 95% confidence interval [CI] 0.16-0.56), in-hospital mortality (aOR 0.28, 95% CI 0.14-0.56) and unfavorable outcome (aOR 0.51, 95% CI 0.27-0.98). Moreover, SAH patients with a small DC size (<75 cm2 ) were more likely to require prolonged (>3 days, aOR 3.60, 95% CI 1.37-9.42) and enhanced (aOR 2.31, 95% CI 1.12-4.74) postoperative ICP treatment. CONCLUSION This is the first study showing the impact of DC size on postoperative ICP control and patient outcome in the context of SAH; specifically, a large craniectomy flap (>105 cm2 ) might lead to better outcomes in SAH patients requiring decompressive surgery.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Shi-Qing He
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany.,Department of Neurosurgery, Affiliated Nanhua Hospital, Hengyang Medical College, University of South China, Hengyang, Hunan, China
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
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Wang T, Kleiven S, Li X. Designing electrode configuration of electroosmosis based edema treatment as a complement to hyperosmotic therapy. Acta Neurochir (Wien) 2021; 163:2603-2614. [PMID: 34291383 PMCID: PMC8357759 DOI: 10.1007/s00701-021-04938-5] [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: 05/05/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hyperosmotic therapy is a mainstay treatment for cerebral edema. Although often effective, its disadvantages include mainly acting on the normal brain region with limited effectiveness in eliminating excess fluid in the edema region. This study investigates how to configure our previously proposed novel electroosmosis based edema treatment as a complement to hyperosmotic therapy. METHODS Three electrode configurations are designed to drive the excess fluid out of the edema region, including 2-electrode, 3-electrode, and 5-electrode designs. The focality and directionality of the induced electroosmotic flow (EOF) are then investigated using the same patient-specific head model with localized edema. RESULTS The 5-electrode design shows improved EOF focality with reduced effect on the normal brain region than the other two designs. Importantly, this design also achieves better directionality driving excess edema tissue fluid to a larger region of surrounding normal brain where hyperosmotic therapy functions better. Thus, the 5-electrode design is suggested to treat edema more efficiently via a synergic effect: the excess fluid is first driven out from the edema to surrounding normal brain via EOF, where it can then be treated with hyperosmotic therapy. Meanwhile, the 5-electrode design drives 2.22 mL excess fluid from the edema region in an hour comparable to the other designs, indicating a similar efficiency of EOF. CONCLUSIONS The results show that the promise of our previously proposed novel electroosmosis based edema treatment can be designed to achieve better focality and directionality towards a complement to hyperosmotic therapy.
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Affiliation(s)
- Teng Wang
- Division of Neuronic Engineering, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Hälsovägen 11C, SE-141 52, Huddinge, Sweden.
| | - Svein Kleiven
- Division of Neuronic Engineering, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Hälsovägen 11C, SE-141 52, Huddinge, Sweden
| | - Xiaogai Li
- Division of Neuronic Engineering, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Hälsovägen 11C, SE-141 52, Huddinge, Sweden
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Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: Who and when? – A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 199:106252. [DOI: 10.1016/j.clineuro.2020.106252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
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Yu H, Guo L, He J, Kong J, Yang M. Role of decompressive craniectomy in the management of poor-grade aneurysmal subarachnoid hemorrhage: short- and long-term outcomes in a matched-pair study. Br J Neurosurg 2020; 35:785-791. [PMID: 32945182 DOI: 10.1080/02688697.2020.1817851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the short- and long-term therapeutic effect and possibility of decompressive craniectomy (DC) for patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). METHODS Patients suffering from aSAH (Hunt-Hess grades IV, V) who underwent DC from January 2008 to April 2016 were enrolled in this study, and a sample-matched control group was set up. Information regarding participants' demography, clinical characteristics, and neuroimaging findings was systematically established. The outcome of a 6-month to 3-year follow-up was assessed according to the Glasgow outcome scale (GOS), modified Rankin Scale (mRS) and Barthel Index (BI). RESULTS Patients who had DC (21) experienced a statistically significant decrease in short-term mortality compared with those without DC (24, p < 0.05) and showed a decrease in intracranial pressure (ICP) after surgery. However, there was no significant difference in the long-term assessment (GOS/mRS/BI) between the two groups. CONCLUSIONS Some critical patients who have refractory ICP after poor-grade aSAH would benefit from DC for prolonging life in the short term if performed early. Nevertheless, the overall outcome for the long term remains disappointing, larger and longer prospective studies are urgently needed to investigate this issue.
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Affiliation(s)
- Hai Yu
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Liang Guo
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Junhua He
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Jun Kong
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Min Yang
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
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12
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Jabbarli R, Darkwah Oppong M, Roelz R, Pierscianek D, Shah M, Dammann P, Scheiwe C, Kaier K, Wrede KH, Beck J, Sure U. The PRESSURE score to predict decompressive craniectomy after aneurysmal subarachnoid haemorrhage. Brain Commun 2020; 2:fcaa134. [PMID: 33215084 PMCID: PMC7660044 DOI: 10.1093/braincomms/fcaa134] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 12/14/2022] Open
Abstract
The prognosis of patients with aneurysmal subarachnoid haemorrhage requiring decompressive craniectomy is usually poor. Proper selection and early performing of decompressive craniectomy might improve the patients’ outcome. We aimed at developing a risk score for prediction of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. All consecutive aneurysmal subarachnoid haemorrhage cases treated at the University Hospital of Essen between January 2003 and June 2016 (test cohort) and the University Medical Center Freiburg between January 2005 and December 2012 (validation cohort) were eligible for this study. Various parameters collected within 72 h after aneurysmal subarachnoid haemorrhage were evaluated through univariate and multivariate analyses to predict separately primary (PrimDC) and secondary decompressive craniectomy (SecDC). The final analysis included 1376 patients. The constructed risk score included the following parameters: intracerebral (‘Parenchymal’) haemorrhage (1 point), ‘Rapid’ vasospasm on angiography (1 point), Early cerebral infarction (1 point), aneurysm Sac > 5 mm (1 point), clipping (‘Surgery’, 1 point), age Under 55 years (2 points), Hunt and Hess grade ≥ 4 (‘Reduced consciousness’, 1 point) and External ventricular drain (1 point). The PRESSURE score (0–9 points) showed high diagnostic accuracy for the prediction of PrimDC and SecDC in the test (area under the curve = 0.842/0.818) and validation cohorts (area under the curve = 0.903/0.823), respectively. 63.7% of the patients scoring ≥6 points required decompressive craniectomy (versus 12% for the PRESSURE < 6 points, P < 0.0001). In the subgroup of the patients with the PRESSURE ≥6 points and absence of dilated/fixed pupils, PrimDC within 24 h after aneurysmal subarachnoid haemorrhage was independently associated with lower risk of unfavourable outcome (modified Rankin Scale >3 at 6 months) than in individuals with later or no decompressive craniectomy (P < 0.0001). Our risk score was successfully validated as reliable predictor of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. The PRESSURE score might present a background for a prospective randomized clinical trial addressing the utility of early prophylactic decompressive craniectomy in aneurysmal subarachnoid haemorrhage.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
| | | | - Roland Roelz
- Department of Neurosurgery, Medical Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
| | - Mukesch Shah
- Department of Neurosurgery, Medical Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg Institute for Medical Biometry and Medical Informatics, University Medical Center Freiburg, D-79106 Freiburg, Germany
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany
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13
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Primary decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage: long-term outcome in a single-center study and systematic review of literature. Neurosurg Rev 2020; 44:2153-2162. [PMID: 32920754 PMCID: PMC8338868 DOI: 10.1007/s10143-020-01383-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/16/2020] [Accepted: 09/01/2020] [Indexed: 11/16/2022]
Abstract
Primary decompressive craniectomy (PDC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in order to decrease elevated intracranial pressure (ICP) is controversially discussed. The aim of this study was to analyze the effect of PDC on long-term clinical outcome in these patients in a single-center cohort and to perform a systematic review of literature. Eighty-seven consecutive poor-grade SAH patients (World Federation of Neurosurgical Societies (WFNS) grades IV and V) were analyzed between October 2012 and August 2017 at the author’s institution. PDC was performed due to clinical signs of herniation or brain swelling according to the treating surgeon. Outcome was analyzed according to the modified Rankin Scale (mRS). Literature was systematically reviewed up to August 2019, and data of poor-grade aSAH patients who underwent PDC was extracted for statistical analyses. Of 87 patients with poor-grade aSAH in the single-center cohort, 38 underwent PDC and 49 did not. Favorable outcome at 2 years post-hemorrhage did not differ significantly between the two groups (26% versus 20%). Systematic literature review revealed 9 studies: Overall, a favorable outcome could be achieved in nearly half of the patients (49%), with an overall mortality of 24% (median follow-up 11 months). Despite a worse clinical status at presentation (significantly higher rate of mydriasis and additional ICH), poor-grade aSAH patients with PDC achieve favorable outcome in a significant number of patients. Therefore, treatment and PDC should not be omitted in this severely ill patient collective. Prospective controlled studies are warranted.
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14
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Kolar M, Nohejlova K, Duska F, Mares J, Pachl J. Changes of cortical perfusion in the early phase of subarachnoid bleeding in a rat model and the role of intracranial hypertension. Physiol Res 2018; 66:S545-S551. [PMID: 29355383 DOI: 10.33549/physiolres.933795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Brain perfusion is reduced early after subarachnoid hemorrhage (SAH) due to intracranial hypertension and early vasospasm. The contribution of these two mechanisms is unknown. By performing a prophylactic decompressive craniectomy (DC) in a rat model of SAH we aimed to study brain perfusion after the component of intracranial hypertension has been eliminated. We used 2x2 factorial design, where rats received either decompressive craniectomy or sham operation followed by injection of 250 microl of blood or normal saline into prechiasmatic cistern. The cortical perfusion has been continually measured by laser speckle-contrast analysis for 30 min. Injection of blood caused a sudden increase of intracranial pressure (ICP) and drop of cerebral perfusion, which returned to baseline within 6 min. DC effectively prevented the rise of ICP, but brain perfusion after SAH was significantly lower and took longer to normalize compared to non-DC animals due to increased cerebral vascular resistance, which lasted throughout 30 min experimental period. Our findings suggest that intracranial hypertension plays dominant role in the very early hypoperfusion after SAH whilst the role of early vasospasm is only minor. Prophylactic DC effectively maintained cerebral perfusion pressure, but worsened cerebral perfusion by increased vascular resistance.
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Affiliation(s)
- M Kolar
- Department of Anesthesiology and Critical Care Medicine, Teaching Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic.
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15
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Pilipenko YV, Konovalov AN, Eliava SS, Belousova OB, Okishev DN, Sazonov IA, Tabasaranskiy TF. [Reasonability and efficacy of decompressive craniectomy in patients with subarachnoid hemorrhage after microsurgical aneurysm exclusion]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018. [PMID: 29543217 DOI: 10.17116/neiro201882159-71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, the so-called primary or preventive decompressive craniectomy (DC) has been increasingly used in patients with aneurysmal subarachnoid hemorrhage (SAH). The main goal of the technique is prevention of refractory intracranial hypertension (ICH) and its consequences. PURPOSE The study purpose was to define the CT criteria for reasonability and efficacy of DC as well as clarification of the indications for preventive DC in patients with SAH after microsurgical aneurysm exclusion. MATERIAL AND METHODS The study included 46 patients who underwent microsurgical clipping of aneurysms and DC in the period between 2010 and 2016. All patients underwent surgery in the period of 1 to 12 days after SAH. Preventive DC (imultaneously with clipping of aneurysms) was performed in 38 patients. Secondary (delayed) DC was performed in 8 patients. RESULTS Mortality in a group of all patients with DC was 15.2%. Preventive DC was considered as 'reasonable' when the patient had signs of cerebral edema in the postoperative period. The X-ray criteria of reasonable DC included a more than 5 mm brain prolapse into the trephination defect or a lateral dislocation of more than 5 mm. If the patient had no prolapse and dislocation in the postoperative period, DC was considered 'unreasonable'. Among patients with ICH in the postoperative period, including 20 patients with reasonable preventive DC and 8 patients with delayed DC, mortality was 25%. The CT signs of efficient DC were found to be a more than 5 mm brain prolapse into the trephination defect in combination with a decrease in the lateral dislocation less than 5 mm. All seven patients with inefficient DC in our group died. To clarify the indications for preventive DC, we analyzed various preoperative factors in patients with reasonable and unreasonable DC. CONCLUSION In most cases, preventive DC in microsurgical aneurysm exclusion is indicated for patients in an extremely grave condition (Hunt-Hess Grade V), a lateral displacement of the mline structures of more than 5 mm, an intracranial hematoma of over 30 mL, and symptoms of acute cerebral ischemia (pronounced cerebral vasospasm and emerging ischemic foci).
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Affiliation(s)
- Yu V Pilipenko
- Burdenko Neurosurgery Institute, str. 4-ya Tverskaya-Yamskaya, 16, Moscow, Russia, 125047
| | - An N Konovalov
- Burdenko Neurosurgery Institute, str. 4-ya Tverskaya-Yamskaya, 16, Moscow, Russia, 125047
| | - Sh Sh Eliava
- Burdenko Neurosurgery Institute, str. 4-ya Tverskaya-Yamskaya, 16, Moscow, Russia, 125047
| | - O B Belousova
- Burdenko Neurosurgery Institute, str. 4-ya Tverskaya-Yamskaya, 16, Moscow, Russia, 125047
| | - D N Okishev
- Burdenko Neurosurgery Institute, str. 4-ya Tverskaya-Yamskaya, 16, Moscow, Russia, 125047
| | - I A Sazonov
- Burdenko Neurosurgery Institute, str. 4-ya Tverskaya-Yamskaya, 16, Moscow, Russia, 125047
| | - T F Tabasaranskiy
- Burdenko Neurosurgery Institute, str. 4-ya Tverskaya-Yamskaya, 16, Moscow, Russia, 125047
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16
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Alotaibi NM, Elkarim GA, Samuel N, Ayling OGS, Guha D, Fallah A, Aldakkan A, Jaja BNR, de Oliveira Manoel AL, Ibrahim GM, Macdonald RL. Effects of decompressive craniectomy on functional outcomes and death in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg 2017; 127:1315-1325. [PMID: 28059660 DOI: 10.3171/2016.9.jns161383] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) (World Federation of Neurosurgical Societies Grade IV or V) are often considered for decompressive craniectomy (DC) as a rescue therapy for refractory intracranial hypertension. The authors performed a systematic review and meta-analysis to assess the impact of DC on functional outcome and death in patients after poor-grade aSAH. METHODS A systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were identified through the Ovid Medline, Embase, Web of Science, and Cochrane Library databases from inception to October 2015. Only studies dedicated to patients with poor-grade aSAH were included. Primary outcomes were death and functional outcome assessed at any time period. Patients were grouped as having a favorable outcome (modified Rankin Scale [mRS] Scores 1-3, Glasgow Outcome Scale [GOS] Scores 4 and 5, extended Glasgow Outcome Scale [GOSE] Scores 5-8) or unfavorable outcome (mRS Scores 4-6, GOS Scores 1-3, GOSE Scores 1-4). Pooled estimates of event rates and odds ratios with 95% confidence intervals were calculated using the random-effects model. RESULTS Fifteen studies encompassing 407 patients were included in the meta-analysis (all observational cohorts). The pooled event rate for poor outcome across all studies was 61.2% (95% CI 52%-69%) and for death was 27.8% (95% CI 21%-35%) at a median of 12 months after aSAH. Primary (or early) DC resulted in a lower overall event rate for unfavorable outcome than secondary (or delayed) DC (47.5% [95% CI 31%-64%] vs 74.4% [95% CI 43%-91%], respectively). Among studies with comparison groups, there was a trend toward a reduced mortality rate 1–3 months after discharge among patients who underwent DC (OR 0.58 [95% CI 0.27–1.25]; p = 0.168). However, this trend was not sustained at the 1-year follow-up (OR 1.09 [95% CI 0.55-2.13]; p = 0.79). CONCLUSIONS Results of this study summarize the best evidence available in the literature for DC in patients with poor-grade aSAH. DC is associated with high rates of unfavorable outcome and death. Because of the lack of robust control groups in a majority of the studies, the effect of DC on functional outcomes versus that of other interventions for refractory intracranial hypertension is still unknown. A randomized trial is needed.
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Affiliation(s)
- Naif M Alotaibi
- 1Division of Neurosurgery, Department of Surgery, and
- 2Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario
| | | | - Nardin Samuel
- 1Division of Neurosurgery, Department of Surgery, and
| | - Oliver G S Ayling
- 3Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Daipayan Guha
- 1Division of Neurosurgery, Department of Surgery, and
- 2Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario
| | - Aria Fallah
- 4Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abdulrahman Aldakkan
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, King Saud University, Riyadh, Saudi Arabia
| | - Blessing N R Jaja
- 6Division of Neurosurgery, St. Michael's Hospital; and
- 7Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Airton Leonardo de Oliveira Manoel
- 6Division of Neurosurgery, St. Michael's Hospital; and
- 7Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada
| | | | - R Loch Macdonald
- 1Division of Neurosurgery, Department of Surgery, and
- 6Division of Neurosurgery, St. Michael's Hospital; and
- 7Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada
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17
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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: 11] [Impact Index Per Article: 1.6] [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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18
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Goedemans T, Verbaan D, Coert BA, Kerklaan BJ, van den Berg R, Coutinho JM, van Middelaar T, Nederkoorn PJ, Vandertop WP, van den Munckhof P. Neurologic Outcome After Decompressive Craniectomy: Predictors of Outcome in Different Pathologic Conditions. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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19
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Moringlane RB, Keric N, Freimann FB, Mielke D, Burger R, Duncker D, Rohde V, Eckardstein KLV. Efficacy and safety of durotomy after decompressive hemicraniectomy in traumatic brain injury. Neurosurg Rev 2017; 40:655-661. [DOI: 10.1007/s10143-017-0823-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/17/2017] [Accepted: 01/24/2017] [Indexed: 11/29/2022]
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20
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Jabbarli R, Oppong MD, Dammann P, Wrede KH, El Hindy N, Özkan N, Müller O, Forsting M, Sure U. Time Is Brain! Analysis of 245 Cases with Decompressive Craniectomy due to Subarachnoid Hemorrhage. World Neurosurg 2017; 98:689-694.e2. [DOI: 10.1016/j.wneu.2016.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/04/2016] [Accepted: 12/05/2016] [Indexed: 12/14/2022]
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21
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Zhao B, Tan X, Zhao Y, Cao Y, Wu J, Zhong M, Wang S. Variation in Patient Characteristics and Outcomes Between Early and Delayed Surgery in Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2016; 78:224-31. [PMID: 26421588 DOI: 10.1227/neu.0000000000001038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is no consensus regarding the optimal timing for surgery for poor-grade aneurysmal subarachnoid hemorrhage. OBJECTIVE To retrospectively evaluate variation in patient characteristics and outcomes between early and delayed surgery groups. METHODS Poor-grade aneurysmal subarachnoid hemorrhage was defined as a World Federation of Neurosurgical Societies grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 hours of ictus, and delayed surgery was defined as surgery after 72 hours. Outcomes were assessed by modified Rankin score. The mean time of follow-up was 12.5 ± 3.4 months. RESULTS Of the 118 patients included in the study, 80 (68%) underwent early surgery and 38 (32%) underwent delayed surgery. Patients with brain herniation (P < .001) and a lower Fisher grade (P = .02) more often underwent early surgery. Patients in the early group more often underwent decompressive craniectomy (P < .001). Postoperative complications and length of hospital stay did not differ, and outcomes were similar between the 2 groups. Forty (34%) patients had an excellent outcome (modified Rankin score 0-1). Multivariate analysis showed a slight trend toward an excellent outcome in the early surgery group. Younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were independent predictors of an excellent outcome. CONCLUSION Although patients with brain herniation and a lower Fisher grade were more likely to undergo early surgery, there was a slight trend toward an excellent outcome in the early surgery group. Patients with a younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were more likely to experience an excellent outcome.
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Affiliation(s)
- Bing Zhao
- *Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; ‡Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; §Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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22
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de Oliveira Manoel AL, Goffi A, Marotta TR, Schweizer TA, Abrahamson S, Macdonald RL. The critical care management of poor-grade subarachnoid haemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:21. [PMID: 26801901 PMCID: PMC4724088 DOI: 10.1186/s13054-016-1193-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Aneurysmal subarachnoid haemorrhage is a neurological syndrome with complex systemic complications. The rupture of an intracranial aneurysm leads to the acute extravasation of arterial blood under high pressure into the subarachnoid space and often into the brain parenchyma and ventricles. The haemorrhage triggers a cascade of complex events, which ultimately can result in early brain injury, delayed cerebral ischaemia, and systemic complications. Although patients with poor-grade subarachnoid haemorrhage (World Federation of Neurosurgical Societies 4 and 5) are at higher risk of early brain injury, delayed cerebral ischaemia, and systemic complications, the early and aggressive treatment of this patient population has decreased overall mortality from more than 50% to 35% in the last four decades. These management strategies include (1) transfer to a high-volume centre, (2) neurological and systemic support in a dedicated neurological intensive care unit, (3) early aneurysm repair, (4) use of multimodal neuromonitoring, (5) control of intracranial pressure and the optimisation of cerebral oxygen delivery, (6) prevention and treatment of medical complications, and (7) prevention, monitoring, and aggressive treatment of delayed cerebral ischaemia. The aim of this article is to provide a summary of critical care management strategies applied to the subarachnoid haemorrhage population, especially for patients in poor neurological condition, on the basis of the modern concepts of early brain injury and delayed cerebral ischaemia.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada. .,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Alberto Goffi
- Toronto Western Hospital MSNICU, 2nd Floor McLaughlin Room 411-H, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Tom R Marotta
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Simon Abrahamson
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - R Loch Macdonald
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
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23
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Neugebauer H, Jüttler E, Mitchell P, Hacke W. Decompressive Craniectomy for Infarction and Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00076-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Konovalov AN, Belousova OB, Pilipenko YV, Eliava SS. [Decompressive craniotomy in patients with intracranial aneurysmal hemorrhage]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016. [PMID: 28635699 DOI: 10.17116/neiro2016805144-150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Decompressive craniotomy (DCT) has been used for treatment of patients with acute aneurysmal subarachnoid hemorrhage (SAH) for more than 20 years. But so far, the attitude to this surgery is controversial, and the indications and contraindications for it are not clearly defined. The article reviews the domestic and foreign literature devoted to the issues of validity and efficacy of DCT in treatment of cerebral edema and intracranial hypertension in patients with aneurysmal SAH.
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Affiliation(s)
| | | | | | - Sh Sh Eliava
- Burdenko Neurosurgical Institute, Moscow, Russia
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25
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Meneghelli P, Cozzi F, Hasanbelliu A, Locatelli F, Pasqualin A. Surgical Management of Aneurysmal Hematomas: Prognostic Factors and Outcome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 123:3-11. [PMID: 27637622 DOI: 10.1007/978-3-319-29887-0_1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
From 1991 until 2013, 304 patients with intracranial hematomas from aneurysmal rupture were managed surgically in our department, constituting 17 % of all patients with aneurysmal rupture. Of them, 242 patents presented with isolated intracerebral hematomas (in 69 cases associated with significant intraventricular hemorrhage), 50 patients presented with combined intracerebral and subdural hematomas (in 11 cases associated with significant intraventricular hemorrhage), and 12 presented with an isolated subdural hematoma. The surgical procedure consisted of simultaneous clipping of the aneurysm and evacuation of the hematoma in all cases. After surgery, 16 patients (5 %) submitted to an additional decompressive hemicraniectomy, and 66 patients (21 %) submitted to a ventriculo-peritoneal shunt. Clinical outcomes were assessed at discharge and at 6 months, using the modified Rankin Scale (mRS); a favorable outcome (mRS 0-2) was observed in 10 % of the cases at discharge, increasing to 31 % at 6 months; 6-month mortality was 40 %. Applying uni- and multivariate analysis, the following risk factors were associated with a significantly worse outcome: age >60; preoperative Hunt-Hess grades IV-V; pupillary mydriasis (only on univariate); midline shift >10 mm; hematoma volume >30 cc; and the presence of hemocephalus (i.e., packed intraventricular hemorrhage). Based on these results, an aggressive surgical treatment should be adopted for most cases with aneurysmal hematomas, excluding patients with bilateral mydriasis persisting after rescue therapy.
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MESH Headings
- Adolescent
- Adult
- Age Factors
- Aged
- Aged, 80 and over
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/surgery
- Cerebral Angiography
- Computed Tomography Angiography
- Decompressive Craniectomy
- Endovascular Procedures
- Female
- Hematoma/diagnostic imaging
- Hematoma/etiology
- Hematoma/surgery
- Hematoma, Subdural, Intracranial/diagnostic imaging
- Hematoma, Subdural, Intracranial/etiology
- Hematoma, Subdural, Intracranial/surgery
- Humans
- Intracranial Aneurysm/complications
- Intracranial Aneurysm/diagnostic imaging
- Intracranial Aneurysm/surgery
- Male
- Middle Aged
- Multivariate Analysis
- Mydriasis/etiology
- Neurosurgical Procedures
- Prognosis
- Retrospective Studies
- Risk Factors
- Rupture, Spontaneous
- Subarachnoid Hemorrhage/diagnostic imaging
- Subarachnoid Hemorrhage/etiology
- Subarachnoid Hemorrhage/surgery
- Surgical Instruments
- Tomography, X-Ray Computed
- Treatment Outcome
- Ventriculoperitoneal Shunt
- Young Adult
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Affiliation(s)
- P Meneghelli
- Section of Vascular Neurosurgery, Institute of Neurosurgery, University and City Hospital, Piazzale Stefani 1, 37128, Verona, Italy
| | - F Cozzi
- Section of Vascular Neurosurgery, Institute of Neurosurgery, University and City Hospital, Piazzale Stefani 1, 37128, Verona, Italy
| | - A Hasanbelliu
- Section of Vascular Neurosurgery, Institute of Neurosurgery, University and City Hospital, Piazzale Stefani 1, 37128, Verona, Italy
| | - F Locatelli
- Unit of Epidemiology and Medical Statistics, Department of Public Health and Community Medicine, University and City Hospital, Verona, Italy
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurosurgery, University and City Hospital, Piazzale Stefani 1, 37128, Verona, Italy.
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Crudele A, Shah SO, Bar B. Decompressive Hemicraniectomy in Acute Neurological Diseases. J Intensive Care Med 2015; 31:587-96. [PMID: 26324162 DOI: 10.1177/0885066615601607] [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: 01/18/2015] [Accepted: 07/15/2015] [Indexed: 01/08/2023]
Abstract
Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions-both medical and surgical-exist to manage increased ICP. Medical management is used as first-line therapy; however, it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.
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Affiliation(s)
- Angela Crudele
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Syed Omar Shah
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Barak Bar
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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27
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Primary decompressive craniectomy for poor-grade middle cerebral artery aneurysms with associated intracerebral hemorrhage. Clin Neurol Neurosurg 2015; 133:1-5. [DOI: 10.1016/j.clineuro.2015.03.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 02/17/2015] [Accepted: 03/07/2015] [Indexed: 11/19/2022]
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28
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Bühler D, Azghandi S, Schüller K, Plesnila N. Effect of Decompressive Craniectomy on Outcome Following Subarachnoid Hemorrhage in Mice. Stroke 2015; 46:819-26. [DOI: 10.1161/strokeaha.114.007703] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dominik Bühler
- From the Laboratory of Experimental Stroke Research, Institute for Stroke and Dementia Research, University of Munich Medical Center, Munich, Germany (D.B., S.A., K.S., N.P.); and Munich Cluster for Systems Neurology (Synergy), Munich, Germany (N.P.)
| | - Sepiede Azghandi
- From the Laboratory of Experimental Stroke Research, Institute for Stroke and Dementia Research, University of Munich Medical Center, Munich, Germany (D.B., S.A., K.S., N.P.); and Munich Cluster for Systems Neurology (Synergy), Munich, Germany (N.P.)
| | - Kathrin Schüller
- From the Laboratory of Experimental Stroke Research, Institute for Stroke and Dementia Research, University of Munich Medical Center, Munich, Germany (D.B., S.A., K.S., N.P.); and Munich Cluster for Systems Neurology (Synergy), Munich, Germany (N.P.)
| | - Nikolaus Plesnila
- From the Laboratory of Experimental Stroke Research, Institute for Stroke and Dementia Research, University of Munich Medical Center, Munich, Germany (D.B., S.A., K.S., N.P.); and Munich Cluster for Systems Neurology (Synergy), Munich, Germany (N.P.)
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29
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Soleman J, Schatlo B, Dan-Ura H, Remonda L, Fandino J, Fathi AR. Craniotomy without flap replacement for ruptured intracranial aneurysms to reduce ischemic brain injury: a preliminary safety and feasibility analysis. ACTA NEUROCHIRURGICA. SUPPLEMENT 2014; 120:217-22. [PMID: 25366627 DOI: 10.1007/978-3-319-04981-6_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
BACKGROUND Cortical and subcortical brain ischemia following aneurysmal subarachnoid hemorrhage (aSAH) remains a central challenge in improving patient outcome. Generally the bone flap is replaced after surgical clipping and no decompression is practiced in endovascularly treated patients. The aim of this preliminary safety and feasibility study is to clarify whether a first-line decompression would improve brain perfusion and salvage more tissue at risk in patients who developed delayed vasospasm. In addition, we assessed whether the risks involved with a second surgery to replace the bone flap would affect patient outcome. METHODS We retrospectively analyzed patients with aSAH who underwent surgical clipping and developed cerebral vasospasm from 2009 to 2012 at our institution. We selected cases where the bone flap was not replaced at initial surgery and needed a second procedure for bone flap replacement. Primary end points were new delayed ischemic neurological deficits (DINDs), the extent of brain infarctions, and patient functional outcome. Secondary end points were hazards of the second procedure for bone replacement. RESULTS We identified six patients in whom the surgeon chose not to replace the bone flap. In four patients, this was a pterional bone flap (standard), and in two patients it was a larger frontotemporoparietal flap. Despite the limited extent of the craniotomy, only one patient (16 %) required additional decompression. Two patients (33%) developed DINDs and five patients (83 %) showed delayed cerebral infarctions on computed tomography. Of those, three patients showed good outcome (Glasgow Outcome Scale score >4 and modified Rankin Scale score <3). No complications or new neurological deficits occurred during the second surgery for bone replacement. CONCLUSIONS To date, no standardized criteria exist to decide whether the bone flap should be removed or replaced at initial surgery. Our single-center experience in a limited number of patients reveals a pattern with respect to initial clinical parameters and imaging findings that might be a first step in developing standardized decision parameters. This may prevent secondary surgery for decompression in deleterious conditions during the vasospasm phase. Based on these findings, we have developed a protocol for a prospective study that will further investigate the benefits of this management.
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Affiliation(s)
- Jehuda Soleman
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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30
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Uozumi Y, Sakowitz O, Orakcioglu B, Santos E, Kentar M, Haux D, Unterberg A. Decompressive Craniectomy in Patients with Aneurysmal Subarachnoid Hemorrhage: A Single-Center Matched-Pair Analysis. Cerebrovasc Dis 2014; 37:109-15. [DOI: 10.1159/000356979] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 10/30/2013] [Indexed: 11/19/2022] Open
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31
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32
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Mak CHK, Lu YY, Wong GKC. Review and recommendations on management of refractory raised intracranial pressure in aneurysmal subarachnoid hemorrhage. Vasc Health Risk Manag 2013; 9:353-9. [PMID: 23874101 PMCID: PMC3714000 DOI: 10.2147/vhrm.s34046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Intracranial hypertension is commonly encountered in poor-grade aneurysmal subarachnoid hemorrhage patients. Refractory raised intracranial pressure is associated with poor prognosis. The management of raised intracranial pressure is commonly referenced to experiences in traumatic brain injury. However, pathophysiologically, aneurysmal subarachnoid hemorrhage is different from traumatic brain injury. Currently, there is a paucity of consensus on the management of refractory raised intracranial pressure in spontaneous subarachnoid hemorrhage. We discuss in this paper the role of hyperosmolar agents, hypothermia, barbiturates, and decompressive craniectomy in managing raised intracranial pressure refractory to first-line treatment, in which preliminary data supported the use of hypertonic saline and secondary decompressive craniectomy. Future clinical trials should be carried out to delineate better their roles in management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage patients.
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33
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Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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34
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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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35
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Abstract
Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.
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36
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Hempenstall J, Sadek AR, Eynon CA. Decompressive Craniectomy in Acute Brain Injury – Lifting the lid on Neurosurgical Practice. J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Decompressive craniectomy (DC) is an effective method of controlling rising intracranial pressure (ICP) refractory to medical treatment in a range of conditions: traumatic brain injury in both adults and children, malignant middle cerebral artery infarction and following subarachnoid haemorrhage. Herein, we describe its indications, prognosis, current operative methods and postoperative management.
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Affiliation(s)
- Jonathan Hempenstall
- University Hospital Southampton NHS FoundationTrust and Division of Clinical Neurosciences, School of Medicine, University of Southampton
| | - Ahmed-Ramadan Sadek
- Walport Academic Clinical Fellow in Neurosurgery, Jason Brice Fellow in Neurosurgical Research
- University Hospital Southampton NHS FoundationTrust and Division of Clinical Neurosciences, School of Medicine, University of Southampton
| | - C Andrew Eynon
- Director of Major Trauma, Consultant in Neurosciences Intensive Care, Honorary Senior Lecturer
- University Hospital Southampton NHS FoundationTrust and Division of Clinical Neurosciences, School of Medicine, University of Southampton
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37
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Abstract
Decompressive craniectomy (DC) is the surgical management removing part of the skull vault over a swollen brain used to treat elevated intracranial pressure that is unresponsive to maximal medical therapy. The commonest indication for DC is traumatic brain injury (TBI) or middle cerebral artery (MCA) infarction, though DC has been reported to have been used for treatment of aneurysmal subarachnoid haemorrhage and venous infarction. 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 are retrospective, the recent publication of several randomised prospective studies prompts a re-evaluation of the use of DC. We review the literature concerning the pathophysiology, indication, surgical techniques and timing, complications and long-term effects of DC (including reversal with cranioplasty), in order to rationalise its use. We conclude that at the time of this review, though we cannot support the routine use of DC in TBI or MCA stroke, there is evidence that early and aggressive use of DC in TBI patients with intracranial haematomas or younger malignant MCA stroke patients may improve outcome. Though the results of the DECRA trial suggest that primary DC may worsen outcome, the decision to perform DC after diffuse TBI is still individualised. We await the results of the RESCUEicp trial to ascertain whether an evidence-based protocol for its use can be agreed in the future.
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Affiliation(s)
| | - A Tarnaris
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, UK
| | - J Wasserberg
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, UK
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38
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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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39
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Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage. World Neurosurg 2011; 74:465-71. [PMID: 21492596 DOI: 10.1016/j.wneu.2010.08.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 07/29/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to document the effects of decompressive hemicraniectomy (DHC) on neurologic outcome in patients treated for aneurysmal subarachnoid hemorrhage (SAH) and developing otherwise uncontrollable intracranial hypertension. METHODS Sixty-six of the 964 patients (6.8%) treated for aneurysmal SAH underwent DHC and were stratified as follows: Group 1, patients undergoing aneurysm clipping and DHC in one surgical sitting (i.e., primary DHC). Group 2, patients receiving aneurysm embolization and thereafter undergoing DHC. Group 3, patients undergoing standard aneurysm surgery and requiring DHC later in the post-SAH period. Group 4, patients with insufficient primary DHC and later requiring surgical enlargement of the craniectomy. RESULTS Outcome was not influenced by the timing of DHC, but depended on the pathology underlying intracranial hypertension (i.e., whether lesions were primary hemorrhagic or secondary ischemic in origin). Patients with large hematomas, undergoing primary, secondary, or repeat DHC (46/66) had significantly better outcomes than the 20 patients treated for edema and delayed ischemic infarctions. There were 16 (34.8%) of the 46 patients in the hematoma group, but only 2 (10.0%) of the 20 patients in the ischemia group had favorable neurologic outcomes, defined as modified Rankin Scale scores 0-3 (P value = 0.038). CONCLUSIONS In the largest series of SAH patients to date who received both microsurgical and endovascular treatment of ruptured aneurysms, and who underwent DHC for otherwise uncontrollable intracranial hypertension. Neurologic outcome was significantly correlated with the pathology underlying intracranial hypertension. DHC beneficially affected neurologic outcomes in patients with space-occupying hematomas, whereas patients suffering delayed ischemic strokes did not benefit to the same extent.
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40
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Diedler J, Sykora M, Hacke W. Critical Care of the Patient with Acute Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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41
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Jüttler E, Hacke W. Cerebral Infarction. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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42
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KAZUMATA K, KAMIYAMA H, YOKOYAMA Y, ASAOKA K, TERASAKA S, ITAMOTO K, OSANAI T. Poor-Grade Ruptured Middle Cerebral Artery Aneurysm With Intracerebral Hematoma: Bleeding Characteristics and Management. Neurol Med Chir (Tokyo) 2010; 50:884-92. [DOI: 10.2176/nmc.50.884] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ken KAZUMATA
- Department of Neurosurgery, Teine Keijinkai Hospital
| | | | - Yuka YOKOYAMA
- Department of Neurosurgery, Teine Keijinkai Hospital
| | | | | | - Kouji ITAMOTO
- Department of Neurosurgery, Teine Keijinkai Hospital
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43
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Tong Y, Gu J, Fan WJ, Yu JB, Pan JW, Wan S, Zhou YQ, Zheng XJ, Zhan RY. Patients with supratentorial aneurysmal subarachnoid hemorrhage during the intermediate period: waiting or actively treating. Int J Neurosci 2009; 119:1956-67. [PMID: 19922395 DOI: 10.1080/00207450903140042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Perhaps the most difficult practical decision for neurosurgeons these days is whether to secure aneurysms during the intermediate period (4-10 days) after aneurysmal subarachnoid hemorrhage (SAH). We retrospectively reviewed a series of 115 patients with a Hunt-Hess grade I-III upon admission who were admitted 4-10 days after initial supratentorial aneurysmal SAH. Patients who underwent active treatment in the intermediate period were assigned to the intermediate group (n = 49) while those who accepted delayed obliteration of a ruptured aneurysm (11-30 days) were assigned to the late group (n = 66). The demographic characteristics, size and site of aneurysms, and clinical conditions were well balanced in the two groups. There was no difference in outcome between the two groups according to the Glasgow Outcome Scale (GOS) at discharge or a six-month follow-up. Rebleeding before aneurysms obliteration was the leading factor resulting in poor outcome. In conclusion, for patients with supratentorial aneurysmal SAH who were in good clinical condition upon admission, active treatment during the intermediate period offered a good chance of a favorable outcome. An even larger number of patients from randomized clinical trials might be necessary to draw more reliable conclusions.
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Affiliation(s)
- Ying Tong
- Department of Neurosurgery, The First Affiliated Hospital, College of Medicine Zhejiang University, Hangzhou, P.R. China
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44
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Tong Y, Gu J, Fan WJ, Yu JB, Pan JW, Wan S, Zhou YQ, Zheng XJ, Zhan RY. Patients with Supratentorial Aneurysmal Subarachnoid Hemorrhage During the Intermediate Period: Waiting or Actively Treating. Int J Neurosci 2009; 119:1494-506. [DOI: 10.1080/00207450903084208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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45
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Morgan Stuart R, Claassen J, Schmidt M, Helbok R, Kurtz P, Fernandez L, Lee K, Badjatia N, Mayer SA, Lavine S, Sander Connolly E. Multimodality Neuromonitoring and Decompressive Hemicraniectomy After Subarachnoid Hemorrhage. Neurocrit Care 2009; 15:146-50. [DOI: 10.1007/s12028-009-9264-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 07/30/2009] [Indexed: 11/28/2022]
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46
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Güresir E, Schuss P, Vatter H, Raabe A, Seifert V, Beck J. Decompressive craniectomy in subarachnoid hemorrhage. Neurosurg Focus 2009; 26:E4. [DOI: 10.3171/2009.3.focus0954] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to analyze decompressive craniectomy (DC) in the setting of subarachnoid hemorrhage (SAH) with bleeding, infarction, or brain swelling as the underlying pathology in a large cohort of consecutive patients.
Methods
Decompressive craniectomy was performed in 79 of 939 patients with SAH. Patients were stratified according to the indication for DC: 1) primary brain swelling without or 2) with additional intracerebral hematoma, 3) secondary brain swelling without rebleeding or infarcts, and 4) secondary brain swelling with infarcts or 5) with rebleeding. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months (mRS Score 0–3 favorable vs 4–6 unfavorable).
Results
Overall, 61 (77.2%) of 79 patients who did and 292 (34%) of the 860 patients who did not undergo DC had a poor clinical grade on admission (World Federation of Neurosurgical Societies Grade IV–V, p < 0.0001). A favorable outcome was attained in 21 (26.6%) of 79 patients who had undergone DC. In a comparison of favorable outcomes in patients with primary (28.0%) or secondary DC (25.5%), no difference could be found (p = 0.8). Subgroup analysis with respect to the underlying indication for DC (brain swelling vs bleeding vs infarction) revealed no difference in the rate of favorable outcomes. On multivariate analysis, acute hydrocephalus (p = 0.009) and clinical signs of herniation (p = 0.02) were significantly associated with an unfavorable outcome.
Conclusions
Based on the data in this study the authors concluded that primary as well as secondary craniectomy might be warranted, regardless of the underlying etiology (hemorrhage, infarction, or brain swelling) and admission clinical grade of the patient. The time from the onset of intractable intracranial pressure to DC seems to be crucial for a favorable outcome, even when a DC is performed late in the disease course after SAH.
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47
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Diedler J, Sykora M, Blatow M, Jüttler E, Unterberg A, Hacke W. Decompressive surgery for severe brain edema. J Intensive Care Med 2009; 24:168-78. [PMID: 19321537 DOI: 10.1177/0885066609332808] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Decompressive surgery has since long been a promising therapeutic approach for patients with acute severe brain injury at risk to develop severe brain edema. The underlying rationale of removing part of the cranium is to create space for the expanding brain to prevent secondary damage to vital brain tissue. However, until recently, randomized controlled trials that demonstrate the efficacy of decompressive surgery or benefit for outcome were missing. This has changed since the results of 3 randomized trials on hemicraniectomy in malignant infarction of the middle cerebral artery have been published in 2007. In this article, the current evidence for decompressive surgery in the treatment of cerebral ischemia, intracranial hemorrhage, traumatic brain injury, inflammatory diseases, or severe metabolic derangements is reviewed. Although there is increasing evidence for the efficacy of decompressive surgery in reducing intracranial pressure and even mortality, a critical point remains the definition of good or acceptable outcome.
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Affiliation(s)
- Jennifer Diedler
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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48
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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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49
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Mathai KI, Sahoo PK. Decompressive craniectomy: an effective but underutilized option for intracranial pressure management. Indian J Surg 2008; 70:181-3. [PMID: 23133053 DOI: 10.1007/s12262-008-0049-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2008] [Accepted: 07/14/2008] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Decompressive Craniectomy is an effective option in the management of intractable intracranial hypertension. AIM AND OBJECTIVES Neuronal conservation can be achieved by aggressive decompression (hemicraniectomy). MATERIAL AND METHODS In this series 12 patients with a Glasgow Coma Scale score of 8 or <8 with increased intracranial pressure underwent decompressive hemicraniectomy. RESULTS The outcomes were prospectively evaluated. Eight patients were victims of traumatic brain injury. There were two patients who had suffered malignant Middle Cerebral Artery Infarctions, one patient had a cerebral venous thrombosis and one, an intracerebral hematoma. Four patients in this cohort died, while five had good outcomes. CONCLUSION The rationale and role of this relatively easy but underutilised procedure are discussed.
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Affiliation(s)
- K I Mathai
- Department of Neurosurgery, Armed Forces Medical College, Pune, India
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50
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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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