Risk factors for post-traumatic hydrocephalus following decompressive craniectomy

Predictive factors influencing outcome of early cranioplasty after decompressive craniectomy: a outcome prediction model study

Objective

The timing of cranioplasty (CP) has become a widely debated topic in research, there is currently no unified standard. To this end, we established a outcome prediction model to explore the factors influencing the outcome of early CP. Our aim is to provide theoretical and practical basis for whether patients with skull defects after decompressive craniectomy (DC) are suitable for early CP.

Methods

A total of 90 patients with early CP after DC from January 2020 to December 2021 were retrospectively collected as the training group, and another 52 patients with early CP after DC from January 2022 to March 2023 were collected as the validation group. The Nomogram was established to explore the predictive factors that affect the outcome of early CP by Least absolute shrinkage analysis and selection operator (LASSO) regression and Logistic regression analysis. Receiver operating characteristic (ROC) curve was used to evaluate the discrimination of the prediction model. Calibration curve was used to evaluate the accuracy of data fitting, and decision curve analysis (DCA) diagram was used to evaluate the benefit of using the model.

Results

Age, preoperative GCS, preoperative NIHSS, defect area, and interval time from DC to CP were the predictors of the risk prediction model of early CP in patients with skull defects. The area under ROC curve (AUC) of the training group was 0.924 (95%CI: 0.867-0.980), and the AUC of the validation group was 0.918 (95%CI, 0.842-0.993). Hosmer-Lemeshow fit test showed that the mean absolute error was small, and the fit degree was good. The probability threshold of decision risk curve was wide and had practical value.

Conclusion

The prediction model that considers the age, preoperative GCS, preoperative NIHSS, defect area, and interval time from DC has good predictive ability.

Incidence and Risk Model of Post-Traumatic Hydrocephalus in Patients with Traumatic Brain Injury

OBJECTIVE

Post-traumatic hydrocephalus (PTH) is a complication following traumatic brain injury (TBI). Early diagnosis and treatment are essential to improving outcomes. We report the incidence and risk factors of PTH in a large TBI population while considering death as a competing risk.

METHODS

We conducted a retrospective cohort study on consecutive TBI patients with radiographic intracranial abnormalities admitted to our academic medical center from 2009 to 2015. We assessed patient demographics, perioperative data, and in-hospital data as risk factors for PTH using survival analysis with death as a competing risk.

RESULTS

Among 7,473 patients, the overall incidence of PTH requiring shunt surgery was 0.94%. The adjusted cumulative incidence was 0.99%. The all-cause cumulative hazard for death was 32.6%, which was considered a competing risk during analysis. Craniectomy (HR 11.53, P < 0.001, 95% CI 5.57-223.85), venous sinus injury (HR 4.13, P = 0.01, 95% CI 1.53-11.16), and age ≤5 (P < 0.001) were significant risk factors for PTH. Glasgow Coma Score (GCS) > 13 was protective against shunt placement (HR 0.50, P = 0.04, 95% CI 0.26-0.97). Shunt surgery occurred after hospital discharge in 60% of patients.

CONCLUSIONS

We describe the incidence and risk factors for PTH in a large traumatic brain injury (TBI) population. Most cases of PTH were diagnosed after hospital discharge, suggesting that close follow-up and multidisciplinary diagnostic vigilance for PTH are needed to prevent morbidity and disability.

Post-traumatic decompressive craniectomy: Prognostic factors and long-term follow-up

Background

Decompressive craniectomy (DC) is still controversial in neurosurgery. According to the most recent trials, DC seems to increase survival in case of refractory intracranial pressure. On the other hand, the risk of postsurgical poor outcomes remain high. The present study aimed to evaluate a series of preoperative factors potentially impacting on long-term follow-up of traumatic brain injury (TBI) patients treated with DC.

Methods

We analyzed the first follow-up year of a series of 75 TBI patients treated with DC at our department in five years (2015-2019). Demographic, clinical, and radiological parameters were retrospectively collected from clinical records. Blood examinations were analyzed to calculate the preoperative neutrophil-to-lymphocyte ratio (NLR). Disability rating scale (DRS) was used to classify patients' outcomes (good outcome [G.O.] if DRS ≤11 and poor outcome [P.O.] if DRS ≥12) at 6 and 12 months.

Results

At six months follow-up, 25 out of 75 patients had DRS ≤11, while at 12 months, 30 out of 75 patients were included in the G.O. group . Admission Glasgow Coma Scale (GCS) >8 was significantly associated with six months G.O. Increased NLR values and the interval between DC and cranioplasty >3 months were significantly correlated to a P.O. at 6- and 12-month follow-up.

Conclusion

Since DC still represents a controversial therapeutic strategy, selecting parameters to help stratify TBI patients' potential outcomes is paramount. GCS at admission, the interval between DC and cranioplasty, and preoperative NLR values seem to correlate with the long-term outcome.

Effect of microorganisms isolated by preoperative osseous sampling on surgical site infection after autologous cranioplasty: A single-center experience

PURPOSE

The most frequent postoperative complication in autologous cranioplasty (AC) is infection. European recommendations include osseous sampling before cryogenic storage of a bone flap. We evaluated the clinical impact of this sampling.

METHODS

All patients who underwent decompressive craniectomy (DC) and AC in our center between November 2010 and September 2021 were reviewed. The main outcome was the rate of reoperation for infection of the cranioplasty. We evaluated risk factors for bone flap infection, rate of reoperation for any reason (hematoma, skin erosion, cosmetic request, or bone resorption), and radiological evidence of bone flap resorption.

RESULTS

A total of 195 patients with a median age of 50 (interquartile range: 38.0-57.0) years underwent DC and AC between 2010 and 2021. Of the 195 bone flaps, 54 (27.7%) had a positive culture, including 48 (88.9%) with Cutibacterium acnes. Of the 14 patients who underwent reoperation for bone flap re-removal for infection, 5 and 9 had positive and negative bacteriological cultures, respectively. Of patients who did not have bone flap infection, 49 and 132 had positive and negative bacteriological cultures, respectively. There were no significant differences between patients with and without positive bacteriological culture of bone flaps in the rates of late bone necrosis and reoperation for bone flap infection.

CONCLUSIONS

A positive culture of intraoperative osseous sampling during DC is not associated with a higher risk of re-intervention after AC.

Outcomes of Cranioplasty: A Single-Center Experience

Background Cranioplasty (CP) is a common cranial reconstructive procedure. It is performed after craniectomy due to various causes such as relieving increased intracranial pressure, infection, and tumor infiltration. Although CP is an easy procedure, it is associated with a high rate of complications. We aimed to retrospectively investigate the outcomes of CP at the King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah (KAMC-J). Methods This is a retrospective observational study that included all patients who had CP (first time or redo) at KAMC-J from 1st January 2010 to 31st December 2020. Patients with congenital cranial malformation were excluded.  Result A total of 68 patients underwent CP. Of those, 23 (34%) had complications. The most common complication was infection (10.3%). Twelve of the 23 patients had major complications that necessitated reoperation. Of those 12, six underwent redo CP; three out of these six patients had further complications which were also managed surgically. On bivariate analysis, cranial defects over 50 cm² were associated with a higher rate of both infection and hydrocephalus (p=0.018) while the frontal site was associated with a higher rate of infection (p=0.014). Moreover, traumatic brain injury as an etiology was exclusively associated with post-cranioplasty hydrocephalus (p=0.03).  Conclusion Patients undergoing CP after craniectomy are prone to a considerably high rate of adverse outcomes. The overall rate of complications in this study was 34%, with an infection rate of 10.3% and a 1.5% mortality rate. Consistent with other studies, larger cranial defects as well as frontal sites have a higher rate of infection.

Factors associated with post traumatic hydrocephalus following decompressive craniectomy: A single-center experience

Background

A decompressive craniectomy (DC) is a surgical procedure sometimes utilized to manage refractory intracranial hypertension following severe traumatic brain injury (sTBI). The previous studies have established a relationship between DC and post traumatic hydrocephalus (PTH). This study aimed to identify the factors responsible for developing shunt-amenable PTH in patients who underwent DC following sTBI.

Methods

A review of a prospectively collected database of all patients admitted with severe TBI in a tertiary neurosurgical center in North-west England between January 2012 and May 2022 was performed. PTH was defined as evidence of progressive ventricular dilatation, clinical deterioration, and/or the eventual need for cerebrospinal fluid diversion (i.e., a ventriculoperitoneal shunt). Statistical analysis was carried out using IBM SPSS versus 28.0.1.

Results

Sixty-five patients met the eligibility criteria and were included in the study. The mean age of the PTH group was 31.38 ± 14.67, while the mean age of the non-PTH group was slightly higher at 39.96 ± 14.85. No statistically significant difference was observed between the two groups' mechanisms of traumatic injury (P = 0.945). Of the predictors investigated, cerebellar hematoma (and contusions) was significantly associated with PTH (P = 0.006).

Conclusion

This study concludes that cerebellar hematoma (and contusions) are associated with developing PTH in patients undergoing DC.

Predictors of Clinical Outcomes in Autologous Cranioplasty

BACKGROUND

Cranioplasty is a common neurosurgical procedure and autologous grafts are preferred due to their aesthetic and biocompatibility benefits. Multiple risk factors are implicated as predictors for neurologic outcome. This study focuses on risk factors that may be associated with complications and analyzes the predictors of neurologic outcomes after autologous cranioplasty.

METHODS

This is a retrospective observational study conducted at a tertiary care center between 2015 and 2021. Adults with autologous cranioplasty (n = 132) were recruited from procedure logs and the hospital electronic health record. Clinicodemographic parameters, risk factors, and complications were recorded. Neurologic outcomes were measured using the dichotomized Glasgow Outcome Scale (GOS). Primary outcome measure was pre- and post-cranioplasty GOS at the last follow up. Secondary outcome measures were the predicting factors that contributed to enhanced neurologic outcome post-cranioplasty.

RESULTS

Mean age was 41.4 (standard deviation ± 13.5) years with male predominance (12.2:1). Complications developed in 12.9% (n = 17), with infections in 3.8% (n = 5) and hydrocephalus in 2.3% (n = 3). In bivariate analysis, pre-cranioplasty GOS good grades 4 and 5 (P < 0.001), trauma as an indication for decompressive craniectomy (DC) (P < 0.001), and early cranioplasty ≤12 weeks (P = 0.023) were statistically significant predictors for post-cranioplasty neurologic recovery at follow-up. In a multiple logistic regression model, adjusted odds ratio for pre-cranioplasty GOS was 28.77 (95% confidence interval [CI] 7.21-114.74, P < 0.001), for trauma as indication for DC was 5.15 (95% CI 1.65-16.05, P = 0.003), and for early cranioplasty ≤12 weeks was 3.04 (95% CI 1.12-8.27 P = 0.029).

CONCLUSIONS

Autologous cranioplasty contributes to a quantifiable neurologic outcome. Pre-cranioplasty neurologic status, cranioplasty done for traumatic DC and early cranioplasty may have potential for enhanced neurologic recovery. Further clinical studies with better evidence may expound upon these findings.

Brainstem Hemorrhage Following Lumbar Drain for Post-traumatic Hydrocephalus

Post-traumatic hydrocephalus is common after traumatic brain injury (TBI), particularly following decompressive craniectomy. Cerebrospinal fluid (CSF) removal by lumbar drain (LD) aids in the workup of post-traumatic hydrocephalus and serves as a bridge to definitive CSF diversion. Hemorrhagic complications following LD are rare but can include intracranial hemorrhage. We present a case of fatal brainstem hemorrhage following LD in a patient three months after craniectomy.

A 32-year-old male presented with severe TBI and an acute subdural hematoma. He underwent emergent decompressive craniectomy and hematoma evacuation. The next day, he required ventriculostomy for elevated intracranial pressure (ICP), which was able to be successfully removed. Three months after the injury, the patient’s neurological exam declined, and computed tomography (CT) findings were consistent with communicating hydrocephalus. An LD was placed with 15 mL of CSF and drained every two hours. Five days after LD placement, the CSF became blood-tinged, and a repeat head CT demonstrated an acute brainstem hemorrhage. The patient ultimately expired.

Given the prevalence of post-traumatic hydrocephalus and the frequent use of CSF diversion in the management of this condition, it is important for neurosurgeons to remain cognizant of the potential risk for catastrophic brainstem hemorrhage following LD in decompressive craniectomy patients.

Strokectomy for malignant middle cerebral artery infarction: experience and meta-analysis of current evidence

Strokectomy means surgical excision of infarcted brain tissue post-stroke with preservation of skull integrity, distinguishing it from decompressive hemicraniectomy. Both can mitigate malignant middle cerebral artery (MCA) syndrome but evidence regarding strokectomy is sparse. Here, we report our data and meta-analysis of strokectomy compared to hemicraniectomy for malignant MCA infarction. All malignant MCA stroke cases requiring surgical intervention in a large tertiary centre (January 2012-December 2017, N = 24) were analysed for craniotomy diameter, complications, length of follow-up and outcome measured using the modified Rankin score (mRS). Good outcome was defined as mRS 0-3 at 12 months. In a meta-analysis, outcome from strokectomy (pooled from our cohort and published strokectomy studies) was compared with hemicraniectomy (our cohort pooled with published DECIMAL, DESTINY and HAMLET clinical trial data). In our series (N = 24, 12/12 F/M; mean age: 45.83 ± 8.91, range 29-63 years), 4 patients underwent strokectomy (SC) and 20 hemicraniectomy (HC). Among SC patients, craniotomy diameter was smaller, relative to HC patients (86 ± 13.10 mm, 120 ± 4.10 mm, respectively; p = 0.003), complications were less common (25%, 55%) and poor outcomes were less common (25%, 70%). In the pooled data (N = 41 SC, 71 HC), strokectomy tended towards good outcome more than hemicraniectomy (OR 2.2, 95% CI 0.99-4.7; p = 0.051). In conclusion, strokectomy may be non-inferior, lower risk and cost saving relative to hemicraniectomy sufficiently to be worthy of further investigation and maybe a randomised trial.

Post Traumatic Hydrocephalus: Incidence, Pathophysiology and Outcomes

Background

Post-traumatic hydrocephalus (PTH) is a sequel of traumatic brain injury (TBI) that is seen more often in patients undergoing decompressive craniectomy (DC). It is associated with prolonged hospital stay and unfavorable outcomes.

Objective

To study the incidence and risk factors for development of PTH in patients undergoing DC in our institution and to review the literature on PTH with respect to incidence, risk factors, pathophysiology, and outcomes of management.

Methods

Data from 95 patients (among 220 patients who underwent DC for TBI and fulfilled the inclusion criteria) over a 5-year period at Christian Medical College, Vellore were collected and analyzed to study the incidence and possible risk factors for development of PTH. A review of the literature on PTH was performed by searching PUBMED resources.

Results

Thirty (31.6%) out of 95 patients developed post-traumatic ventriculomegaly, of whom seven (7.3%) developed symptomatic PTH, necessitating placement of ventriculoperitoneal shunt (VPS). No risk factor for development of PTH could be identified. The reported incidence of PTH in the literature is from 0.07% to 29%, with patients undergoing DC having a higher incidence. Younger age, subarachnoid hemorrhage, severity of TBI, presence of subdural hygroma, and delayed cranioplasty after DC are the main risk factors reported in the literature.

Conclusions

PTH occurs in a significant proportion of patients with TBI and can lead to unfavorable outcomes. PTH has to be distinguished from asymptomatic ventriculomegaly as early as possible so that a CSF diversion procedure can be planned early during development of PTH.

Cranioplasty Following Severe Traumatic Brain Injury: Role in Neurorecovery

PURPOSE OF REVIEW

Decompressive craniectomy (DC) is a life-saving procedure performed in refractory intracranial pressure increase and mass lesion due to severe traumatic brain injury (TBI). Cranioplasty primarily intends to maintain cerebral protection and reconstruct aesthetic appearance. Also, cranioplasty can enable neurological rehabilitation and potentially augment neurological recovery. This article reviews recent studies on the effect of cranioplasty on neurological recovery in severe TBI.

RECENT FINDINGS

Recent findings suggested that cranioplasty has the potential to enhance neurological recovery after severe TBI. Cranioplasty may alleviate cognitive and functional deficits by reinstating the regular cerebrospinal fluid dynamics and improving brain perfusion. Analyses on the effects of cranioplasty timing on neurological recovery likely favor early cranioplasty. Also, materials used during cranioplasty, autologous and exogenous, were suggested to have similar effects in recovery. Although neurological therapy of TBI patients is still a serious challenge, recent findings represent the possible enhancing effect of cranioplasty on neurological recovery.

Hydrocephalus and Cerebrospinal Fluid Analysis Following Severe Traumatic Brain Injury: Evaluation of a Prospective Cohort

The development of hydrocephalus after severe traumatic brain injury (TBI) is an under-recognized healthcare phenomenon and can increase morbidity. The current study aims to characterize post-traumatic hydrocephalus (PTH) in a large cohort. Patients were prospectively enrolled age 16-80 years old with Glasgow Coma Scale (GCS) score ≤8. Demographics, GCS, Injury Severity Score (ISS), surgery, and cerebrospinal fluid (CSF) were analyzed. Outcomes were shunt failure and Glasgow Outcome Scale (GOS) at 6 and 12-months. Statistical significance was assessed at p < 0.05. In 402 patients, mean age was 38.0 ± 16.7 years and 315 (78.4%) were male. Forty (10.0%) patients developed PTH, with predominant injuries being subdural hemorrhage (36.4%) and diffuse axonal injury (36.4%). Decompressive hemicraniectomy (DHC) was associated with hydrocephalus (OR 3.62, 95% CI (1.62-8.07), p < 0.01). Eighteen (4.5%) patients had shunt failure and proximal obstruction was most common. Differences in baseline CSF cell count were associated with increased shunt failure. PTH was not associated with worse outcomes at 6 (p = 0.55) or 12 (p = 0.47) months. Hydrocephalus is a frequent sequela in 10.0% of patients, particularly after DHC. Shunt placement and revision procedures are common after severe TBI, within the first 4 months of injury and necessitates early recognition by the clinician.

Clinical Study of Cranioplasty Combined With Ipsilateral Ventriculoperitoneal Shunt in the Treatment of Skull Defects With Hydrocephalus

OBJECTIVE

To explore the clinical effect and safety of cranioplasty combined with ipsilateral ventriculoperitoneal shunts in the treatment of skull defects with hydrocephalus.

METHODS

The clinical data of 78 patients with skull defects with hydrocephalus were analyzed retrospectively. All patients were treated with cranioplasty and ventriculoperitoneal shunts in 1 stage, including 35 cases of cranioplasty combined with ipsilateral ventriculoperitoneal shunts (ipsilateral operation group) and 43 cases of contralateral operations (contralateral operation group).

RESULTS

The incision length (28.97 ± 4.55 cm), operation time (139.00 ± 42.27 minutes), and intraoperative hemorrhage (174.57 ± 79.35 mL) in the ipsilateral operation group were significantly better than those in the contralateral operation group (respectively they were 37.15 ± 5.83 cm, 214.07 ± 34.35 minutes, and 257.21 ± 72.02 mL), and the difference was statistically significant (t = 6.786, 8.656, and 4.815, all P < 0.05). The degree of postoperative hydrocephalus was significantly improved in both groups, but there was no statistically significant difference in the degree of hydrocephalus between the 2 groups (P > 0.05). Among the postoperative complications, there was no statistically significant difference in infection, epilepsy, subdural effusion, titanium plate effusion, or excessive cerebrospinal fluid drainage between the 2 groups (P > 0.05), but the incidence of intracranial hemorrhage in the ipsilateral operation group (2.86%) was significantly lower than that in the contralateral operation group (20.93%, χ2 = 4.138, P = 0.042). The postoperative Glasgow Coma Scale scores of the 2 groups were improved compared with those before the operation (P < 0.05), and there was no statistically significant difference in the postoperative Glasgow Coma Scale scores (P > 0.05). At 6 months after surgery, there was no statistically significant difference in Glasgow Outcome Scale effectiveness between the 2 groups (χ2 = 0.005, P = 0.944).

CONCLUSIONS

Cranioplasty combined with ipsilateral ventriculoperitoneal shunt has the same therapeutic effect as a contralateral operation, but it has the advantage of a short operation time, less intraoperative trauma, less bleeding, and less risk of intracranial hemorrhage, which is suitable for clinical applications.

Scoping review of the risk factors and time frame for development of post-traumatic hydrocephalus

Post-traumatic hydrocephalus (PTH) following traumatic brain injury (TBI) may develop within or beyond the acute phase of recovery. Recognition and subsequent treatment of this condition leads to improved neurologic outcomes. In this scoping review, we identify statistically significant demographic, clinical, radiographic, and surgical risk factors as well as a predictive time frame for the onset of PTH in order to facilitate timely diagnosis. Two researchers independently performed a scoping review of the PubMed and Cochrane databases for articles relevant to risk factors for PTH. Articles that met inclusion and exclusion criteria underwent qualitative analysis. Twenty-seven articles were reviewed for statistically significant risk factors and a proposed time frame for the onset of PTH. Variables that could serve as proxies for severe brain injuries were identified as risk factors. The most commonly identified risk factors included either very young or old age, intracranial hemorrhage including intraventricular hemorrhage, hygroma, and need for decompressive craniectomy. Although the timeframe for diagnosis of PTH varied widely from within one week to 31.5 months after injury, the first 50 days were more likely. Established risk factors and timeframe for PTH development may assist clinicians in the early diagnosis of PTH after TBI. Increased consistency in diagnostic criterion and reporting of PTH may improve recognition with early treatment of this condition in order to improve outcomes.

Incidence of post-traumatic hydrocephalus in traumatic brain injury patients that underwent DC versus those that were managed without DC: A systematic review and meta-analysis

Introduction

There is an ongoing debate whether Decompressive Craniectomy (DC) serves as an independent risk factor for the development of Post-traumatic Hydrocephalus (PTH).

Research question

The aim of this systematic review and meta-analysis was to compare the incidence of PTH in TBI patients that underwent DC versus those that were managed without DC.

Materials and methods

The literature was systematically reviewed to identify studies with specific inclusion criteria: (1) Randomized Controlled Trials and observational studies with more than 10 patients in each study arm, (2) comparing the incidence of PTH, (3) in patients aged ≥15 years old, (4) that either underwent DC or received other treatment (non-DC). (5) Only studies in English were included and (6) no restrictions were applied on publication date. The pooled Odds Ratio (OR) and Confidence Interval (CI) were calculated. The quality of the included studies was assessed using the ROBINS and RoB 2.0 tools.

Results

Evidence from six articles was synthesized, incorporating data from 2522 patients. A statistically significant higher occurrence of PTH [OR (95% CI): 4.84 (2.51, 9.31); Pz ​< ​0.00001] was identified in patients undergoing DC for TBI when compared to those that were managed without DC. The same was true when only patients with severe TBI were included in the analysis [OR (95% CI): 2.87 (1.85, 4.43); Pz ​< ​0.00001].

Discussion and conclusion

Our study has shown, within limitations, a clear association between DC and PTH. Further prospective studies, providing high-quality evidence, are needed to definitively establish any causative relationship between DC and PTH.

•

TBIs are associated with the development of PTH.

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Patients undergoing decompressive craniectomy are more likely to develop PTH.

•

Further studies should be conducted to establish a causative relationship.

Retrospective Analytic Study of Neurosurgical Patients Who Developed Postoperative Hydrocephalus

Objective This article discusses the causes, primary pathologies, management, and prognosis of patients who did not have hydrocephalus in preoperative stage, underwent definitive surgical procedure, and developed postoperative hydrocephalus requiring cerebrospinal fluid (CSF) diversion procedures.

Methods Retrospective data collection was done from operation theatre (OT) department database and patient records were obtained for the patients after, related literature was searched, all possible risk factors were analyzed, and our results were compared with other studies.

Results A total of 80 cases were found eligible for the study. Decompressive craniectomy was the most common cause followed by aneurysmal subarachnoid hemorrhage (SAH), intraventricular, and cerebellopontine angle (CPA) tumors. Rate of postsurgical hydrocephalus was 15 to 16%. Cases of decompressive craniectomy presented late, only few cases required diversion procedures during the immediate postop period, mostly aneurysm cases and tumors bed bleed. Out of total 6 mortalities, none of them were directly attributable to hydrocephalus. Since most patient presented after initial stabilization, permanent ventriculoperitoneal shunting was found to be the best option.

Conclusion Cases of decompression surgery should be under vigilant follow-up after discharge and even after cranioplasty for risk of development of hydrocephalus and requirement of permanent shunting. Cases with intraventricular hemorrhage or SAH should be considered as future candidate with risk of developing hydrocephalus. Lamina terminalis opening whenever possible results in favorable outcome in cases of anterior circulation aneurysms. CSF protein analysis in cases of intraventricular and CPA tumors should be done whenever possible, preferably routinely.

Endoscopic-assisted surgery for skull defects with subdural effusion

Introduction

Subdural effusion is a common complication that occurs after decompressive craniectomy. According to the endoscopy results, the formation mechanism of subdural effusion after decompressive craniectomy was discussed.

Aim

The morphological structure of subdural effusion in skull defects was observed with endoscopy, and endoscopic-assisted surgery was performed for subdural effusion.

Material and methods

From January 2018 to March 2020, 19 cases of skull repair and treatment of subdural effusion were performed. The external wall of the capsule was kept intact during the operation, subdural effusion and surgical procedure of the subdural effusion under an endoscope could be observed, and the results of endoscopic observation were described and recorded. A hemostasis gauze was placed between the two layers of the subdural effusion cavity. Another 13 cases of skull defects with subdural effusion treated without endoscopy during the same time period were enrolled in the study as the control group. The postoperative disappearance of effusion and the incidence of postoperative complications were compared between the two groups.

Results

Analysis with an endoscope revealed that all cases of subdural effusion in skull defects presented capsules. The main structures included the outer wall, boundary, inner wall, and fistula. The outer wall was made up of new tissue that had formed after removing the bone flap under the skin flap by artificial peeling under the condition of keeping the whole cavity. The inner wall consisted of thickened arachnoid, dura, and artificial dura. It presented with neovascularization networks, which showed a tendency to form new membrane structures through mutual adhesion and fusion. The inner and outer wall of the skull had fused to form the boundary of the cavity. Cerebrospinal fluid fistulas were detected in 31.6% of the internal walls. Subdural effusion was effectively treated in both the experimental group and the control group. Compared with the control group, complications in the experimental group were significantly reduced.

Conclusions

The effusion cavity can be divided into three types based on its structural characteristics: fistula type, membrane type, and closed type. In this study, the formation mechanism of skull defects combined with subdural effusion was explored. This represents a new method for treating subdural effusion in which hemostasis gauze is placed between the two layers of the effusion cavity and cerebrospinal fluid fistula under an endoscope, which can effectively reduce the incidence of postoperative complications.

Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury

BACKGROUND

Post-traumatic hydrocephalus (PTH) is one of the primary complications during the course of traumatic brain injury (TBI). The aim of this study was to define factors associated with the development of PTH in patients who underwent unilateral decompressive craniectomy (DC) for TBI.

METHODS

A total of 126 patients, who met the inclusion criteria of the study, were divided into two groups: patients with PTH (n = 25) and patients without PTH (n = 101). Their demographic, clinical, radiological, operative, and postoperative factors, which may be associated with the development of PTH, were compared.

RESULTS

Multivariate logistic regression analysis revealed that cranioplasty performed later than 2 months following DC was significantly associated with the requirement for ventriculoperitoneal shunting due to PTH (p < 0.001). Also, a significant unfavorable outcome rate was observed in patients with PTH at 1-year follow-up according to the Glasgow Outcome Scale-Extended (p = 0.047).

CONCLUSIONS

Our results show that early cranioplasty within 2 months after DC was associated with a lower rate of PTH development after TBI.

Can early cranioplasty reduce the incidence of hydrocephalus after decompressive craniectomy? A meta-analysis

Background

Do alterations of cerebrospinal fluid dynamics secondary to decompressive craniectomy (DC) lead to hydrocephalus, and can this effect be mitigated by early cranioplasty (CP)? In this meta-analysis, we evaluated whether the timing of CP decreased the incidence of postoperative hydrocephalus.

Methods

We performed a systematic search of PubMed/MEDLINE, Scopus, and the Cochrane databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for English language articles (1990-2020). We included case series, case-control, and cohort studies, and clinical trials assessing the incidence of hydrocephalus in adult patients undergoing early CP (within 3 months) versus late CP (after 3 months) after DC.

Results

Eleven studies matched the inclusion criteria. The rate of postoperative hydrocephalus was not significantly different between the early (=96/1063; 9.03%) and late CP (=65/966; 6.72%) group (P = 0.09). Only in the three studies specifically reporting on the rate of hydrocephalus after DC performed to address traumatic brain injury (TBI) alone was there a significantly lower incidence of hydrocephalus with early CP (P = 0.01).

Conclusion

Early CP (within 90 days) after DC performed in TBI patients alone was associated with a lower incidence of hydrocephalus. However, this finding was not corroborated in the remaining eight studies involving CP for pathology exclusive of TBI.

Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a 5-year experience

PURPOSE

Decompressive craniectomy is an effective measure to reduce a pathologically elevated intracranial pressure. Patients' survival and life quality following this surgery have been a subject of several studies and significantly differ according to the primary diagnosis. Since this operation is often associated with a wide spectrum of possibly serious complications, we aimed to describe their incidence and possible associated risk factors.

METHODS

We evaluated 118 patients who underwent decompressive craniectomy at our clinic during years 2013-2017. The indications included traumatic brain injuries, ischaemic or haemorrhagic strokes and postoperative complications of planned neurosurgical procedures. Subsequently, we assessed the incidence of early postoperative complications (occurring during the first 3 postoperative weeks). The results were statistically analysed with relation to a wide selection of possible risk factors.

RESULTS

At least one early surgical postoperative complication occurred in 87 (73.73%) patients, the most frequent being a development of an extraaxial fluid collection in 41 (34.75%) patients. We were able to identify risk factors linked with extraaxial fluid collections, subcutaneous and extradural haematomas, postoperative seizures and meningitis. An overall need for reoperation was 13.56%. Neither the duration of the surgery nor the qualification of the operating surgeon had any effect on the complications' occurrence.

CONCLUSIONS

Decompressive craniectomy is associated with numerous early postoperative complications with a various degree of severity. Most cases of complications can, however, be managed in a conservative way. The risk factors linked with postoperative complications should be taken into account during the indication process in each individual patient.

Prognostic significance of subdural hygroma for post-traumatic hydrocephalus after decompressive craniectomy in the traumatic brain injury setting: a systematic review and meta-analysis

Post-traumatic hydrocephalus (PTH) is a potentially morbid sequela of decompressive craniectomy for traumatic brain injury (TBI). Subdural hygromas are commonly identified following decompressive craniectomy, but the clinical relevance and predictive relationship with PTH in this patient cohort is not completely understood. Survey of seven electronic databases from inception to June 2019 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate hazard ratios (HRs) for PTH by the presence of subdural hygroma were extracted and pooled by meta-analysis of proportions with random effects modeling. We systematically identified nine pertinent studies describing outcomes of 1010 TBI patients managed by decompressive craniectomy. Of the overall cohort, there were 211 (21%) females and median age was 37.5 years (range 33-53). On presentation, median Glasgow Coma Scale was 7 (range, 5-8). In sum, PTH was reported in 228/840 (27%) cases, and subdural hygroma was reported in 449/1010 (44%) cases across all studies. Pooling multivariate-derived HRs indicated that subdural hygroma was a significant, independent predictor of PTH (HR, 7.1; 95% CI, 3.3-15.1). The certainty of this association was deemed low due to heterogeneity concerns. The presence of subdural hygroma is associated with increased risk of PTH after decompressive craniectomy among TBI patients based on the current literature and may mandate closer clinical surveillance when detected. Prospective studies, including those of intracranial hydrodynamics following decompressive craniectomy in the setting of TBI, will better validate the certainty of these findings.

Sixth Cranial Nerve Palsy and Craniocervical Junction Instability due to Metastatic Urothelial Bladder Carcinoma

Metastases involving the clivus and craniocervical junction (CCJ) are extremely rare. Skull base involvement can result in cranial nerve palsies, while an extensive CCJ involvement can lead to spinal instability. We describe an unusual case of clival and CCJ metastases presenting with VI cranial nerve palsy and neck pain secondary to CCJ instability from metastatic bladder urothelial carcinoma. The patient was first treated with an endoscopic endonasal approach to the clivus for decompression of the VI cranial nerve and then with occipitocervical fixation and fusion to treat CCJ instability. At the 6-month follow-up, the patient experienced complete recovery of VI cranial nerve palsy. To the best of our knowledge, the simultaneous involvement of the clivus and the CCJ due to metastatic bladder carcinoma has never been reported in the literature. Another peculiarity of this case was the presence of both VI cranial nerve deficit and spinal instability. For this reason, the choice of treatment and timing were challenging. In fact, in case of no neurological deficit and spinal stability, palliative chemo- and radiotherapy are usually indicated. In our patient, the presence of progressive diplopia due to VI cranial nerve palsy required an emergent surgical decompression. In this scenario, the extended endoscopic endonasal approach was chosen as a minimally invasive approach to decompress the VI cranial nerve. Posterior occipitocervical stabilization is highly effective in avoiding patient's neck pain and spinal instability, representing the approach of choice.

Coil Extrusion into the Naso- and Oropharynx Ten Years after Internal Carotid Artery Pseudoaneurysm Embolization: A Case Report

Coil migration and extrusion outside the cranial compartment after embolization of cerebral aneurysms represents a very rare complication of the endovascular procedures and few cases are reported in the literature. Instability of the vascular malformation wall and the resolution of the intramural hematoma, especially in pseudoaneurysm, might generate extravascular migration of the coils in the first months after embolization. However, to the best of our knowledge, an extrusion of coil 10 years after embolization has never been reported. We reported the unique case of a patient with coil extrusion into the naso- and oropharynx 10 years after internal carotid artery pseudoaneurysm embolization. The pseudoaneurysm occurred after an internal carotid artery injury during an endoscopic endonasal surgery for a clival giant cell tumor.

Surgical management of traumatic supra and infratentorial extradural hematomas: our experience and systematic literature review

Post-traumatic supra and infratentorial acute extradural hematomas (SIEDHs) are an uncommon type of extradural hematoma with only few small series published. In this scenario, the purposes of the present study are to present our experience in the management of 8 patients with acute SIEDH and to perform a systematic literature review. The clinical and radiological data of 8 patients operated for SIEDH at our department were analyzed retrospectively. Using the PRISMA guidelines, we reviewed the articles published from January 1990 to January 2018 reporting data about SIEDH. A total of 3 articles fulfilled the inclusion criteria and were analyzed. The incidence of SIEDHs is very rare constituting < 2% of all traumatic extradural hematomas (EDH). SIEDHs are associated with non-specific symptoms. Only 20% of patients were in coma (GCS < 8) at admission. A "lucid interval" was not reported. The source of bleeding of SIEDH was venous in all cases due to the following: bone fracture with diploe bleeding (50%), transverse/sigmoid sinus injury (22%), oozing meningeal venous vessel (8%), detachment of transverse sinus without wall injury (6%), and unknown in the other cases. Due to the venous nature of the source of hemorrhage, the clinical manifestation of a SIEDH may develop in a slow way, but once a critical volume of hematoma is reached, the deterioration can become rapid and fatal for acute brain stem compression. Surgery is the mainstay of SIEDHs treatment: among 42 cases with SIEDH included in this review, 40 (95.23%) patients were treated with surgery while only two were managed conservatively. Also in our series, all patients underwent surgery. A combined supratentorial craniotomy and suboccipital craniotomy leaving in a bone bridge over the transverse sinus for dural tenting sutures resulted the most used and safe surgical approach. SIEDH is a rare type of EDH. Early diagnosis of SIEDH and prompt surgical evacuation with a combined supratentorial and suboccipital approach provide excellent recovery.

New or Blossoming Hemorrhagic Contusions After Decompressive Craniectomy in Traumatic Brain Injury: Analysis of Risk Factors

Background: The development or expansion of a cerebral hemorrhagic contusion after decompressive craniectomy (DC) for traumatic brain injury (TBI) occurs commonly and it can result in an unfavorable outcome. However, risk factors predicting contusion expansion after DC are still uncertain. The aim of this study was to identify the factors associated with the growth or expansion of hemorrhagic contusion after DC in TBI. Then we evaluated the impact of contusion progression on outcome.

Methods: We collected the data of patients treated with DC for TBI in our Center. Then we analyzed the risk factors associated with the growth or expansion of a hemorrhagic contusion after DC.

Results: 182 patients (149 males and 41 females) were included in this study. Hemorrhagic contusions were detected on the initial CT scan or in the last CT scan before surgery in 103 out of 182 patients. New or blossoming hemorrhagic contusions were registered after DC in 47 patients out of 182 (25.82%). At multivariate analysis, only the presence of an acute subdural hematoma (p = 0.0076) and a total volume of contusions >20 cc before DC (p = < 0.0001) were significantly associated with blossoming contusions. The total volume of contusions before DC resulted to have higher accuracy and ability to predict postoperative blossoming of contusion with strong statistical significance rather than the presence of acute subdural hematoma (these risk factors presented respectively an area under the curve [AUC] of 0.896 vs. 0.595; P < 0.001). Patients with blossoming contusions presented an unfavorable outcome compared to patients without contusion progression (p < 0.0185).

Conclusions: The presence of an acute subdural hematoma was associated with an increasing rate of new or expanded hemorrhagic contusions after DC. The total volume of hemorrhagic contusions > 20 cc before surgery was an independent and extremely accurate predictive radiological sign of contusion blossoming in decompressed patients for severe TBI. After DC, the patients who develop new or expanding contusions presented an increased risk for unfavorable outcome.

Relationship between the location of the ventricular catheter tip and the ventriculoperitoneal shunt malfunction

OBJECTIVE

Ventriculoperitoneal (VP) shunt is the most common neurosurgical procedure to treat obstructive and communicating hydrocephalus, but failures are frequent. The most common causes of shunt failure are malpositioning and obstruction of the ventricular catheter by debris or blood clothes. The knowledge of the relationship between ventricular catheter tip position, etiology of hydrocephalus and patient's age with shunt malfunction may be useful to avoid shunt failure.

PATIENTS AND METHODS

We retrospectively analyze 89 adult patients affected by obstructive and communicating hydrocephalus operated with Ventriculoperitoneal shunt at our Institute. Patients with evident abdominal shunt malfunction were excluded from this study. Statistical analysis was performed in the group of patients with intracranial catheter malfunction in order to correlate shunt malfunction with the position of the catheter tip in brain ventricles, etiology of hydrocephalus and patient's age.

RESULTS

Shunt revision was performed in 26 patients out of 89 and cranial catheter malfunction was documented in 11 patients out of 26. Tip position in Monro foramen, lateral ventricles and third ventricle ("good position") had a lower rate of surgical shunt revision compared to septum pellucidum and wall of lateral ventricle ("bad position") p value = 0,049. No statistical significant association was observed between shunt malfunction and etiology of the hydrocephalus or patient's age.

CONCLUSIONS

Ventricular catheter tip position is one the most important factor for shunt function.