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Solomou G, Sunny J, Mohan M, Hossain I, Kolias AG, Hutchinson PJ. Decompressive craniectomy in trauma: What you need to know. J Trauma Acute Care Surg 2024; 97:490-496. [PMID: 39137371 PMCID: PMC11446508 DOI: 10.1097/ta.0000000000004357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/23/2024] [Accepted: 04/01/2024] [Indexed: 08/15/2024]
Abstract
ABSTRACT Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.
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Enomoto N, Matsuzaki K, Matsuda T, Yamaguchi T, Miyamoto T, Hanaoka M, Teshima N, Kageyama A, Satoh Y, Haboshi T, Korai M, Shimada K, Niki H, Satoh K, Takagi Y. Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma. Acta Neurochir (Wien) 2024; 166:272. [PMID: 38888676 DOI: 10.1007/s00701-024-06167-y] [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: 02/01/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. METHODS From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. RESULTS Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. CONCLUSIONS The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.
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Affiliation(s)
- Noriya Enomoto
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan.
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan.
| | - Kazuhito Matsuzaki
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Tomohiro Matsuda
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Tadashi Yamaguchi
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Takeshi Miyamoto
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Mami Hanaoka
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Natsumi Teshima
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Ayato Kageyama
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yuichi Satoh
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Tatsuya Haboshi
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Masaaki Korai
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Hitoshi Niki
- Department of Neurology, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Koichi Satoh
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
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Siahaan AMP, Nainggolan BWM, Susanto M, Indharty RS, Tandean S. Managing the "big black brain" in low resource setting: A case report of early outcome after hinge craniotomy. Surg Neurol Int 2023; 14:427. [PMID: 38213438 PMCID: PMC10783690 DOI: 10.25259/sni_715_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/09/2023] [Indexed: 01/13/2024] Open
Abstract
Background The big black brain (BBB) phenomenon is described as an infant's response to an acute subdural hematoma (SDH). It is characterized by hypodensity and swelling of the supratentorial compartment as a whole. Numerous factors may contribute to the formation of the BBB. Due to its high morbidity and mortality, the management of BBB is still debatable. In this report, we describe a 2-month-old boy who had bilateral hemispheric hypodensity and underwent hinge craniotomy. Case Description The patient was referred to our hospital with decreased consciousness. The patient had a history of seizures and cardiopulmonary arrest. There is no history of trauma. The computed tomography revealed a subacute SDH on the left parietal and occipital lobe along with hypodensity in both hemispheres with preservation of posterior fossa, consistent with hemispheric hypodensity. We performed a hinge craniotomy for the emergency procedure and evacuated only the hemisphere with the bleeding side. The patient cried spontaneously 24 hours after the procedure and was discharged six days later. Conclusion Early outcomes of hinge craniotomy as an alternative procedure for treating the BBB were positive. However, long-term outcomes, particularly the infant's development, should be monitored.
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Affiliation(s)
| | | | - Martin Susanto
- School of Medicine, Universitas Sumatera Utara, Medan, North Sumatera, Indonesia
| | - Rr Suzy Indharty
- Department of Neurosurgery, Universitas Sumatera Utara, Medan, North Sumatera, Indonesia
| | - Steven Tandean
- Department of Neurosurgery, Universitas Sumatera Utara, Medan, North Sumatera, Indonesia
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Biroli A, Bignotti V, Biroli P, Buffoli B, Rasulo FA, Doglietto F, Rezzani R, Fiorindi A, Fontanella MM, Belotti F. Hinge craniotomy versus standard decompressive hemicraniectomy: an experimental preclinical comparative study. Acta Neurochir (Wien) 2023; 165:2365-2375. [PMID: 37452903 DOI: 10.1007/s00701-023-05715-2] [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: 03/05/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Decompressive craniectomy (DC) is the most common surgical procedure to manage increased intracranial pressure (ICP). Hinge craniotomy (HC), which consists of fixing the bone operculum with a pivot, is an alternative method conceived to avoid some DC-related complications; nonetheless, it is debated whether it can provide enough volume expansion. In this study, we aimed to analyze the volume and ICP obtained with HC using an experimental cadaver-based preclinical model and compare the results to baseline and DC. METHODS Baseline conditions, HC, and DC were compared on both sides of five anatomical specimens. Volume and ICP values were measured with a custom-made system. Local polynomial regression was used to investigate volume differences. RESULTS The area of the bone opercula resulting from measurements was 115.55 cm2; the mean supratentorial volume was 955 mL. HC led to intermediate results compared to baseline and DC. At an ICP of 50 mmHg, HC offers 130 mL extra space but 172 mL less than a DC. Based on local polynomial regression, the mean volume difference between HC and the standard craniotomy was 10%; 14% between DC and HC; both are higher than the volume of brain herniation reported in the literature in the clinical setting. The volume leading to an ICP of 50 mmHg at baseline was less than the volume needed to reach an ICP of 20 mmHg after HC (10.05% and 14.95% from baseline, respectively). CONCLUSIONS These data confirm the efficacy of HC in providing sufficient volume expansion. HC is a valid intermediate alternative in case of potentially evolutionary lesions and non-massive edema, especially in developing countries.
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Affiliation(s)
- Antonio Biroli
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Valentina Bignotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Pietro Biroli
- Department of Economics, University of Bologna, Via Zamboni 33, 40126, Bologna, Italy
| | - Barbara Buffoli
- Section of Anatomy and Pathophysiology, Department of Clinical and Experimental Sciences, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco A Rasulo
- Unit of Anesthesia, Critical Care and Emergency, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco Doglietto
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy
- Unit of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Rita Rezzani
- Section of Anatomy and Pathophysiology, Department of Clinical and Experimental Sciences, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Alessandro Fiorindi
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco Belotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy.
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Omerhodzic I, Dzurlic A, Rovcanin B, Rotim K, Hadzimehmedagic A, Ahmetspahic A, Zvizdic Z, Granov N, Suljic E. Hinge craniotomy as an alternative technique for patients with refractory intracranial hypertension. BRAIN & SPINE 2023; 3:101758. [PMID: 37383443 PMCID: PMC10293230 DOI: 10.1016/j.bas.2023.101758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Abstract
Introduction Decompressive craniectomy (DC) can save brain tissue, but unfortunately it has many limitations and complications. Hinge craniotomy (HC), as less aggressive method seems to be adequate alternative not only to DC but also to conservative treatment. Research question Presentation of the results of modified surgical techniques of cranial decompression and comparing with more and less aggressive medical options. Material and methods A prospective clinical study was conducted during 86 months. Comatose patients who suffered refractory intracranial hypertension (RIH) were treated. Altogether, 137 patients have been evaluated. The final outcome of all patients in the study was evaluated after 6 months. Results Both surgical options resulted in adequate control of intracranial pressure (ICP). HC method was shown to have the lowest probability of worsening from a prior state of relative stability. Discussion and conclusion There was no statistically significant difference between methods to treatment of DC or HC, meaning the final outcome of patients treated in any manner. There was similar rate of early and late complications.
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Affiliation(s)
- Ibrahim Omerhodzic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Almir Dzurlic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Bekir Rovcanin
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Kresimir Rotim
- Department of Neurosurgery, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia
| | - Amel Hadzimehmedagic
- Department of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Adi Ahmetspahic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Zlatan Zvizdic
- Department of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Nermir Granov
- Department of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Enra Suljic
- Department of Neurology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Ahmed AK, Jagtiani P, Jones S. Technical Optimization of Decompressive Craniectomy for Possible Conversion to Hinge Craniotomy in Traumatic Brain Injury. Cureus 2023; 15:e39767. [PMID: 37398770 PMCID: PMC10312037 DOI: 10.7759/cureus.39767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Hinge craniotomy for the management of elevated intracranial pressure (ICP) in traumatic brain injury remains a technique not widely adopted. The hinged bone flap decreases the allowable intracranial volume expansion, which can lead to persistent post-operative elevated ICP and the need for salvage craniectomy. Herein, we describe the technical nuances in performing a decompressive craniectomy that, when optimized, allows for stronger consideration for hinge craniotomy as a definitive technique. To conclude, hinge craniotomy is a reasonable option in the setting of traumatic brain injury. Trauma neurosurgeons can consider the technical steps to optimize a decompressive craniectomy and perform hinge craniotomy when allowable.
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Affiliation(s)
| | - Pemla Jagtiani
- Medical School, State University of New York Downstate Health Sciences University, New York, USA
| | - Salazar Jones
- Neurological Surgery, Mount Sinai Hospital, New York, USA
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Montalbetti M, Lörcher S, Nowacki A, Häni L, Z'Graggen WJ, Raabe A, Schucht P. How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery. BRAIN & SPINE 2023; 3:101730. [PMID: 37383456 PMCID: PMC10293220 DOI: 10.1016/j.bas.2023.101730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 06/30/2023]
Abstract
Introduction Decompressive hemicraniectomy (DCE) is routinely performed for intracranial pressure control after malignant middle cerebral artery (MCA) infarction. Decompressed patients are at risk of traumatic brain injury and the syndrome of the trephined until cranioplasty. Cranioplasty after DCE is itself associated with high complication rates. Single-stage surgical strategies may eliminate the need for follow-up surgery while allowing for safe brain expansion and protection from environmental factors. Research question Assess the volume needed for safe expansion of the brain to enable single-stage surgery. Materials and methods We performed a retrospective radiological and volumetric analysis of all patients that had DCE in our clinic between January 2009 and December 2018 and met inclusion criteria. We investigated prognostic parameters in perioperative imaging and assessed clinical outcome. Results Of 86 patients with DCE, 44 fulfilled the inclusion criteria. Median brain swelling was 75.35 mL (8.7-151.2 mL). Median bone flap volume was 113.3 mL (73.34-146.1 mL). Median brain swelling was 1.62 mm below the previous outer rim of the skull (5.3 mm to -2.19 mm). In 79.6% of the patients, the volume of removed bone alone was equivalent to or larger than the additional intracranial volume needed for brain swelling. Discussion and conclusion The space provided by removal of the bone alone was sufficient to match the expansion of the injured brain after malignant MCA infarction in the vast majority of our patientsA subgaleal space-expanding flap with a minimal offset can provide protection from trauma and atmospheric pressure without compromising brain expansion.
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Affiliation(s)
- Matteo Montalbetti
- Corresponding author. Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 16, 3010, Bern, Switzerland.
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8
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Servadei F, Cannizzaro D, Zaed I, Iaccarino C, Cardia A. Neurotrauma Care: A Worldwide Perspective. J Neurotrauma 2023; 40:597-601. [PMID: 36893218 DOI: 10.1089/neu.2023.29137.fs] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Affiliation(s)
- Franco Servadei
- Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | - Delia Cannizzaro
- Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | - Ismail Zaed
- Department of Neurosurgery, Neurocenter of South Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Corrado Iaccarino
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cardia
- Department of Neurosurgery, Neurocenter of South Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
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Berra LV, Cedrone G, Di Norcia V, D'Angelo L, Brunetto F, Familiari P, Palmieri M, Capobianco M, Pappone F, Santoro A. Development of a Novel Device for Decompressive Craniectomy: An Experimental and Cadaveric Study and Preliminary Clinical Application. Oper Neurosurg (Hagerstown) 2023; 24:324-330. [PMID: 36701747 DOI: 10.1227/ons.0000000000000530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 09/20/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Decompressive craniectomy is an intervention of established efficacy in patients with intractable cerebral edema. OBJECTIVE To evaluate a new device used in alternative to decompressive craniectomy. This device is designed to perform an augmentative craniotomy by keeping the bone flap elevated using specific cranial suspension titanium plates and giving the brain enough room to swell. METHODS We tested the mechanical characteristics of the cranial brackets on dried skulls, on 3D-printed skull models, and on a preserved cadaver head. The resistance of the device was examined through dynamometric testing, and the feasibility of the surgical technique, including the suspension of the bone flap and the skin closure, was investigated on the cadaveric model. A preliminary clinical series of 2 patients is also reported. RESULTS The laboratory tests have shown that this system allows an adequate expansion of the intracranial volume and it could withstand a force up to 637 ± 13 N in the synthetic model and up to 658 ± 9 N in the human skull without dislocation or failure of the brackets nor fractures of the bone ridges. Preliminary application in the clinical setting has shown that augmentative craniotomy is effective in the control of intracranial hypertension and could reduce the costs and complications associated with the classical decompressive craniectomy technique. CONCLUSION Preliminary laboratory and clinical results show augmentative craniotomy to be a promising, alternative technique to decompressive craniectomy. Further clinical studies will be needed to validate its efficacy.
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Affiliation(s)
- Luigi Valentino Berra
- Department of Neurosurgery, Policlinico Umberto I, Sapienza Università di Roma, Roma, Italy
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10
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Schucht P, Nowacki A, Osmanagic A, Murek M, Z'Graggen WJ, Montalbetti M, Beck J, Stieglitz L, Raabe A. Space-expanding flap in decompressive hemicraniectomy for stroke. J Neurosurg 2023; 138:382-389. [PMID: 35901672 DOI: 10.3171/2022.5.jns22381] [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: 02/17/2022] [Accepted: 05/11/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Decompressive hemicraniectomy (DCE) is the standard of care for space-occupying malignant infarction of the medial cerebral artery in suitable patients. After DCE, the brain is susceptible to trauma and at risk for the syndrome of the trephined. This study aimed to assess the feasibility of using temporary space-expanding flaps, implanted during DCE, to shield the brain from these risks while permitting the injured brain to expand. METHODS The authors performed a prospective feasibility study to analyze the safety of space-expanding flaps in 10 patients undergoing DCE and evaluated clinical and radiological outcomes. RESULTS The relatives of 1 patient withdrew consent, leaving 9 patients in the final analysis. No patients required removal of the space-expanding flap because of uncontrolled increase of intracranial pressure or infection. One patient required additional external ventricular drainage and 1 received mannitol. The mean (range) midline shift decreased from 6.67 (3-12) mm to 1.26 (0-2.6) mm after DCE with the space-expanding flap. The authors observed no cases of sinking skin flap syndrome, other complications, or deaths. One patient underwent further treatment due to infection of the reimplanted autologous bone flap. Two patients later refused cranioplasty, preferring to keep the space-expanding flap and thus avoid the potential risks of cranioplasty. CONCLUSIONS This feasibility study showed that the concurrent use of space-expanding flaps appeared to be safe in patients who underwent DCE for malignant infarction of the medial cerebral artery. Moreover, space-expanding flaps may permit patients to avoid a second surgery for reimplantation of the autologous bone flap and the risks inherent to this procedure.
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Affiliation(s)
- Philippe Schucht
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Nowacki
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Armin Osmanagic
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Murek
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matteo Montalbetti
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- 2Department of Neurosurgery, University Hospital Freiburg im Breisgau, Germany; and
| | - Lennart Stieglitz
- 3Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas Raabe
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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11
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The intracranial pressure-volume relationship following decompressive hinge craniotomy compared to decompressive craniectomy-a human cadaver study. Acta Neurochir (Wien) 2023; 165:271-277. [PMID: 36369396 DOI: 10.1007/s00701-022-05409-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Decompressive hinge craniotomy (DHC) is an alternative treatment option to decompressive craniectomy (DC) for elevated intracranial pressure (ICP). The aim of this study was to characterize the difference in pressure-volume relationship between DHC and DC. METHODS We compared the intracranial pressure-volume relationship in a human cadaver model following either DHC, DC, or fixing of the bone plate by titanium clamps. We inserted an intracranial expandable device in two human cadaver specimens, performed either DHC, DC, or bone plate fixation, and gradually increased the intracranial volume while measuring ICP. Following DHC, we also performed CT-scans at pre-defined intervals. RESULTS Before ICP exceeded a threshold of 20 mmHg, a fixed bone plate tolerated an increase of 130 ml of intracranial volume, while DHC and DC allowed an increase of 190 ml and 290 ml, respectively. CT-derived calculations following DHC determined that the increase in intracranial volume at ICP 22 mmHg was 65 ml, the maximal increase of intracranial volume was 84 ml, the maximal bone displacement was 21 mm, and the bone plate volume to be 82 ml. Manual stress test of the hinged bone plate did not allow misalignment or intracranial displacement of the bone plate. CONCLUSION DHC increases the intracranial volume by up to 84 ml and allows for approximately 60 ml increase of intracranial volume before ICP exceeds 20 mmHg. This indicates, when comparing with results from previous studies of herniation volumes, that DHC will be sufficient in many patients with head injury or cerebral infarction with treatment refractory intracranial hypertension.
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12
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Khanna R, Munz M, Baxter S, Han P. Dynamic Craniotomy With NuCrani Reversibly Expandable Cranial Bone Flap Fixation Plates: A Technical Report. Oper Neurosurg (Hagerstown) 2023; 24:94-102. [PMID: 36519883 DOI: 10.1227/ons.0000000000000438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 07/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Dynamic craniotomy provides cranial decompression without bone flap removal along with avoidance of cranioplasty and reduced risks for complications. OBJECTIVE To report the first clinical cases using a novel dynamic craniotomy bone flap fixation system. The NeuroVention NuCrani reversibly expandable cranial bone flap fixation plates provide dynamic bone flap movement to accommodate changes in intracranial pressure (ICP) after a craniotomy. METHODS The reversibly expandable cranial bone flap fixation plates were used for management of cerebral swelling in a patient with a subdural hemorrhage after severe traumatic brain injury and another patient with a hemorrhagic stroke. RESULTS Both cases had high ICP's which normalized immediately after the dynamic craniotomy. Progressive postoperative cerebral swelling was noted which was compensated by progressive outward bone flap migration thereby maintaining a normal ICP, and with resolution of the cerebral swelling, the plates retracted the bone flaps to an anatomic flush position. CONCLUSION The reversibly expandable plates provide an unhinged cranial bone flap outward migration with an increase in ICP and retract the bone flap after resolution of brain swelling while also preventing the bone flap from sinking inside the skull.
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Affiliation(s)
- Rohit Khanna
- Department of Neurosurgery, University of Florida at Halifax Health, Daytona Beach, Florida, USA
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13
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Wu YY, Chen HJ, Lu K, Lin IF. Superimposing Pre-Cranioplasty on Pre-Craniectomy Images to Gauge Feasibility of Early Cranioplasty: A Proof of Concept. Neurotrauma Rep 2022; 3:333-338. [PMID: 36060452 PMCID: PMC9438448 DOI: 10.1089/neur.2022.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yu-ying Wu
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Han-Jung Chen
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Kang Lu
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - I-Fan Lin
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
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14
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Zhang ZD, Zhao LY, Liu YR, Zhang JY, Xie SH, Lin YQ, Tang ZN, Fang HY, Yang Y, Li SZ, Liu JX, Sheng HS. Absorbable Artificial Dura Versus Nonabsorbable Artificial Dura in Decompressive Craniectomy for Severe Traumatic Brain Injury: A Retrospective Cohort Study in Two Centers. Front Surg 2022; 9:877038. [PMID: 35865039 PMCID: PMC9295144 DOI: 10.3389/fsurg.2022.877038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background Severe traumatic brain injury (TBI) patients usually need decompressive craniectomy (DC) to decrease intracranial pressure. Duraplasty is an important step in DC with various dura substitute choices. This study aims to compare absorbable dura with nonabsorbable dura in duraplasty for severe TBI patients. Methods One hundred and three severe TBI patients who underwent DC and dura repair were included in this study. Thirty-nine cases used absorbable artificial dura (DuraMax) and 64 cases used nonabsorbable artificial dura (NormalGEN). Postoperative complications, mortality and Karnofsky Performance Scale (KPS) score in one year were compared in both groups. Results Absorbable dura group had higher complication rates in transcalvarial cerebral herniation (TCH) (43.59% in absorbable dura group vs. 17.19% in nonabsorbable dura group, P = 0.003) and CSF leakage (15.38% in absorbable dura group vs. 1.56% in nonabsorbable dura group, P = 0.021). But severity of TCH described with hernial distance and herniation volume demonstrated no difference in both groups. There was no statistically significant difference in rates of postoperative intracranial infection, hematoma progression, secondary operation, hydrocephalus, subdural hygroma and seizure in both groups. KPS score in absorbable dura group (37.95 ± 28.58) was statistically higher than nonabsorbable dura group (49.05 ± 24.85) in one year after operation (P = 0.040), while no difference was found in the rate of functional independence (KPS ≥ 70). Besides, among all patients in this study, TCH patients had a higher mortality rate (P = 0.008), lower KPS scores (P < 0.001) and lower functionally independent rate (P = 0.049) in one year after surgery than patients without TCH. Conclusions In terms of artificial biological dura, nonabsorbable dura is superior to absorbable dura in treatment of severe TBI patients with DC. Suturable nonabsorbable dura has fewer complications of TCH and CFS leakage, and manifest lower mortality and better prognosis. Postoperative TCH is an important complication in severe TBI which usually leads to a poor prognosis.
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Affiliation(s)
- Zhong-Ding Zhang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Li-Yan Zhao
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yi-Ru Liu
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Jing-Yu Zhang
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Shang-Hui Xie
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yan-Qi Lin
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Zhuo-Ning Tang
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Huang-Yi Fang
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yue Yang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Shi-Ze Li
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Jian-Xi Liu
- Department of Neurosurgery, Yueqing Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Han-Song Sheng
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
- Correspondence: Han-Song Sheng
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15
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Hemicraniectomy and externalized ventricular drain placement in a pediatric patient with myelin oligodendrocyte glycoprotein-associated tumefactive demyelinating disease. Childs Nerv Syst 2022; 38:185-189. [PMID: 33796928 DOI: 10.1007/s00381-021-05139-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Acquired demyelination of the central nervous system in children can manifest as multiple sclerosis, neuromyelitis optica, myelin oligodendrocyte glycoprotein (MOG)-associated demyelination, or as an acute monophasic illness without serum antibodies. Rarely do patients with demyelinating disease need surgical intervention for fulminant crises. CASE We report a case of anti-MOG antibody-related tumefactive demyelination in a 10-year-old female who required urgent hemicraniectomy and external ventricular drain placement for progressive white matter edema with obstructive hydrocephalus, subfalcine, and transtentorial herniation.
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16
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Mishra T, Kishore K, Jayan M, Thaploo D, Shanbhag NC, Bhat DI, Shukla DP, Konar SK, Devi BI, Hutchinson PJ. When the Bone Flap Expands Like Bellows of Accordion: Feasibility Study Using Novel Technique of Expansile (Hinge) Craniotomy for Severe Traumatic Brain Injury. Neurol India 2021; 69:973-978. [PMID: 34507424 DOI: 10.4103/0028-3886.325310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Decompressive craniectomy (DC) is a rescue operation performed for reduction of intracranial pressure due to progressive brain swelling, mandating the need for cranioplasty. Objective To describe expansile craniotomy (EC) as a noninferior technique that may be effectively utilized in situations requiring standard DC. Materials and Methods A decision to perform DC or EC was taken by consecutively allocation to either of the procedures. The bone flap was divided into three pieces, which were tied loosely to each other and to the skull using silk threads. The primary outcome included functional assessment using Glasgow outcome scale (GOS) score at 1 year. Results and Conclusions Total 67 patients were included in the analyses, of which, 31 underwent EC and 36 underwent DC. Both the cohorts were matched in terms of baseline determinants for age, Glasgow coma scale, and Rotterdam score at admission. There was no significant difference in GOS scores and the extent of volume expansion obtained by EC as compared to DC. Complication rates though less in EC group did not differ significantly between the groups. EC appears to be the safe and effective alternative to DC in the management of brain swelling due to TBI with a potential to obviate the need of cranioplasty.
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Affiliation(s)
- Tejesh Mishra
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Kislay Kishore
- Department of Neurosurgery; Department of Biostatistics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Mini Jayan
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Divesh Thaploo
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India; Department of Otorhinolaryngology, Smell and Taste Clinic, TU Dresden, Germany
| | - Nagesh C Shanbhag
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India; Department of Experimental Medical Science, Biomedical Centre, Lund University, Lund, Sweden
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom; RV Aster Hospital, Bangalore, Karnataka, India
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Subhas K Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Bhagavatula I Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- NIHR Global Health Research Group on Neurotrauma; Department of Clinical Neurosciences, University of Cambridge; Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
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17
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Han Y, Wang H. Reply to the editor. Childs Nerv Syst 2021; 37:1821-1822. [PMID: 33939018 DOI: 10.1007/s00381-021-05192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Yong Han
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, China
| | - Hangzhou Wang
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, China.
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18
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Mohan M, Layard Horsfall H, Solla DJF, Robertson FC, Adeleye AO, Teklemariam TL, Khan MM, Servadei F, Khan T, Karekezi C, Rubiano AM, Hutchinson PJ, Paiva WS, Kolias AG, Devi BI. Decompressive craniotomy: an international survey of practice. Acta Neurochir (Wien) 2021; 163:1415-1422. [PMID: 33738561 PMCID: PMC8053664 DOI: 10.1007/s00701-021-04783-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/22/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide. METHOD A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019. RESULTS We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC. CONCLUSION Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.
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Affiliation(s)
- Midhun Mohan
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Box 167, Cambridge, CB2 0QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
| | - Hugo Layard Horsfall
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Box 167, Cambridge, CB2 0QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | | | - Faith C Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Amos O Adeleye
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Tsegazeab Laeke Teklemariam
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Addis Ababa University, College of Health Science, Addis Ababa, Ethiopia
| | - Muhammad Mukhtar Khan
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University, Department of Biomedical Sciences and Humanitas Clinical and Research Center- IRCCS, Milan, Italy
| | - Tariq Khan
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Claire Karekezi
- Neurosurgery Unit, Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Andres M Rubiano
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- INUB/MEDITECH Research Group, El Bosque University, Bogota, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Box 167, Cambridge, CB2 0QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | | | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Box 167, Cambridge, CB2 0QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - B Indira Devi
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
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19
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Wang Y, Han Y, Chen M, Wang H. Three-pillar expansive craniotomy: a new surgical technique for cerebral decompression in children. Childs Nerv Syst 2021; 37:1723-1728. [PMID: 33559054 DOI: 10.1007/s00381-021-05073-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study is to conduct a retrospective review of data obtained in all consecutive patients who had undergone cerebral decompression using the 3-pillar expansive craniotomy (3PEC) in our hospital between 2016 and 2020. METHODS AND RESULTS We developed a novel craniotomy technique using expansion cranioplasty in patients with traumatic brain injury or stroke, which could relieve intracranial hypertension, maintain cerebral protection, and avoid subsequent cranial repair. Sixteen patients aged 2-18 years old underwent the 3PEC. Two patients, who presented very severe neurological conditions at the admission, died. All surviving patients showed good neurological outcome. None of the survived patients presented with bone flap resorption or sinking flap syndrome. CONCLUSION The role of decompressive craniectomy has been recently questioned in the pediatric population by the use of decompressive craniotomy. In this limited study of children patients experiencing stroke or traumatic brain injury, 3PEC was proved useful in reducing intracranial pressure (ICP), thus, questioning the role of decompressive craniectomy in children. The technique effectively reduces postoperative complications and eliminates subsequent cranioplasty procedures otherwise introduced by traditional decompressive craniectomy.
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Affiliation(s)
- Yongqiang Wang
- Department of Neurosurgery, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Yong Han
- Department of Neurosurgery, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Min Chen
- Department of Neurosurgery, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Hangzhou Wang
- Department of Neurosurgery, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, Jiangsu, 215006, People's Republic of China.
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20
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Wong AK, Wong RH. Split-Thickness Decompression in the Management of Intracranial Pressure. Korean J Neurotrauma 2021; 17:48-53. [PMID: 33981643 PMCID: PMC8093029 DOI: 10.13004/kjnt.2021.17.e6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/02/2021] [Accepted: 01/14/2021] [Indexed: 11/15/2022] Open
Abstract
Surgical management of elevated intracranial pressures due to stroke or traumatic brain injury has classically been through decompressive craniectomy (DC). There is significant morbidity associated with DC including subdural hygromas, syndrome of the trephined, and the need for subsequent cranioplasty. Alternative techniques including the hinged and floating craniotomy have shown promise though can still suffer from complications associated with an unsecured bone flap. We report a case in which a patient who presented with an acute subdural hematoma and associated midline shift that was successfully treated with decompression via thinning and re-securing of the bone flap in a “split-thickness decompression.”
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Affiliation(s)
- Andrew K. Wong
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Ricky H. Wong
- Department of Neurosurgery, NorthShore University Health System, Evanston, IL, USA
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21
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Park YS, Kogeichi Y, Haku T, Kim TK, Yokota H, Nakagawa I, Motoyama Y, Nakase H. Hinge and floating decompressive craniotomy for infantile acute subdural hematoma: technical note. Childs Nerv Syst 2021; 37:295-298. [PMID: 33108518 DOI: 10.1007/s00381-020-04942-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/21/2020] [Indexed: 11/26/2022]
Abstract
Cranioplasty complications after decompressive craniectomy (DC) in infants are not fully recognized. We aimed to devise and assess the efficacy of a hinge and floating DC (HFDC) technique for treating infantile acute subdural hematoma. Five infants, aged 2-20 months, were included. Intracranial pressure was controlled below 20 mmHg, no additional surgery was required, and there was no incidence of surgical site infection or bone graft resorption.
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Affiliation(s)
- Young-Soo Park
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan.
- Division of Neurosurgery, Children's Medical Center, Nara Medical University Hospital, 840 Shijo-cho, Kashihara, Nara, Japan.
| | - Yohei Kogeichi
- Department of Emergency and Critical Care Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Takahide Haku
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Tae Kyun Kim
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Hiroshi Yokota
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
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22
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Zaed I, Rossini Z, Faedo F, Fontanella MM, Cardia A, Servadei F. Long-term follow-up of custom-made porous hydroxyapatite cranioplasty in adult patients: a multicenter European study. Can we trust self-reported complications? J Neurosurg Sci 2020; 66:335-341. [PMID: 32989979 DOI: 10.23736/s0390-5616.20.05138-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cranioplasty is a surgical intervention aiming to re-establish the integrity of skull defects. Autologous bone and different heterologous materials are used for this purpose, with various reported related complications. The aim of the study was to evaluate the complication rate in a multicentric cohort of patients underwent porous hydroxyapatite (PHA) cranioplasty implantation and to assess the validity of company post-market clinical analysis. METHODS Authors analyzed a company based register of 6279 PHA cranioplasty implanted all over the world. In these adult patients only self-reported complications were available. We then obtained the data of adult patients treated with custom-made porous HA prostheses (CustomBone Service) in 20 institutions from different European countries through an on-site interview with the physicians in charge of the patients (494 patients). The endpoints were the incidence of adverse events and of related implant removal. RESULTS The groups of patients had similar demographics characteristics. The average follow-up was 26.7 months. A significantly higher number of complications was recorded in the group of patients underwent onsite interview. Thirty-nine complications were reported (7.89%) with an explantation rate of 4.25% (21 cases) in the series, compared to the data reported from the Company (complications rate of 3.3% and explantation rate of 3.1%). The most common complications were infection (4.86%), hematomas (1.22%), fractures (1.01%), mobilization (0.4%) and scar retraction (0.4%). CONCLUSIONS Our data confirm that porous HA cranioplasty is at least as effective as other heterologous materials to repair cranial defects. Another interesting finding is that self-reporting complicantions by surgeons does not give a precise picture of the real rate of complications of the devices. These data in future studies need to be re-confirmed with on-site interviews.
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Affiliation(s)
- Ismail Zaed
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy - .,Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy -
| | - Zefferino Rossini
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Francesca Faedo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Marco M Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Cardia
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
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23
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Smith M, Servadei F, Hutchinson PJ. What is new in decompressive craniectomy in neurological emergencies: the good, the bad and the ugly. Intensive Care Med 2020; 46:1023-1026. [PMID: 31996957 DOI: 10.1007/s00134-020-05933-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/11/2020] [Indexed: 10/25/2022]
Affiliation(s)
- M Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK. .,Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - F Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milano, Italy
| | - P J Hutchinson
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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