Contralateral subdural effusion after aneurysm surgery and decompressive craniectomy: case report and review of the literature

Subdural Hygroma After Management of Ruptured Intracranial Aneurysms: Incidence, Associated Factors, Clinical Course, and Management Options

OBJECTIVE

To evaluate the incidence, associated factors, clinical course, and management options of subdural hygroma in patients treated for aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

From January 2013 until June 2022, 336 consecutive patients with aSAH underwent treatment in our center. No one patient was excluded from the study cohort. Computed tomography (CT) examinations were performed at admission, immediately after surgery and on the first postoperative day, and subsequently in case of any neurologic deterioration or, at least, once per week until discharge from the hospital. Thereafter, CT examinations were at the discretion of specialists in the rehabilitation facility, referring physicians, or neurosurgeons at the outpatient clinic.

RESULTS

The length of radiologic follow-up starting from CT at admission ranged from 1 to 3286 days (mean, 673 ± 895 days; median, 150 days). Subdural hygromas developed in 84 patients (25%). An average interval until this imaging finding from the initial CT examination was 25 ± 55 days (median, 8 days; range, 0-362 days). Evaluation in the multivariate model showed that patient age ≥72 years (P < 0.0001), cerebrospinal fluid (CSF) shunting (P < 0.0001), and microsurgical clipping of ruptured intracranial aneurysm (RIA; P < 0.0001) are independently associated with the development of subdural hygroma. In 54 of 84 cases (64%), subdural hygromas required observation only. Increase of the lesion size with (5 cases) or without (10 cases) appearance of midline shift was associated with patient age <72 years (P = 0.0398), decompressive craniotomy (P = 0.0192), and CSF shunting (P = 0.0009), whereas evaluation of these factors in the multivariate model confirmed independent association of only CSF shunting (P = 0.0003). Active management of subdural hygromas included adjustment of the shunt programmable valve opening pressure, cranioplasty, external subdural drainage, or their combination. Overall, during follow-up (mean, 531 ± 824 days; median, 119 days; range, 2-3285 days) after the start of observation or applied treatment, subdural hygromas showed either decrease (50 cases) or stabilization (34 cases) of their sizes, and no one lesion showed progression again.

CONCLUSIONS

The clinical course of subdural hygromas in patients treated for aSAH is generally favorable, but occasionally these lesions show progressive enlargement with or without the appearance of midline shift, which requires active management.

Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy

OBJECTIVE

Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC.

METHODS

The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema.

RESULTS

A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21).

CONCLUSIONS

In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.

Effects of Cranioplasty on Contralateral Subdural Effusion After Decompressive Craniectomy: A Literature Review

BACKGROUND

Contralateral subdural effusion(CSE) after decompressive craniectomy (CSEDC) is occasionally observed. Cranioplasty is routinely performed for reconstruction and has recently been associated with improving contralateral subdural effusion .

OBJECTIVE

To systematically review all available literature and evaluate the effectiveness of cranioplasty for CSE.

METHODS

A PubMed, Web of Science, and Google Scholar search was conducted for preferred reporting items following the guidelines of systematic review and meta-analysis, including studies reporting patients who underwent cranioplasty because of CSEDC.

RESULTS

The search yielded eight articles. A total of 56 patients ranging in age from 21 to 71 years, developed CSEDC. Of them, 32 patients underwent cranioplasty. Eighteen cases with symptomatic CSE underwent cranioplasty alone, two cases received Ommaya drainage later because of a a recurrence of CDC, and one case underwent a ventriculoperitoneal shunt because the CSE did not resolve completely and the ventricle was dilated again. The symptoms of 14 cases lessened without recurrence after simultaneous cranioplasty and drainage or a shunt. The total success rate(CSE disappeared without recurrence) was 90.6% for patients who underwent cranioplasty; however, the total incidence of hydrocephalus was 40.1%.

CONCLUSIONS

This review suggests that cranioplasty is effective for the treatment of CSEDC, particularly intractable cases, but early cranioplasty may be more effective. In addition, hydrocephalus is fairly common after cranioplasty and requires further treatment.

Contralateral subdural effusion after decompressive craniectomy: What is the optimal treatment?

OBJECTIVE

Contralateral subdural effusion after decompressive craniectomy (CSEDC) is rare, and the optimal treatment is not determined. We present 11 cases of CSEDC and give an overview of the English literature pertaining to this disease.

METHODS

We searched the database at our institution and performed a search of English literature in PubMed and Google Scholar. Keywords used were as follows (single word or combination): "subdural hygroma"; "subdural effusion"; "decompressive craniectomy". Only patients with CSEDC and contained adequate clinical information pertinent to the analysis were included.

RESULTS

11 cases of CSEDC were recorded at our institution. They comprised ten men and one woman with an average age of 41.9 years. All the 8 symptomatic patients underwent surgery and the CSEDC resolved gradually. 68 cases of CSEDC were found in the literature. Including ours, a total of 79 patients were analyzed. Conservative treatment was effective in the asymptomatic patients. 41.7% of the symptomatic CSEDC underwent burr hole drainage and successfully drained the CSEDC. However, 76% of them received subsequent surgery to manage the reaccumulation of CSEDC. 25% of the symptomatic patients underwent cranioplasty, while 13.3% of them received Ommaya drainage later because of CSEDC recurrence. 18.3% of the symptomatic patients underwent cranioplasty plus subduroperitoneal shunting, and all CSEDC resolved completely.

CONCLUSIONS

Burr hole drainage appears to be only a temporary measure. Early cranioplasty should be performed for patients with CSEDC. CSF shunting procedures may be required for patients in whom CSEDC have not been solved or hydrocephalus manifest after cranioplasty.

Cranioplasty as the treatment for contralateral subdural effusion secondary to decompressive craniectomy: a case report and review of the relevant literature

Subdural effusion (SDE) is a common complication secondary to decompressive craniectomy (DC). This current case report describes a patient with contralateral SDE with a typical clinical course. Initially, he made a good recovery following a head trauma that caused a loss of consciousness and was treated with decompressive craniectomy. However, he only achieved temporary relief after each percutaneous fluid aspiration from an Ommaya reservoir implanted into the cavity of the SDE. He was eventually transferred to the authors’ hospital where he underwent cranioplasty, which finally lead to the reduction and disappearance of his contralateral SDE. Unexpectedly, his clinical condition deteriorated again 2 weeks after the cranioplasty with symptoms of an uncontrolled bladder. A subsequent CT scan found the apparent expansion of the whole cerebral ventricular system, indicating symptomatic communicating hydrocephalus. He then underwent a ventriculoperitoneal shunt procedure, which resulted in a favourable outcome and he was discharged 2 weeks later. A review of the current literature identified only 14 cases of contralateral SDE that were cured by cranioplasty alone. The mechanism of contralateral SDE has been widely discussed. Although the exact mechanism of contralateral SDE and why cranioplasty is effective remain unclear, cranioplasty could be an alternative treatment option for contralateral SDE.

Factors involved in the development of subdural hygroma after decompressive craniectomy for traumatic brain injury. A systematic review and meta-analysis

Subdural hygroma (SDG) represents a common complication following decompressive craniectomy (DC). To our knowledge we present the first meta-analysis investigating the role of clinical and technical factors in the development of SDG after DC for traumatic brain injury. We further investigated the impact of SDG on the final prognosis of patients. The systematic review of the literature was done according to the PRISMA guidelines. Two different online medical databases (PubMed/Medline and Scopus) were screened. Four articles were included in this meta-analysis. Data regarding age, sex, trauma dynamic, Glasgow Coma Scale (GCS), pupil reactivity and CT scan findings on admission were collected for meta-analysis in order to evaluate the possible role in the SDG formation. Moreover we studied the possible impact of SDG on the outcome by evaluating the rate of patients dead at final follow-up and the Glasgow Outcome Scale (GOS) at final follow-up. Among the factors available for meta-analysis only the basal cistern involvement on CT scan was associated with the development of a SDG after DC (p < 0.001). Moreover, patients without SDG had a statistically significant better outcome compared with patients who developed SDG after DC in terms of GOS (p < 0.001). The rate of patients dead at follow-up was lower in the group of patients without SDH (8.25%) compared with patients who developed SDG (11.51%). SDG after DC is a serious complication affecting the prognosis of patients. Further studies are needed to define the role of some adjustable technical aspect of DC in preventing such a complication.

Decompressive craniectomy in aneurysmal subarachnoid haemorrhage for hematoma or oedema versus secondary infarction

PURPOSE

Decompressive craniectomy (DC) has been proposed as lifesaving treatment in aneurysmal subarachnoid haemorrhage (aSAH) patients with elevated intracranial pressure (ICP). However, data is sparse and controversy exists whether the underlying cause of elevated ICP influences neurological outcome. The purpose of this study is to clarify the role of the underlying cause of elevated ICP on outcome after DC.

MATERIALS AND METHODS

We retrospectively studied the one-year neurological outcome in a single-centre cohort to identify predictors of favourable (Glasgow Outcome Scale (GOS) 4-5) and unfavourable (GOS 1-3) outcome. Additionally, available individual patient data in the literature was reviewed with a special emphasis on the underlying reason for DC.

RESULTS

From 2006-2015, 53 consecutive aSAH patients underwent DC. Nine (17%) achieved favourable, 44 (83%) unfavourable outcome (31 patients died). One fourth of the patients undergoing DC for hematoma or (hematoma-related) oedema survived favourably (increasing to 46% for patients aged <51 years), versus none of the patients undergoing DC for secondary infarction. Analysis of individual data of 105 literature patients showed a similar trend, although overall outcome was much better: half of the patients undergoing DC for hematoma/oedema regained independence, versus less than one-fourth of patients undergoing DC for secondary infarction.

CONCLUSIONS

DC in aSAH patients is associated with high rates of unfavourable outcome and mortality, but hematoma or oedema as underlying reason for DC is associated with better outcome profiles compared to secondary infarction. Future observational cohort studies are needed to further explore the different outcome profiles among subpopulations of aSAH patients requiring DC.

The Risk Factors for Hydrocephalus and Subdural Hygroma after Decompressive Craniectomy in Head Injured Patients

Objective

The present study aims to investigate 1) the risk factors for hydrocephalus and subdural hygroma (SDG) occurring after decompressive craniectomy (DC), and 2) the association between the type of SDG and hydrocephalus.

Methods

We retrospectively reviewed the clinical and radiological features of 92 patients who underwent DC procedures after severe head injuries. The risk factors for developing post-traumatic hydrocephalus (PTH) and SDG were analyzed. Types of SDGs were classified according to location and their relationship with hydrocephalus was investigated.

Results

Ultimately, 26.09% (24/92) of these patients developed PTH. In the univariate analyses, hydrocephalus was statically associated with large bone flap diameter, large craniectomy area, bilateral craniectomy, intraventricular hemorrhage, contralateral or interhemisheric SDGs, and delayed cranioplasty. However, in the multivariate analysis, only large craniectomy area (adjusted OR=4.66; p=0.0239) and contralateral SDG (adjusted OR=6.62; p=0.0105) were significant independent risk factors for developing hydrocephalus after DC. The incidence of overall SDGs after DC was 55.43% (51/92). Subgroup analysis results were separated by SDG types. Statistically significant associations between hydrocephalus were found in multivariate analysis in the contralateral (adjusted OR=5.58; p=0.0074) and interhemispheric (adjusted OR=17.63; p=0.0113) types.

Conclusion

For patients who are subjected to DC following severe head trauma, hydrocephalus is associated with a large craniectomy area and contralateral SDG. For SDGs after DC that occur on the interhemispherical or controlateral side of the craniectomy, careful follow-up monitoring for the potential progression into hydrocephalus is needed.

Preparation of Porous Chitosan-Siloxane Hybrids Coated with Hydroxyapatite Particles

This paper describes the apatite deposition of chitosan-silicate porous hybrids derived from chitosan and γ-glycidoxypropyltrimethoxysilane (GPTMS) in alkaline phosphate solution. The preparation of porous hybrids with needle-like apatite on their surfaces is described. Following apatite deposition the porous hybrids maintained high porosity. The enzymatic degradation rate was low even after 6 months and the porous hybrids were very flexible and cut easily using surgical scissors.

Symptomatic contralateral subdural hygromas after decompressive craniectomy: plausible causes and management protocols

OBJECT

Contralateral subdural hygromas are occasionally observed after decompressive craniectomies (DCs). Some of these hygromas are symptomatic, and the etiology and management of these symptomatic contralateral subdural collections (CLDCs) present surgical challenges. The authors share their experience with managing symptomatic CLSDCs after a DC.

METHODS

During a 10-month period, 306 patients underwent a DC. Of these patients, 266 had a head injury, 25 a middle cerebral artery infarction (that is, a thrombotic stroke), and 15 an infarction due to a vasospasm (resulting from an aneurysmal subarachnoid hemorrhage [SAH]). Seventeen patients (15 with a head injury and 2 with an SAH) developed a CLSDC, and 7 of these patients showed overt symptoms of the fluid collection. These patients were treated with a trial intervention consisting of bur hole drainage followed by cranioplasty. If required, a ventriculo- or thecoperitoneal shunt was inserted at a later time.

RESULTS

Seven patients developed a symptomatic CLSDC after a DC, 6 of whom had a head injury and 1 had an SAH. The average length of time between the DC and CLSDC formation was 24 days. Fluid drainage via a bur hole was attempted in the first 5 patients. However, symptoms in these patients improved only temporarily. All 7 patients (including the 5 in whom the bur hole drainage had failed and 2 directly after the DC) underwent a cranioplasty, and the CLSDC resolved in all of these patients. The average time it took for the CLSDC to resolve after the cranioplasty was 34 days. Three patients developed hydrocephalus after the cranioplasty, requiring a diversion procedure, and 1 patient contracted meningitis and died.

CONCLUSIONS

Arachnoid tears and blockage of arachnoid villi appear to be the underlying causes of a CLSDC. The absence of sufficient fluid pressure required for CSF absorption after a DC further aggravates such fluid collections. Underlying hydrocephalus may appear as subdural collections in some patients after the DC. Bur hole drainage appears to be only a temporary measure and leads to recurrence of a CLSDC. Therefore, cranioplasty is the definitive treatment for such collections and, if performed early, may even avert CLSDC formation. A temporary ventriculostomy or an external lumbar drainage may be added to aid the cranioplasty and may be removed postoperatively. Ventriculoperitoneal or thecoperitoneal shunting may be required for patients in whom a hydrocephalus manifests after cranioplasty and underlies the CLSDC.

Simultaneous cranioplasty and subdural-peritoneal shunting for contralateral symptomatic subdural hygroma following decompressive craniectomy

BACKGROUND

Contralateral subdural hygroma caused by decompressive craniectomy tends to combine with external cerebral herniation, causing neurological deficits.

MATERIAL AND METHODS

Nine patients who underwent one-stage, simultaneous cranioplasty and contralateral subdural-peritoneal shunting were included in this study. Clinical outcome was assessed by Glasgow Outcome Scale as well as Glasgow Coma Scale, muscle power scoring system, and complications.

RESULTS

Postoperative computed tomography scans demonstrated completely resolved subdural hygroma and reversed midline shifts, indicating excellent outcome. Among these 9 patients, 4 patients (44%) had improved GOS following the proposed surgery. Four out of 4 patients with lethargy became alert and orientated following surgical intervention. Muscle strength improved significantly 5 months after surgery in 7 out of 7 patients with weakness. Two out of 9 patients presented with drowsiness due to hydrocephalus at an average time of 65 days after surgery. Double gradient shunting is useful to eliminate the respective hydrocephalus and contralateral subdural hygroma.

CONCLUSION

The described surgical technique is effective in treating symptomatic contralateral subdural hygroma following decompressive craniectomy and is associated with an excellent structural and functional outcome. However, subdural-peritoneal shunting plus cranioplasty thoroughly resolves the subdural hygroma collection, which might deteriorate the cerebrospinal fluid circulation, leading to hydrocephalus.

Neurological susceptibility to a skull defect

BACKGROUND

There continues to be considerable interest in the use of decompressive craniectomy in the management of neurological emergencies. The procedure is technically straightforward; however, it is becoming increasingly apparent that it is associated with significant complications. One complication that has received relatively little attention is the neurological dysfunction that can occur due to the absence of the bone flap and the subsequent distortion of the brain under the scalp as cerebral swelling subsides. The aim of this narrative review was to examine the literature available regarding the clinical features described, outline the proposed pathophysiology for these clinical manifestations and highlight the implications that this may have for rehabilitation of patients with a large skull defect.

METHODS

A literature search was performed in the MEDLINE database (1966 to June 2012). The following keywords were used: Hemicraniectomy, decompressive craniectomy, complications, syndrome of the trephined, syndrome of the sinking scalp flap, motor trephined syndrome. The bibliographies of retrieved reports were searched for additional references.

RESULTS

Various terms have been used to describe the different neurological signs and symptoms with which patients with a skull defect can present. These include; syndrome of the trephined, posttraumatic syndrome, syndrome of the sinking scalp flap, and motor trephined syndrome. There is, however, considerable overlap between the conditions described and a patient's individual clinical presentation.

CONCLUSION

It is becoming increasingly apparent that certain patients are particularly susceptible to the presence of a large skull defect. The term "Neurological Susceptibility to a Skull Defect" (NSSD) is therefore suggested as a blanket term to describe any neurological change attributable to the absence of cranial coverage.

Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring

Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.

Contralateral subdural effusion related to decompressive craniectomy performed in patients with severe traumatic brain injury

BACKGROUND

Contralateral subdural effusion caused by decompressive craniectomy (DC) is not uncommon. However, it has rarely been reported.

METHOD

From 2004 to 2008, 123 severe traumatic brain injury (TBI) patients were identified as having undergone DC for increased intracranial pressure (IICP) with or without removal of a blood clot or contused brain. Of these 123 patients, nine developed delayed contralateral subdural effusion. Demographics, clinical presentations, treatment and outcome were reported.

RESULTS

The overall incidence of contralateral subdural effusion was 7.3%. On average, this complication was found 23 days after DC. Of the nine patients, six had neurological deterioration and received drainage through a burr hole. One patient needed a subsequent subduro-peritoneal shunting because of recurrent subdural effusion.

CONCLUSION

Contralateral subdural effusions may be not uncommon and need more aggressive treatment because of their tendency to cause midline shift. Surgical intervention may be warranted if the patients develop deteriorating clinical manifestations or if the subdural effusion has an apparent mass effect.

Decompressive craniectomy - operative technique and perioperative care

With improvements in neurocritical care advanced measures of treating raised intracranial pressure (ICP) are more frequently utilised. Decompressive craniectomy is an effective ICP-lowering procedure; however its benefits are maximised with optimal surgical technique and perioperative care, as well as by paying attention to possible complications. This article focuses on the current indications and rationale for decompressive craniectomy, and the surgical technique of bifrontal and unilateral decompression. The key surgical points include a large craniectomy window and opening of the dura, leaving it unsutured or performing a wide non-constricting duroplasty. Perioperative care and possible complications are also discussed.

Contralateral subdural effusion after decompressive craniectomy in patients with severe traumatic brain injury: clinical features and outcome

BACKGROUND

Contralateral subdural effusion (SDE) is usually considered as an uncommon complication after decompressive craniectomy (DC) for head trauma. This complication may need more aggressive treatment because of its tendency to cause midline shift and neurologic deterioration. In this article, we present our experience with this group of patients and discuss the diagnosis and management of this entity.

METHODS

This study included 13 patients with severe traumatic brain injury who developed contralateral SDE after DC. Clinical and radiographic information was obtained through a retrospective review of the medical records and the radiographs.

RESULTS

The average time from the procedure of DC to the diagnosis of contralateral SDE was 13 days. Deterioration of clinical condition or appearance of new symptoms/signs related to the contralateral SDE was noted in four patients. In the remaining nine patients without apparent clinical deterioration, the contralateral SDE was discovered on routine computed tomography scan. Six patients were treated conservatively and the contralateral SDE resolved gradually. In six patients who underwent burr hole craniectomy to evacuate the SDE, the operation had successfully drained the SDE in four patients. Two patients received subsequent subduroperitoneal shunt to manage the reaccumulation of SDE. In one patient, subduroperitoneal shunt and cranioplasty were performed simultaneously to treat the SDE. Subsequently, six patients (46.2%) developed hydrocephalus and underwent ventriculoperitoneal shunt operation.

CONCLUSIONS

Contralateral SDE may not be a rare complication after DC. Its diagnosis may be delayed or missed when it is asymptomatic or the clinical condition of the patient masks its clinical manifestations. It may be reasonable to repeat a computed tomography scan to detect contralateral SDE 2 weeks to 3 weeks after DC, irrespective of the clinical condition. In addition, posttraumatic hydrocephalus is a common late consequence in these patients. Close surveillance in these patients is indicated to prompt appropriate management.

Bipolar duraplasty: a new technique for reducing transcranial cerebral herniation to allow for definitive cranioplasty

Large, full-thickness calvarial defects cause increased brain tissue compliance, often resulting in transient, transcranial herniation in the setting of normotensive intracranial pressures. Cranioplasty serves to protect the cerebrum from external injury, provide an aesthetic contour, and alleviate neurological symptoms. Traditional options for management include head elevation, osmotic diuresis, mild hyperventilation, durotomy with closure following fluid evacuation, expansile cranioplasty, lobectomy, and procedure abortion with prolonged helmet therapy. Patients treated conservatively with helmet therapy commonly are noncompliant and sustain repeated minor trauma to unprotected cerebral contents. Furthermore, recent literature suggests that early cranioplasty may improve outcomes and reduce costs. The authors present a novel solution, bipolar duraplasty, which allows safe, transient reduction of normotensive parenchymal herniation using bipolar electrocautery. The dura of the herniated sac is cauterized using a low-set, bipolar current in a series of sagittal and coronal lines, resulting in immediate contraction and reduction allowing for definitive cranioplasty. This new method was used in a patient with a 30-cm(2) frontal bone defect following resection of a right falcine atypical meningioma. In this scenario, bipolar duraplasty was performed free of complication, and the patient has remained asymptomatic and greatly satisfied for 1 year since the procedure. This technique might facilitate earlier cranioplasty, could be applied to a wide range of patients, and may afford better neurological outcomes at a reduced cost.

Decompressive hemicraniectomy after malignant middle cerebral artery infarction: rationale and controversies

Malignant middle cerebral artery stroke carries a very poor prognosis. Significant retrospective data support the hypothesis that decompressive hemicraniectomy decreases mortality rates due to this disease entity. Recently, 3 randomized controlled studies have been published and shed light on these issues and enhance the quality of evidence revolving around this procedure. In this review, the rationale, risks, benefits, and unanswered questions related to hemicraniectomy for acute ischemic stroke are reviewed with an emphasis on how 3 randomized trials have influenced knowledge on this life-saving yet controversial procedure. Further randomized studies are needed to clarify lingering questions regarding age indications and impact on quality of life.

Life-saving decompressive craniectomy for diffuse cerebral edema during an episode of new-onset diabetic ketoacidosis: case report and review of the literature

PURPOSE

Diabetic ketoacidosis (DKA), a well-known complication of diabetes mellitus, is associated with severe diffuse cerebral edema leading to brain herniation and death. Survival from an episode of symptomatic cerebral edema has been associated with debilitating neurological sequelae, including motor deficits, visual impairment, memory loss, seizures, and persistent vegetative states. A review of the literature reveals scant information regarding the potential surgical options for these cases. The authors present their case in which they used a craniectomy to treat this life-threatening condition.

METHODS

After reportedly suffering nausea and vomiting, a 12-year-old male presented to the emergency room with lethargy and was diagnosed with acute DKA. After appropriate treatment, the patient became comatose. A CT scan revealed diffuse cerebral edema. To decrease intracranial pressure and prevent further progression of brain herniation, a bifrontal decompressive craniectomy with duraplasty was performed.

RESULTS

The patient's neurological function gradually improved, and he returned to school and his regular activities with only minimal cognitive deficits.

CONCLUSION

Given the high mortality and morbidity associated with DKA-related edema, we believe decompressive craniectomy should be considered for malignant cerebral edema and herniation syndrome.

Subdural effusions with hydrocephalus after severe head injury: successful treatment with ventriculoperitoneal shunt placement: report of 3 adult cases

Background. Subdural collections of cerebrospinal fluid (CSF) with associated hydrocephalus have been described by several different and sometimes inaccurate terms. It has been proposed that a subdural effusion with hydrocephalus (SDEH) can be treated effectively with a ventriculoperitoneal shunt (V-P shunt). In this study, we present our experience treating patients with SDEH without directly treating the subdural collection. Methods. We treated three patients with subdural effusions and hydrocephalus as a result of a head injury. All the patients were treated with a V-P shunt despite the fact that there was an extra-axial CSF collection with midline shift. Results. In all of the patients, the subdural effusions subsided and the ventricular dilatation improved in the postoperative period. The final clinical outcome remains difficult to predict and depends not only on the successful CSF diversion but also on the primary and secondary brain insult. Conclusion. Subdural effusions with hydrocephalus can be safely and effectively treated with V-P shunting, without directly treating the subdural effusion which subsides along with the treatment of hydrocephalus. However, it is extremely important to make an accurate diagnosis of an SDEH and differentiate this condition from other subdural collections which require different management.

Technical considerations in decompressive craniectomy in the treatment of traumatic brain injury

Refractory intracranial hypertension is a leading cause of poor neurological outcomes in patients with severe traumatic brain injury. Decompressive craniectomy has been used in the management of refractory intracranial hypertension for about a century, and is presently one of the most important methods for its control. However, there is still a lack of conclusive evidence for its efficacy in terms of patient outcome. In this article, we focus on the technical aspects of decompressive craniectomy and review different methods for this procedure. Moreover, we review technical improvements in large decompressive craniectomy, which is currently recommended by most authors and is aimed at increasing the decompressive effect, avoiding surgical complications, and facilitating subsequent management. At present, in the absence of prospective randomized controlled trials to prove the role of decompressive craniectomy in the treatment of traumatic brain injury, these technical improvements are valuable.

Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: relation to cerebral perfusion pressure and metabolism

INTRODUCTION

Outcome is poor in aneurysmal subarachnoid hemorrhage (SAH) patients with intracranial hypertension. As one treatment option for increased intracranial pressure (ICP), decompressive craniectomy (DC) is discussed. Its impact on cerebral metabolism and outcome in SAH patients is evaluated in this pilot study.

METHODS

A prospectively collected database of cerebral metabolism in SAH patients was analyzed retrospectively for individuals developing high ICP (>20 mmHg > 6 h/day, n = 18). Patients with intracranial hypertension were classified into groups with (n = 7) and without DC (n = 11). An age-matched control group was established (n = 89). Cerebral perfusion pressure (CPP) and high ICP treatment were analyzed for 7 days after SAH (or 72 h after craniectomy, respectively). Cerebral microdialysates were analyzed hourly. Twelve-month outcome was evaluated.

RESULTS

Groups were comparable for age, WFNS grade, and outcome. ICP was significantly reduced by DC (P < 0.01), however, in 43% of patients the effect was transient. An increase in the lactate/pyruvate ratio (P < 0.001) and glycerol levels (>200 muM) was observed before DC. In the DC group, glucose (P = 0.005) and pyruvate (P = 0.04) were higher, while glycerol levels were lower (P = 0.007) compared to the non-DC group, reflecting better aerobic glucose utilization and reduced cellular stress.

CONCLUSION

Outcome was poor in all SAH patients with intracranial hypertension. Although glucose utilization was improved after DC, no improvement in outcome could be shown for this small patient population. Future studies will have to demonstrate whether markers of cerebral crisis may support the decision for DC in aneurysmal SAH patients.

A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis

OBJECT

Hinge craniotomy (HC) has recently been described as an alternative to decompressive craniectomy (DC). Although HC may obviate the need for cranial reconstruction, an analysis comparing HC to DC has not yet been published.

METHODS

A retrospective review was conducted of 50 patients who underwent cranial decompression (20 with HC, 30 with DC). Baseline demographics, neurological examination results, and underlying pathology were reviewed. Clinical outcome was assessed by length of ventilatory support, length of intensive care unit stay, and survival at discharge. Control of intracranial hypertension was assessed by average daily intracranial pressure (ICP) for the duration of ICP monitoring and an ICP therapeutic intensity index. Radiographic outcomes were assessed by comparing preoperative and postoperative CT scans for: 1) Rotterdam score; 2) postoperative volume of cerebral expansion; 3) presence of uncal herniation; 4) intracerebral hemorrhage; and 5) extraaxial hematoma. Postoperative CT scans were analyzed for the size of the craniotomy/craniectomy and magnitude of extracranial herniation.

RESULTS

No significant differences were identified in baseline demographics, neurological examination results, or Rotterdam score between the HC and DC groups. Both HC and DC resulted in adequate control of ICP, as reflected in the average ICP for each group of patients (HC = 12.0 +/- 5.6 mm Hg, DC = 12.7 +/- 4.4 mm Hg; p > 0.05) at the same average therapeutic intensity index (HC = 1.2 +/- 0.3, DC = 1.2 +/- 0.4; p > 0.05). The need for reoperation (3 [15%] of 20 patients in the HC group, 3 [10%] of 30 patients in the DC group; p > 0.05), hospital survival (15 [75%] of 20 in the HC group, 21 [70%] of 30 in the DC group; p > 0.05), and mean duration of both mechanical ventilation (9.0 +/- 7.2 days in the HC group, 11.7 +/- 12.0 days in the DC group; p > 0.05) and intensive care unit stay (11.6 +/- 7.7 days in the HC group, 15.6 +/- 15.3 days in the DC group; p > 0.05) were similar. The difference in operative time for the two procedures was not statistically significant (130.4 +/- 71.9 minutes in the HC group, 124.9 +/- 63.3 minutes in the DC group; p > 0.05). The size of the cranial defect was comparable between the 2 groups. Postoperative imaging characteristics, including Rotterdam score, also did not differ significantly. Although a smaller volume of cerebral expansion was associated with HC (77.5 +/- 54.1 ml) than DC (105.1 +/- 65.1 ml), this difference was not statistically significant.

CONCLUSIONS

Hinge craniotomy appears to be at least as good as DC in providing postoperative ICP control and results in equivalent early clinical outcomes.

Dynamics of subdural hygroma following decompressive craniectomy: a comparative study

Object

This retrospective comparative cohort study was aimed at discovering the risk factors associated with subdural hygroma (SDG) following decompressive craniectomy (DC) to relieve intracranial hypertension in severe head injury.

Methods

Sixty-eight of 104 patients who had undergone DC during a 48-month period and survived > 30 days were eligible for this study. To assess the dynamics of subdural fluid collections, the authors compared CT scanning data from and the characteristics of 39 patients who had SDGs with the data in 29 patients who did not have hygromas. Variables significant in the appearance, evolution, and resolution of this complication were analyzed in a 36-week longitudinal study.

Results

The earliest imaging evidence of SDG was seen during the 1st week after DC. The SDG volume peaked between Weeks 3 and 4 post-DC and was gradually resolved by the 17th week. Among the mechanisms of injury, motor vehicle accidents were most often linked to the development of an SDG after DC (p < 0.0007), and falls were least often associated (p < 0.005). Moreover, patients with diffuse brain injury were more prone to this complication (p < 0.0299) than those with an evacuated mass (p < 0.0001). There were no statistically significant differences between patients with and without hygromas in terms of age, sex, Glasgow Coma Scale score, intraventricular and subarachnoid hemorrhage, levels of intracranial pressure and cerebral perfusion pressure, timing of decompression, and the need for CSF diversion. More than 90% of the SDGs were ipsilateral to the side of the craniectomy, and 3 (8%) of 39 SDGs showed evidence of internal bleeding at ~ 8 weeks postinjury. Surgical evacuation was needed in 4 patients with SDGs.

Conclusions

High dynamic accidents and patients with diffuse injury were more prone to SDGs. Close to 8% of SDGs converted themselves into subdural hematomas at ~ 2 months postinjury. Although SDGs developed in 39 (~ 60%) of 68 post-DC patients, surgical evacuation was needed in only 4.

Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases

BACKGROUND

Decompressive craniectomy is an important method for managing refractory intracranial hypertension in patients with head injury. We reviewed a large series of patients who underwent this surgical procedure to establish the incidence and type of postoperative complications.

METHODS

From 1998 to 2005, decompressive craniectomy was performed in 108 patients who suffered from a closed head injury. The incidence rates of complications secondary to decompressive craniectomy and risk factors for developing these complications were analysed. In addition, the relationship between outcome and clinical factors was analysed.

FINDINGS

Twenty-five of the 108 patients died within the first month after surgical decompression. A lower GCS at admission seemed to be associated with a poorer outcome. Complications related to surgical decompression occurred in 54 of the 108 (50%) patients; of these, 28 (25.9%) patients developed more than one type of complication. Herniation through the cranial defect was the most frequent complication within 1 week and 1 month, and subdural effusion was another frequent complication during this period. After 1 month, the "syndrome of the trephined" and hydrocephalus were the most frequent complications. Older patients and/or those with more severe head trauma had a higher occurrence rate of complications.

CONCLUSIONS

The potential benefits of decompressive craniectomy can be adversely affected by the occurrence of complications. Each complication secondary to surgical decompression had its own typical time window for occurrence. In addition, the severity of head injury was related to the development of a complication.

Decompressive Craniectomy

Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies is retrospective, the recent publication of several randomized prospective studies prompts a reevaluation of the utility of DC. We review the literature concerning the use of DC in TBI, MCA infarction, and SAH and address the evidence regarding common questions pertaining to the timing of and laterality of the procedure. We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.

Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma

Large cranial defects resulting from decompressive craniectomy performed for refractory intracranial hypertension after head trauma is one of the indications for cranioplasty, and this procedure is commonly performed 3 months after craniectomy. However, the large cranial defect would lead to the kinds of complications early during the phase of these patients' recovery, which would go against rehabilitation. This study retrospectively reviewed 23 patients undergoing early cranioplasty (5-8 weeks after craniectomy) in the last 4 years with a detailed choice of patients, outcome of complications after head trauma and large craniectomy, as well as assessment of prognosis. The early outcome (1 month later) revealed most of the patients who had conscious disturbance before the cranioplasty recovered their consciousness and presented an improved neurologic function. The long-dated prognosis (18 months later) revealed that 17 patients were good (independent patients) in this series (74%), whereas four patients survived with a severe disability (17%) and two remained in a vegetative state (9%). No dead patients or intracranial infection after the procedure were found in this study. Most patients' complications were relieved after the cranioplasty with improvements of symptoms or image of computed tomography scan. In conclusion, we consider that with the appropriate choice of patients and materials, early cranioplasty for large cranial defects after decompressive craniectomy would be safe and helpful for the improvement of patients' neurologic function and prognosis. To our knowledge, this series may be the first detailed report in English about early cranioplasty after decompressive craniectomy. We are going to perform prospective and retrospective contrastive studies to further confirm the effects of this procedure on the patients with large cranial defects after decompressive craniectomy.

Early surgical treatment of middle cerebral artery aneurysms associated with intracerebral haematoma

OBJECTIVE

Patients with haematoma secondary to middle cerebral artery aneurysm often require urgent surgical treatment consisting of evacuation of the haematoma and aneurysmal clipping.

METHODS

. We present our experience over 5 years with 12 patients who underwent surgery before the first 8h of bleeding. Surgery included craniotomy, evacuation of the haematoma, and aneurysmal clipping. Preoperative angiography was performed in all cases.

RESULTS

All patients had a score of 4 or 5 on the scale of the World Federation of Neurological Surgeons. Five of the patients were evolving well after 1 year. Clinical status upon admission, temporal lobe versus sylvian location of the haematoma, right-hemisphere involvement, and a midline deviation of less than 2 cm, were all most frequently associated with a good prognosis.

CONCLUSIONS

In our experience, and in the literature available to us, early surgery in patients with haematoma secondary to middle cerebral artery aneurysm offers acceptable results in patients with World Federation of Neurological Surgeons scores of 4 or 5.