Addition of zygomatic arch resection in decompressive craniectomy

Shape-based interpolation method in measuring intracranial volume for pre- and post-operative decompressive craniectomy using open source software

INTRODUCTION

Intracranial volume (ICV) is an important tool in the management of patients undergoing decompressive craniectomy (DC) surgery. The aim of this study was to validate ICV measurement applying the shape-based interpolation (SBI) method using open source software on computed tomography (CT) images.

METHODS

The pre- and post-operative CT images of 55 patients undergoing DC surgery were analyzed. The ICV was measured by segmenting every slice of the CT images, and compared with estimated ICV calculated using the 1-in-10 sampling strategy and processed using the SBI method. An independent t test was conducted to compare the ICV measurements between the two different methods. The calculation using this method was repeated three times for reliability analysis using the intraclass correlations coefficient (ICC). The Bland-Altman plot was used to measure agreement between the methods for both pre- and post-operative ICV measurements.

RESULTS

The mean ICV (±SD) were 1341.1±122.1ml (manual) and 1344.11±122.6ml (SBI) for the preoperative CT data. The mean ICV (±SD) were 1396.4±132.4ml (manual) and 1400.53±132.1ml (SBI) for the post-operative CT data. No significant difference was found in ICV measurements using the manual and the SBI methods (p=.983 for pre-op, and p=.960 for post-op). The intrarater ICC showed a significant correlation; ICC=1.00. The Bland-Altman plot showed good agreement between the manual and the SBI method.

CONCLUSION

The shape-based interpolation method with 1-in-10 sampling strategy gave comparable results in estimating ICV compared to manual segmentation. Thus, this method could be used in clinical settings for rapid, reliable and repeatable ICV estimations.

Novel Hemicraniectomy Technique for Malignant Middle Cerebral Artery Infarction: Technical Note

BACKGROUND AND IMPORTANCE

Decompressive hemicraniectomy (DH) is the mainstay of treatment for malignant middle cerebral artery infarction (MMI). Although this operation significantly reduces mortality and improves functional outcomes, the conventional technique involves a reverse question mark incision starting anterior to the tragus that can injure the scalp's major blood supply, the superficial temporal artery (STA), which increases the risk of postoperative complications.

CLINICAL PRESENTATION

We developed a modified DH technique to reduce surgical morbidity associated with injury to the STA, accommodate a large bone window for effective decompression, and improve operative speed. After performing hospital chart review, a total of 34 patients were found who underwent this DH technique for MMI. Of these, 22 patients had this performed for right-sided MMI and 12 patients had this performed for left-sided MMI.

CONCLUSION

In each case, our approach preserved the STA and thereby minimized the risk for ischemic necrosis of the scalp flap. Since our technique avoids dissection of the preauricular temporalis muscle, we believe operative times can be decreased while still accommodating a large bone window to allow for effective decompression of the infarcted brain parenchyma.

Neurologic Functional Outcomes of Decompressive Hemicraniectomy Versus Conventional Treatment for Malignant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis

OBJECTIVE

The aims of this study were to evaluate decompressive hemicraniectomy (DHC) versus conventional treatment (CT) for patients with malignant middle cerebral artery (MCA) infarction and to investigate the impact of age and surgical timing on neurologic function and mortality.

METHODS

We searched English and Chinese databases for randomized controlled trials or observational studies published before August 2016. Outcomes included good functional outcome (GFO), mortality, and National Institutes of Health Stroke Scale and Barthel index scores.

RESULTS

This meta-analysis included 25 studies (1727 patients). There were statistically significant differences between DHC and CT groups in terms of GFO (P < 0.0001), mortality (P < 0.00001), and National Institutes of Health Stroke Scale and Barthel index scores (P < 0.0001) at different follow-up points. Significant differences were observed between the groups in survival with moderately severe disability (P < 0.00001); no differences were observed in survival with severe disability. In the subgroup analysis, in the DHC group, GFO was less in patients >60 years old (9.65%) versus ≤60 years old (38.94%); more patients >60 years old had moderately severe or severe disability (55.27%) compared with patients ≤60 years old (44.21%).

CONCLUSIONS

DHC could significantly improve GFO and reduces mortality of patients of all ages with malignant MCA infarction compared with CT, without increasing the number of patients surviving with severe disability. However, patients in the DHC group more frequently had moderately severe disability. Patients >60 years old with malignant MCA infarction had a higher risk of surviving with moderately severe or severe disability and less GFO.

Addition of Resection of Temporal Muscle and Fascia in Decompressive Craniectomy in the Treatment of Traumatic Brain Injury

OBJECTIVE

Decompressive craniectomy (DC) is a widely used surgical procedure for control of severely increased intracranial pressure in various conditions. The goal of this study is to evaluate the effectiveness of the addition of resection of temporalis muscle and fascia in DC particularly in the treatment of traumatic brain injury.

METHODS

Twenty patients underwent temporalis muscle and fascia resection in addition to conventional DC and duroplasty due to massive brain swelling in a single tertiary hospital from 2013 to 2015 were enrolled. Twenty other patients who received the standard techniques by other neurosurgeons in the same period were gathered for the control group. Postoperative computed tomography (CT) as well as functional outcome in both groups were analyzed retrospectively.

RESULTS

CT volumetry showed a significant increase of 85.19 mL (p<0.001) of extracranial herniation volume in the research group compared with the control group. Using modified Rankin Scale and Glasgow Outcome Scale, there was no statistically significant difference in functional outcome between the two groups.

CONCLUSION

Although preliminary, the procedure appears to show a meaningful increase in extracranial herniation volume with minimal masticatory and cosmetic impairment.