Paradoxical Brain Herniation After Decompressive Craniectomy Provoked by Drainage of Subdural Hygroma

Paradoxical herniation associated with hyperbaric oxygen therapy after decompressive craniectomy: A case report

BACKGROUND

Whether hyperbaric oxygen therapy (HBOT) can cause paradoxical herniation is still unclear.

CASE SUMMARY

A 65-year-old patient who was comatose due to brain trauma underwent decompressive craniotomy and gradually regained consciousness after surgery. HBOT was administered 22 d after surgery due to speech impairment. Paradoxical herniation appeared on the second day after treatment, and the patient's condition worsened after receiving mannitol treatment at the rehabilitation hospital. After timely skull repair, the paradoxical herniation was resolved, and the patient regained consciousness and had a good recovery as observed at the follow-up visit.

CONCLUSION

Paradoxical herniation is rare and may be caused by HBOT. However, the underlying mechanism is unknown, and the understanding of this phenomenon is insufficient. The use of mannitol may worsen this condition. Timely skull repair can treat paradoxical herniation and prevent serious complications.

Improved strategy for post-traumatic hydrocephalus following decompressive craniectomy: Experience of a single center

Background

Patients with head trauma may develop hydrocephalus after decompressive craniectomy. Many studies have referred one-stage cranioplasty (CP) and ventriculoperitoneal shunt (VPS) was applied to treat cranial defect with post-traumatic hydrocephalus (PTH), but the safety and efficiency of the procedure remain controversial.

Methods

This is a retrospective cohort study including 70 patients of PTH following decompressive craniectomy who underwent simultaneous (50) and separated (20) procedures of cranioplasty and VPS from March 2014 to March 2021 at the authors' institution with at least 30 days of follow-up. Patient characteristics, clinical findings, and complications were collected and analyzed.

Results

Fifty patients with PTH underwent improved simultaneous procedures and 20 patients underwent staged surgeries. Among the cases, the overall complication rate was 22.86%. Complications suffered by patients who underwent one-stage procedure of CP and VPS did not differ significantly, compared with patients in the group of staged procedures (22% vs. 25%, p = 0.763). The significant difference was not observed in the two groups, regarding the complications of subdural/epidural fluid collection (4%/6% vs. 0/2%, p = 1.000/1.000), epidural hemorrhage (6% vs. 4%, p = 0.942), dysfunction of shunting system (0 vs. 2%, p = 0.286), postoperative seizure (8% vs. 4%, p = 1.000), and reoperation case (0 vs. 2%, p = 0.286). No case of subdural hemorrhage, incision/intracranial/abdominal infection, shunting system dysfunction, or reoperation was observed in the group of simultaneous procedure. Complications including subdural/epidural fluid collection, subdural hemorrhage, and incision/intracranial infection were not shown in the case series of the staged procedure group.

Conclusion

The improved simultaneous procedure of cranioplasty and VPS is effective and safe to treat cranial defect and post-traumatic hydrocephalus with low risk of complications.

Head CT for the intensivist: 10 tips and pearls

Head imaging is an essential diagnostic tool for the management of patients with most acute neurological emergencies involving the brain. While numerous modalities including magnetic resonance imaging and catheter angiography play a role, computed tomography (CT) of the brain is far and away the most widely utilized technique because of its widespread availability and the fact that it is usually easier to implement in critically ill and potentially unstable patients. CT is particularly useful in identifying acute intracranial hemorrhage and this makes it often indispensable in the management of patients with traumatic brain injury and hemorrhagic stroke. However, shortcomings in identifying early ischemia on non-contrast CT mean that care must be taken in considering findings early after symptom onset, with newer CT sequences such as CT angiography and CT perfusion adding value. The critical role played by intensivist in managing neurocritical care patients necessitates familiarity and ability with viewing and understanding the advantages and shortcomings of head CT imaging and under which circumstances other modalities may be appropriate to obtain. This manuscript provides ten different circumstances commonly encountered in neurocritical care and how intensivists can use CT for the benefit of their patients.

Vacuum Drains versus Passive Drains versus No Drains in Decompressive Craniectomies-A Randomized Controlled Trial on Subgaleal Drain Complication Rates (VADER Trial)

OBJECTIVE

Subgaleal drains are generally deemed necessary for cranial surgeries including decompressive craniectomies (DCs) to avoid excessive postoperative subgaleal hematoma (SGH) formation. Many surgeries have moved away from routine prophylactic drainage but the role of subgaleal drainage in cranial surgeries has not been addressed.

METHODS

This was a randomized controlled trial at 2 centers. A total of 78 patients requiring DC were randomized in a 1:1:1 ratio into 3 groups: vacuum drains (VD), passive drains (PD), and no drains (ND). Complications studied were need for surgical revision, SGH amount, new remote hematomas, postcraniectomy hydrocephalus (PCH), functional outcomes, and mortality.

RESULTS

Only 1 VD patient required surgical revision to evacuate SGH. There was no difference in SGH thickness and volume among the 3 drain types (P = 0.171 and P = 0.320, respectively). Rate of new remote hematoma and PCH was not significantly different (P = 0.647 and P = 0.083, respectively), but the ND group did not have any patient with PCH. In the subgroup analysis of 49 patients with traumatic brain injury, the SGH amount of the PD and ND group was significantly higher than that of the VD group. However, these higher amounts did not translate as a significant risk factor for poor functional outcome or mortality. VD may have better functional outcome and mortality.

CONCLUSIONS

In terms of complication rates, VD, PD, and ND may be used safely in DC. A higher amount of SGH was not associated with poorer outcomes. Further studies are needed to clarify the advantage of VD regarding functional outcome and mortality, and if ND reduces PCH rates.

Clinical and radiological risk factors of autograft cranioplasty resorption after decompressive craniectomy for traumatic brain injury

OBJECTIVE

The repositioning of an autologous bone flap after decompressive craniectomy (DC) for traumatic intracranial hypertension remains the first-line treatment for cranial reconstruction. Aseptic autologous bone flap resorption (BFR) is the most frequent complication. The identification of possible predictive parameters for BFR would help to improve the management of these patients.

PATIENTS AND METHODS

Three hundred and nine patients undergoing autologous bone flap repositioning after previous DC for TBI between September 2003 and September 2017 were included in the study.

RESULTS

BFR was identified in 76 (24,59 %) of the 309 patients undergoing autologous CP. Age of ≤ 45 years and CP bone fragmentation were seen to be significant independent risk factors for BFR (p =  0.001 and p =  0.018, respectively) using multivariate logistic regression analysis. Of the radiologic predictors, CP size and the gap between CP and the skull defect were independently associated with BFR (p =  0.034 and p =  0.0003, respectively). The Youden index and ROC curve analysis were used to estimate the cut-off values for the continuous parameters and determine the sensitivity and specificity of the radiologic risk factors. The cut-off value for these two factors was found to be 114,98 cm2 and ≥ 578,5 mm2, respectively. The area under the ROC curve was 0.627 for bone flap size and 0.758 for the DC-CP gap. The DC-CP gap had greater sensitivity and specificity as a predictor of BFR, compared to bone flap size (p = 0.079 and p = ≤ 0.001, respectively).

CONCLUSIONS

In this large cohort of patients with autologous cranioplasty, younger age, fragmented autologous bone flap and a wide gap between CP and cranial defect were predictive of bone flap resorption.

Primary Dural Lymphoma: Clinical Cases and Literature Review

Primary dural lymphoma (PDL) is an extranodal non-Hodgkin lymphoma that accounts for less than 1% of all central nervous system lymphomas. Primary dural lymphoma grows from the dura mater, and it is often diagnosed as meningioma or acute subdural hematoma due to its radiological characteristics. Surgery is the gold standard of therapy; in many patients, PDL is relatively benign with good outcome. Authors report their experience in three patients affected by extranodal non-Hodgkin lymphoma (PDL) mimicking a meningioma.

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

Background

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

Methods

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

Results

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

Conclusion

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

Ultra-early surgery in complete cervical spinal cord injury improves neurological recovery: A single-center retrospective study

Background

This study evaluated how the neurological outcome in patients operated on cervical spinal cord injury (SCI) was positively influenced by ultra-early surgery (UES).

Methods

Between 2010 and 2017, 81 patients with traumatic cervical SCI were assigned to the UES group (<12 h after injury; UES) and ES group (surgery between 12 and 48 h after injury; ES). Additional variables evaluated for the two groups included; age, sex, comorbidities charlson comorbidity index (CCI), level of trauma, type of fracture, preoperative and ASIA scores, pre- and post-operative neuroradiological examinations, surgical approaches, and complications.

Results

Forty-seven of 81 (58.02%) patients exhibited improved neurological function 12 months postoperatively; better outcomes were observed in the UES (29 of 40 [72.5%]) versus ES groups (18 of 41 [43.9%]) (P = 0,009). For the 26 patients with complete cervical SCI (ASIA A), ultra-early surgical decompression was associated with significantly greater neurological improvement versus ES (61.53% vs. 7.69%; P = 0.003). Further, more neurological improvement correlated with the younger age, better ASIA grade at admission, and ultra-early surgical timing (< 12 h) both in the univariate and multivariate analysis (P = 0.037, P = 0.017, and P = 0.005, respectively), while CCI was correlated with improvement only in the univariate analysis (P = 0.005).

Conclusion

Ultra-early surgical timing in SCI patients appeared to be the most important factor determining the extent of postoperative neurological improvement, particularly regarding motor function recovery.

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

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

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

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

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

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

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

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

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

Complications of Decompressive Craniectomy

Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.

Risk factors for post-traumatic hydrocephalus following decompressive craniectomy

BACKGROUND

Post-traumatic hydrocephalus (PTH) is one of the main complications of decompressive craniectomy (DC) after traumatic brain injury (TBI). Then, the recognition of risk factors and subsequent prompt diagnosis and treatment of PTH can improve the outcome of these patients. The purpose of this study was to identify factors associated with the development of PTH requiring surgical treatment in patients undergoing DC for TBI.

METHODS

In this study, we collected the data of 190 patients (149 males and 41 females), who underwent DC for TBI in our Center. Then we analyzed the type of surgical treatment for all patients affected by PTH and the risk factors associated with the development of PTH.

RESULTS

Post-traumatic hydrocephalus (PTH) developed in 37 patients out of 130 alive 30 days after DC (28.4%). The development of PTH required ventriculoperitoneal shunt (VPS) in 34 patients out of 37 (91.9%), while, in the remaining 3 patients, cerebrospinal fluid hydrodynamic (CSF) disturbances resolved after urgent cranioplasty and temporary external lumbar drain. Multivariate analysis showed that the presence of interhemispheric hygroma (p < 0.001) and delayed cranioplasty (3 months after DC) (p < 0.001) was significantly associated with the need for a VPS or other surgical procedure for PTH. Finally, among the 130 patients alive after 30 days from DC, PTH was associated with unfavorable outcome as measured by the 6-month Glasgow Outcome Scale score (p < 0.0001).

CONCLUSIONS

Our results showed that delayed cranial reconstruction was associated with an increasing rate of PTH after DC. The presence of an interhemispheric hygroma was an independent predictive radiological sign of PTH in decompressed patients for severe TBI.

Decompressive Craniectomy for Traumatic Brain Injury: The Role of Cranioplasty and Hydrocephalus on Outcome

OBJECTIVE

After severe traumatic brain injury (sTBI) associated with uncontrollable high intracranial pressure (ICP), today the main challenge for neurosurgeons remains to identify who may obtain benefit from decompressive craniectomy (DC) and which factors after DC influence the prognosis of these patients. The aim of this paper was to identify the pre- and postoperative determinants of outcome after DC.

METHODS

This retrospective study included all patients undergoing DC for sTBI from 2003 to 2011. The 6-month outcome, assessed using the Glasgow Outcome Scale (GOS), was dichotomized into favorable (GOS scores 4 and 5) and unfavorable (GOS scores 1-3) outcome. Predictors of outcome were identified by uni- and multivariate analysis.

RESULTS

There were 190 patients who underwent DC for sTBI in this study. Sixty patients (31.6%) died within 30 days after DC. Independent prognostic factors for survival after 30 days were Glasgow Coma Scale score at admission greater than 5 (P = 0.002) and bilateral pupil reactivity (P < 0.0001). Thirty days after DC, 67 patients (51.5%) out of 130 had unfavorable outcome (GOS scores 1-3) and 63 patients (49.5%) presented favorable outcome (GOS scores 4 and 5). The independent preoperative prognostic factors for poor outcome were age over 65 years (P < 0.0001) and bilateral absence of pupil reactivity (P = 0.0165). After DC, onset of postoperative hydrocephalus and delayed cranioplasty (3 months after DC) was associated with unfavorable outcome at multivariate analysis (P = 0.002 and P < 0.0001, respectively).

CONCLUSIONS

In our study, the development of hydrocephalus after DC for sTBI and delayed cranial reconstruction were associated with unfavorable outcome.

Lumbar puncture as possible cause of sudden paradoxical herniation in patient with previous decompressive craniectomy: report of two cases

Background

Lumbar puncture is often used for the diagnosis and treatment of subarchnoid hemorrhage, infection of Cerebro-spinal Fluid (CSF), hydrocephalus in neurosurgery department patients. It is general that paradoxical herniation followed by lumbar puncture is quite rare in decompressive craniectomy cases; the related reports are very few. Moreover, most of the paradoxical herniation cases are chronic, which often occur weeks or even months after the lumbar puncture, to date, barely no reports on the acute onset paradoxical herniation have been found.

Case presentation

Two traumatic brain injury patients with decompressive craniectomy (DC) and hydrocephalus suffered from a sudden paradoxical herniation after lumbar puncture. The symptoms of herniation were improved by treated with Trendelenburg position and rapid intravenous infusion.

Conclusions

Lumbar puncture may have a potential risk of inducing sudden paradoxical herniation in patients with DC. CSF drainage during lumbar puncture should be in small volume for patients with DC. Once a paradoxical herniation occurs after lumbar puncture, an immediate Trendelenburg position and rapid intravenous infusion treatment may be effective.