Decompressive Hemicraniectomies as a Damage Control Approach for Multilobar Firearm Projectile Injuries: A Single-Center Experience

Endolymphatic sac tumor: An urgent case presenting acute intracranial hypertension successfully treated with suboccipital decompressive craniectomy - 8 years of follow-up

Background

Endolymphatic sac tumor (ELST) is a rare lesion. It may be sporadically or associated with Von Hippel-Lindau syndrome. Progressive audiovestibular symptoms characterize the typical clinical presentation. Here, we report a unique case of ELST with acute intracranial hypertension (IH) due to tumor compression, successfully treated with an urgent suboccipital decompressive craniectomy (SDC).

Case Description

A 33-year-old woman previously underwent a biopsy and ventriculoperitoneal shunt. The histopathological finding revealed an ELST. One year later, she developed headache, vomiting, and somnolence due to brainstem compression. An urgent SDC was performed. One month later, preoperative endovascular embolization and partial tumor resection were carried out. After 6 months adjuvant radiotherapy (RT) therapy was administered. She has been under follow-up for 8 years since the last surgical procedure, and the tumor remains stable.

Conclusion

ELST generally has a progressive clinical course. This is a unique case with acute IH due to tumor compression. The tumor's high vascularity and the unavailability of endovascular embolization precluded its resection. SDC was an alternative approach. The final treatment included tumor embolization, surgical resection, and RT. No progression was observed for 8 years after the last procedure, and long-term follow-up is warranted.

Neuro damage control: current concept and civilian applications

Damage control (DC) initially referred to abbreviated (<1 h) surgical procedures to control abdominal hemorrhage in severe trauma patients, to avoid the 'bloody vicious circle' of hypothermia-coagulopathy-acidosis-hypocalcemia. Progressively, the concept was extended to pre-hospital and peri-operative surgical and non-surgical trauma care. The DC strategy can be applied either in a single severe trauma patient at risk of progression toward the bloody vicious circle or in case of limited or overwhelmed health resources (deprived environment, mass casualties, etc.). DC strategies in neurological casualties have improved over the last decade in military neurosurgeons, but remain poorly codified in civilian settings. In this comprehensive review, we summarize the current concept of neuro-DC, which includes surgical and medical care for neurological injuries as part of a DC strategy. Neuro-DC basically consists in: (i) preventing secondary brain injury; (ii) controlling intracranial bleeding; (iii) controlling intracranial pressure; (iv) limiting contamination of compound wounds; and (v) achieving secondary anatomical restoration.