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Tsarukaev BA, Kravchuk AD, Latyshev YA. [Surgical treatment of patients with skull defects and cerebrospinal fluid flow disorders after previous decompressive craniectomy]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:114-119. [PMID: 38054235 DOI: 10.17116/neiro202387061114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Decompressive craniectomy (DC) is performed for refractory intracranial hypertension following severe traumatic brain injury, vascular and oncological diseases. This fact increases the number of patients with extensive and giant skull defects. Cerebrospinal fluid (CSF) flow disorders after DC are often accompanied by ventriculomegaly. However, only some patients with ventriculomegaly have hydrocephalus and require CSF bypass procedures. Differentiation of post-traumatic hydrocephalus requiring surgical treatment and atrophic dilation of ventricular system «ex vacuo» caused by brain injury is still an important issue. Skull sealing as a way to normalize CSF circulation and eliminate hydrocephalus is also an open question. Currently, there is no unified approach to patients with extensive and giant cranial defects combined with post-traumatic hydrocephalus. There is no unified algorithm for sequence of reconstructive and CSF bypass operations in these patients. Literature data on risks of infectious complications for different surgical strategies are controversial.
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Hashmi SMM, Nazir S, Colombo F, Jamil A, Ahmed S. Decompressive Craniectomy for the Treatment of Severe Diffuse Traumatic Brain Injury: A Randomized Controlled Trial. Asian J Neurosurg 2022; 17:455-462. [PMID: 36398189 PMCID: PMC9665987 DOI: 10.1055/s-0042-1756636] [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] [Indexed: 11/17/2022] Open
Abstract
Background Severe traumatic brain injury (TBI) is one of the leading public health problems across the world. TBI is associated with high economic costs to the healthcare system specially in developing countries. Decompressive craniectomy is a procedure in which an area of the skull is removed to increase the volume of intracranial compartment. There are various techniques of decompressive craniectomy used that include subtemporal and circular decompression, and unilateral or bilateral frontotemporoparietal decompression. Objective The aim of this study was to compare the outcome of decompressive craniectomy for the management of severe TBI versus conservative management alone at the Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan. Methods The study (randomized controlled trial) was conducted from February 1, 2014, till June 30, 2017. Results A total of 136 patients were included after following the inclusion criteria. They were randomly assigned to two groups, making it 68 patients in each study group. There were 89 males and 47 females. All the patients received standard care recommended by the Brain Trauma Foundation. The mortality rate observed at 6 months in decompressive craniectomy was 22.05%, while among conservative management group, it was 45.58%. Difference in mortality of both groups at 6 months was significant. Total 61.76% (42) of patients from decompressive craniectomy group had a favorable outcome (Glasgow outcome scale: 4-5) at 6 months. While among conservative management group, total 35.29% (24) had a favorable outcome (Glasgow outcome scale: 4-5). Difference in Glasgow outcome scale at 6 months of both groups was significant. Conclusion In conclusion, decompressive craniectomy is simple, safe, and better than conservative management alone.
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Affiliation(s)
- Syed Muhammad Maroof Hashmi
- Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan,Address for correspondence Syed Muhammad Maroof Hashmi, MBBS, MRCSEd, FRCSEd Department of Neurosurgery, Abbasi Shaheed HospitalKarachi, Pakistan. Postal Address: SU 187, Street 11/A, ASKARI 4, Karachi. 75290Pakistan
| | - Sadaf Nazir
- Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan
| | - Francesca Colombo
- Department of Neurosurgery, Royal Preston Hospital, Lancashire, United Kingdom
| | - Akmal Jamil
- Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan
| | - Shahid Ahmed
- Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan
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Decompressive Hemicraniectomy and Favorable Outcome in a Pediatric Patient with Malignant Middle Cerebral Artery Infarction. Case Rep Pediatr 2022; 2022:6500488. [PMID: 36148024 PMCID: PMC9489348 DOI: 10.1155/2022/6500488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/22/2022] [Indexed: 11/24/2022] Open
Abstract
We report a rare case of middle cerebral artery (MCA) stroke in a teenage girl with initial improvement, followed by progression to malignant MCA infarction, requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement in all areas, including language, comprehension, and motor skills at discharge and the 4-month follow-up. This rare presentation highlights the importance of monitoring the neurological status of a patient with an MCA infarct for progression to a life-threatening malignant MCA infarct. This case report also highlights the importance of consideration of DHC for a favorable outcome of the MMCA infarction.
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Naidu PB, Vivek V, Shareef MH, tilak S, Ganesh K. Decompressive hemicraniectomy in malignant MCA infarct in a tertiary centre. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Iaccarino C, Kolias A, Adelson PD, Rubiano AM, Viaroli E, Buki A, Cinalli G, Fountas K, Khan T, Signoretti S, Waran V, Adeleye AO, Amorim R, Bertuccio A, Cama A, Chesnut RM, De Bonis P, Estraneo A, Figaji A, Florian SI, Formisano R, Frassanito P, Gatos C, Germanò A, Giussani C, Hossain I, Kasprzak P, La Porta F, Lindner D, Maas AIR, Paiva W, Palma P, Park KB, Peretta P, Pompucci A, Posti J, Sengupta SK, Sinha A, Sinha V, Stefini R, Talamonti G, Tasiou A, Zona G, Zucchelli M, Hutchinson PJ, Servadei F. Consensus statement from the international consensus meeting on post-traumatic cranioplasty. Acta Neurochir (Wien) 2021; 163:423-440. [PMID: 33354733 PMCID: PMC7815592 DOI: 10.1007/s00701-020-04663-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/28/2020] [Indexed: 12/26/2022]
Abstract
Background Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach. Methods The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP. Results The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations. Conclusions This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.
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Jo K, Joo WI, Yoo DS, Park HK. Clinical Significance of Decompressive Craniectomy Surface Area and Side. J Korean Neurosurg Soc 2020; 64:261-270. [PMID: 33280352 PMCID: PMC7969045 DOI: 10.3340/jkns.2020.0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Decompressive craniectomy (DC) can partially remove the unyielding skull vault and make affordable space for the expansion of swelling brain contents. The objective of this study was to compare clinical outcome according to DC surface area (DC area) and side.
Methods A total of 324 patients underwent different surgical methods (unilateral DC, 212 cases and bilateral DC, 112 cases) were included in this retrospective analysis. Their mean age was 53.4±16.6 years (median, 54 years). Neurological outcome (Glasgow outcome scale), ventricular intracranial pressure (ICP), and midline shift change (preoperative minus postoperative) were compared according to surgical methods and total DC area, DC surface removal rate (DC%) and side.
Results DC surgery was effective for ICP decrease (32.3±16.7 mmHg vs. 19.2±13.4 mmHg, p<0.001) and midline shift change (12.5±7.6 mm vs. 7.8±6.9 mm, p<0.001). The bilateral DC group showed larger total DC area (125.1±27.8 cm2 for unilateral vs. 198.2±43.0 cm2 for bilateral, p<0.001). Clinical outcomes were nonsignificant according to surgical side (favorable outcome, p=0.173 and mortality, p=0.470), significantly better when total DC area was over 160 cm2 and DC% was 46% (p=0.020 and p=0.037, respectively).
Conclusion DC surgery is effective in decrease the elevated ICP, decrease the midline shift and improve the clinical outcome in massive brain swelling patient. Total DC area and removal rate was larger in bilateral DC than unilateral DC but clinical outcome was not influenced by DC side. DC area more than 160 cm2 and DC surface removal rate more than 46% were more important than DC side.
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Affiliation(s)
- KwangWook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Il Joo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Failures in cranioplasty - A clinical audit & review. J Oral Biol Craniofac Res 2020; 11:66-70. [PMID: 33376668 DOI: 10.1016/j.jobcr.2020.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Cranioplasty, like any other surgical procedure also comes with risk of complications and failure. Failure of cranioplasty may be early or delayed and further can be attributed to the surgical procedure itself or to the reconstruction material used for the procedure. The aim of this clinical audit is to analyze the causes of failure of 14 cases of cranioplasty procedure. Materials and methods This retrospective study analyses the causes of failure of 14 cases of cranioplasty over 8 years at a tertiary care centre and identifies major etiological factors for failure including local and systemic. Further, a correlation between the reconstruction material used for cranioplasty and failure was studied along with other attributable factors such as systemic status of the patient and other local factors. Results The study established that there exists a correlation between failure and the biomaterial used for reconstruction. Various etiological factors like infection, flap break down, fixation protocol and foreign body were identified along with time frame of failure. After failure of cranioplasty, feasibility of a secondary cranioplasty has also been factored into this study, with 8 out of the 14 cases being successfully re-operated. Conclusion Cranioplasty is a technically demanding and demands certain levels of operator skill levels. While formulating a treatment plan for reconstruction of cranial defects, one has to tailor make a strategy considering several factors such as systemic condition of the patient, status of the cranial surgical site, etiology behind craniectomy, choice of reconstruction material, duration from craniectomy and age of the patient. Inspite of best efforts and ideal reconstruction attempts, failures remain a nagging reality.
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Yu H, Guo L, He J, Kong J, Yang M. Role of decompressive craniectomy in the management of poor-grade aneurysmal subarachnoid hemorrhage: short- and long-term outcomes in a matched-pair study. Br J Neurosurg 2020; 35:785-791. [PMID: 32945182 DOI: 10.1080/02688697.2020.1817851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the short- and long-term therapeutic effect and possibility of decompressive craniectomy (DC) for patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). METHODS Patients suffering from aSAH (Hunt-Hess grades IV, V) who underwent DC from January 2008 to April 2016 were enrolled in this study, and a sample-matched control group was set up. Information regarding participants' demography, clinical characteristics, and neuroimaging findings was systematically established. The outcome of a 6-month to 3-year follow-up was assessed according to the Glasgow outcome scale (GOS), modified Rankin Scale (mRS) and Barthel Index (BI). RESULTS Patients who had DC (21) experienced a statistically significant decrease in short-term mortality compared with those without DC (24, p < 0.05) and showed a decrease in intracranial pressure (ICP) after surgery. However, there was no significant difference in the long-term assessment (GOS/mRS/BI) between the two groups. CONCLUSIONS Some critical patients who have refractory ICP after poor-grade aSAH would benefit from DC for prolonging life in the short term if performed early. Nevertheless, the overall outcome for the long term remains disappointing, larger and longer prospective studies are urgently needed to investigate this issue.
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Affiliation(s)
- Hai Yu
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Liang Guo
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Junhua He
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Jun Kong
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Min Yang
- Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
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Callovini GM, Bolognini A, Callovini T, Giordano M, Gazzeri R. Treatment of CSF leakage and infections of dural substitute in decompressive craniectomy using fascia lata implants and related anatomopathological findings. Br J Neurosurg 2020; 35:18-21. [PMID: 32138540 DOI: 10.1080/02688697.2020.1735301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Decompressive craniectomy (DC) is widely used to treat raised intracranial pressure (ICP) in cranial trauma and stroke. It is accompanied by numerous complications. The aim of our study is to assess the surgical treatment of infections related to the use of a dural substitute with concurrent CSF leakage performed at our institution. MATERIAL AND METHODS A retrospective analysis of a series of 72 patients who underwent DC between 2011 and 2017 was performed. Seven cases (9%) showed infection related to the use of xenograft (bovine pericardium) and coexisting CSF leakage. Epidural/subdural empyemas were observed in seven cases; three in conjunction with an intracerebral abscess. For reconstruction, free anterolateral thigh fascia lata flaps were used, based on the size of the defect. RESULTS After removal of the dural substitute and the implant of free fascia lata, infection and CSF leaks resolved in all. An anatomopathological examination of the implant at the later time of cranioplasty (CP) showed the tissue had become vascularized exhibiting integration with the native dura. No complications related to the harvesting of the fascia lata were observed. CONCLUSIONS Fascia lata is a validated source of autologous grafts; it is cost-free and would appear to be the biological material most similar to the dura mater. The implanted material appears to maintain a lasting vitality when covered over with a well-vascularized scalp, even after a period of months, achieving a successful suppression of infection. Subsequent skull reconstruction is performed safely and easily using artificial bone.
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Affiliation(s)
| | - Andrea Bolognini
- Department of Neurosurgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Tommaso Callovini
- Department of Neurosurgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Marco Giordano
- Department of Pathology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Roberto Gazzeri
- Department of Neurosurgery, San Giovanni-Addolorata Hospital, Rome, Italy
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10
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Iaccarino C, Kolias AG, Roumy LG, Fountas K, Adeleye AO. Cranioplasty Following Decompressive Craniectomy. Front Neurol 2020; 10:1357. [PMID: 32063880 PMCID: PMC7000464 DOI: 10.3389/fneur.2019.01357] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 12/09/2019] [Indexed: 11/13/2022] Open
Abstract
Cranioplasty (CP) after decompressive craniectomy (DC) for trauma is a neurosurgical procedure that aims to restore esthesis, improve cerebrospinal fluid (CSF) dynamics, and provide cerebral protection. In turn, this can facilitate neurological rehabilitation and potentially enhance neurological recovery. However, CP can be associated with significant morbidity. Multiple aspects of CP must be considered to optimize its outcomes. Those aspects range from the intricacies of the surgical dissection/reconstruction during the procedure of CP, the types of materials used for the reconstruction, as well as the timing of the CP in relation to the DC. This article is a narrative mini-review that discusses the current evidence base and suggests that no consensus has been reached about several issues, such as an agreement on the best material for use in CP, the appropriate timing of CP after DC, and the optimal management of hydrocephalus in patients who need cranial reconstruction. Moreover, the protocol-driven standards of care for traumatic brain injury (TBI) patients in high-resource settings are virtually out of reach for low-income countries, including those pertaining to CP. Thus, there is a need to design appropriate prospective studies to provide context-specific solid recommendations regarding this topic.
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Affiliation(s)
- Corrado Iaccarino
- Neurosurgery Unit, University Hospital of Parma, Parma, Italy.,Emergency Neurosurgery Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Angelos G Kolias
- Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Louis-Georges Roumy
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
| | - Kostas Fountas
- Department of Neurosurgery, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Amos Olufemi Adeleye
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom.,Division of Neurological Surgery, Department of Surgery, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Nigeria
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Kwan K, Schneider J, Ullman JS. Chapter 12: Decompressive Craniectomy: Long Term Outcome and Ethical Considerations. Front Neurol 2019; 10:876. [PMID: 31555193 PMCID: PMC6742692 DOI: 10.3389/fneur.2019.00876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 07/29/2019] [Indexed: 11/13/2022] Open
Abstract
Decompressive craniectomy (DC) for the treatment of severe traumatic brain injury (TBI) has been established to decrease mortality. Despite the conclusion of the two largest randomized clinical trials associating the effectiveness of decompressive craniectomy vs. medical management for patients with traumatic brain injury (TBI), there is still clinical equipoise concerning the usefulness of DC in the management of refractory intracranial hypertension. Primary outcome data from these studies reveal either potential harm or that decreased mortality only leads to an upsurge in survivors with severe neurologic incapacity. In this chapter, we seek to review the results of the most recent clinical trials, highlight the prevailing controversies, and offer potential solutions to address this dilemma.
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Affiliation(s)
- Kevin Kwan
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Julia Schneider
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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12
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Kutty RK, Sreemathyamma SB, Sivanandapanicker J, Asher P, Prabhakar RB, Peethambaran A, Libu GK. The Conundrum of Ventricular Dilatations Following Decompressive Craniectomy: Is Ventriculoperitoneal Shunt, The Only Panacea? J Neurosci Rural Pract 2019; 9:232-239. [PMID: 29725175 PMCID: PMC5912030 DOI: 10.4103/jnrp.jnrp_395_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Introduction: Ventriculomegaly and hydrocephalus (HCP) are sometimes a bewildering sequela of decompressive craniectomy (DC). The distinguishing criteria between both are less well defined. Majority of the studies quoted in the literature have defined HCP radiologically, rather than considering the clinical status of the patient. Accordingly, these patients have been treated with permanent cerebrospinal fluid (CSF) diversion procedures. We hypothesize that asymptomatic ventriculomegaly following DC should undergo aspiration with cranioplasty and be followed up regularly. Materials and Methods: All patients with post-DC who were scheduled for cranioplasty and satisfied the radiological criteria for HCP were included. These patients were categorized into two groups. Group 1 included ventriculomegaly with clinical signs attributable to HCP and Group 2 constituted ventriculomegaly but no clinical signs attributable to HCP. All patients in Group 1 underwent ventriculoperitoneal shunt followed by cranioplasty, whereas all patients in Group 2 underwent cranioplasty along with simultaneous ventriculostomy and temporary aspiration of the lateral ventricle. All patients were regularly followed as the outpatient basis. Results: There were 21 patients who developed ventriculomegaly following DC. There were 10 patients in Group 1 and 11 patients in Group 2. The average duration of follow-up was from 6 months to 2 years. Two patients in the shunt group - (group 1) had over drainage and required revision. One patient in aspiration group - (group 2) required permanent CSF diversion. Conclusions: Cranioplasty with aspiration is a viable option in selected group of patients in whom there is ventriculomegaly but no signs or symptoms attributable to HCP.
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Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | | | - Prasanth Asher
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
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Rossini Z, Nicolosi F, Kolias AG, Hutchinson PJ, De Sanctis P, Servadei F. The History of Decompressive Craniectomy in Traumatic Brain Injury. Front Neurol 2019; 10:458. [PMID: 31133965 PMCID: PMC6517544 DOI: 10.3389/fneur.2019.00458] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023] Open
Abstract
Decompressive craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.
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Affiliation(s)
- Zefferino Rossini
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Federico Nicolosi
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | | | - Franco Servadei
- Research Hospital, Humanitas University, Pieve Emanuele, Italy
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14
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Desse N, Beucler N, Dagain A. How I do it: supra-tentorial unilateral decompressive craniectomy. Acta Neurochir (Wien) 2019; 161:895-898. [PMID: 30953153 DOI: 10.1007/s00701-019-03880-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/20/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Decompressive craniectomy is a surgical way to treat intracranial hypertension, by removing a large flap of skull bone. METHOD We report the case of a 48 years old right-handed man presenting an acute ischaemic stroke of all the right sylvian artery area, with rapid clinic deterioration then coma. Severe intracranial hypertension was confirmed by transcranial Doppler. In emergency, we decided to perform a right-side decompressive craniectomy. CONCLUSION Six months later, he is in rehabilitation with "only" a left hemiplegia and a very good relational life. His modified Rankin score is 3. Decompressive craniectomy saved this patient's life, that is why we think this surgical technique must be explained and mastered.
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Affiliation(s)
- Nicolas Desse
- Service de Neurochirurgie, Hôpital d'Instruction des Armées Sainte Anne, HIA Sainte Anne - BP600, 83800, Toulon Cedex 9, France.
| | - Nathan Beucler
- Service de Neurochirurgie, Hôpital d'Instruction des Armées Sainte Anne, HIA Sainte Anne - BP600, 83800, Toulon Cedex 9, France
| | - Arnaud Dagain
- Service de Neurochirurgie, Hôpital d'Instruction des Armées Sainte Anne, HIA Sainte Anne - BP600, 83800, Toulon Cedex 9, France
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15
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Dural Sandwich Technique for Hemicraniectomy and Benefits During Cranioplasty. World Neurosurg 2019; 124:125-128. [PMID: 30641235 DOI: 10.1016/j.wneu.2018.12.162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Hemicraniectomy is a commonly performed neurosurgical procedure used in the setting of medically refractory malignant intracranial hypertension. Complications from cranioplasty after hemicraniectomy can be significant, including infection and wound issues. Difficulty with scar tissue during exposure for cranioplasty can be challenging and can lead to prolonged surgical time and increased bleeding. We describe a surgical technique, termed the "dural sandwich," that could provide a significant benefit during cranioplasty as compared with traditional single-layered dural closure. METHODS A retrospective analysis was conducted that included 14 patients who underwent a hemicraniectomy procedure over a 4-year period. Seven patients were identified who received a cranioplasty after dural sandwich technique during craniectomy. They were compared with a similar patient group of 7 patients who received a cranioplasty after conventional hemicraniectomy with single-layered dural closure. Surgical time, estimated blood loss, and complication rates were compared between the 2 groups. Analysis of variance measures were performed to assess for statistically significant differences in blood loss and operative time between the dural sandwich and control groups. Statistical significance was defined as P < 0.05. RESULTS The mean estimated blood loss was 82.1 mL in the dural sandwich craniectomy group versus 150 mL in the conventional hemicraniectomy group (P < 0.05). The mean estimated surgical time was 91.7 minutes in the dural sandwich craniectomy group versus 127.5 minutes in the conventional craniectomy group (P < 0.05). There was no evidence of neurologic deterioration, cerebral spinal fluid leak, or postoperative hematoma requiring evacuation in either group. In the conventional craniectomy group, a single report of a wound infection was noted that was treated conservatively with antibiotics. CONCLUSIONS By layering bovine pericardium above and below the dura during initial hemicraniectomy, an artificial plane is created that improves ease of exposure during cranioplasty. This technique could reduce surgical time and blood loss during subsequent cranioplasty, and potentially reduce recovery time and postoperative complications.
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Abdullah JY, Rajion ZA, Martin AG, Jaafar A, Ghani ARI, Abdullah JM. Shape-based interpolation method in measuring intracranial volume for pre- and post-operative decompressive craniectomy using open source software. Neurocirugia (Astur) 2019; 30:115-123. [PMID: 30782505 DOI: 10.1016/j.neucir.2018.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/25/2018] [Accepted: 12/01/2018] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Johari Yap Abdullah
- Craniofacial Medical Imaging Research Group, School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Zainul Ahmad Rajion
- Craniofacial Medical Imaging Research Group, School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia.
| | - Arvind Gerard Martin
- Department of Neurosurgery, Hospital Tengku Ampuan Afzan, Jalan Air Putih, Kuantan, Pahang, Malaysia
| | - Azlan Jaafar
- Faculty of Dentistry, Universiti Sains Islam Malaysia, Kuala Lumpur, Malaysia
| | - Abdul Rahman Izaini Ghani
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Centre for Neuroscience Services & Research, Universiti Sains Malaysia, Kelantan, Malaysia
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El-Fiki A, Abd-Haleem E. The Use of Hinged Craniotomy in Comparison to Cisternostomy for Avoiding Bone Flap Replacement Second Surgery in Cases of Decompressive Craniotomy in Traumatic Brain Injury. OPEN JOURNAL OF MODERN NEUROSURGERY 2019; 09:7-16. [DOI: 10.4236/ojmn.2019.91002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Garg K, Singh P, Singla R, Aggarwal A, Borle A, Singh M, Chandra PS, Kale S, Mahapatra A. Role of Decompressive Craniectomy in Traumatic Brain Injury – A Meta-analysis of Randomized Controlled Trials. Neurol India 2019; 67:1225-1232. [PMID: 31744947 DOI: 10.4103/0028-3886.271260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Zheng F, Xu H, von Spreckelsen N, Stavrinou P, Timmer M, Goldbrunner R, Cao F, Ran Q, Li G, Fan R, Zhang Q, Chen W, Yao S, Krischek B. Early or late cranioplasty following decompressive craniotomy for traumatic brain injury: A systematic review and meta-analysis. J Int Med Res 2018; 46:2503-2512. [PMID: 29779445 PMCID: PMC6124291 DOI: 10.1177/0300060518755148] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 12/19/2017] [Indexed: 12/03/2022] Open
Abstract
Objective To evaluate the effectiveness of early (<3 months) cranioplasty (CP) and late CP (>3 months) on post-operative complications in patients receiving decompressive craniotomy (DC) for traumatic brain injury (TBI). Methods The Cochrane Library, PubMed and EMBASE databases were systematically searched for studies published prior to May 21, 2017. A meta-analysis examined post-operative overall complication rates, infection rates, subdural fluid collection and operating times according to early and late CP. Results Of the initial 1675 references, five studies, all cohort, involving a total of 413 patients, were selected for the review. There was no difference between early and late CP in post-operative overall complication rate (RR=0.68, 95%CI [0.36, 1.29]) and the post-operative infection rate (RR=0.50, 95%CI [0.20, 1.24]) in patients receiving DC for TBI. However, there was a significant difference in post-operative subdural effusion (RR=0.24, 95%CI [0.07, 0.78]) and mean operative time (mean difference = -33.02 min, 95%CI [-48.19, -17.84]) both in favour of early CP. Conclusions No differences were found between early and late CP in post-operative overall complications and procedural related infections in patients receiving DC for TBI, but early CP reduced the complication of subdural effusion and the mean operating time. These findings need to be confirmed by large, randomised controlled trials.
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Affiliation(s)
- Feng Zheng
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Hao Xu
- Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | | | - Pantelis Stavrinou
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Marco Timmer
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Fang Cao
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qishan Ran
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Gang Li
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Ruiming Fan
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qiang Zhang
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Wei Chen
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Shengtao Yao
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Boris Krischek
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
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Badke GL, Araujo JLV, Miura FK, Guirado VMDP, Saade N, Paiva ALC, Avelar TM, Pedrozo CAG, Veiga JCE. Analysis of direct costs of decompressive craniectomy in victims of traumatic brain injury. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:257-264. [DOI: 10.1590/0004-282x20180016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 12/19/2017] [Indexed: 11/22/2022]
Abstract
ABSTRACT Background: Decompressive craniectomy is a procedure required in some cases of traumatic brain injury (TBI). This manuscript evaluates the direct costs and outcomes of decompressive craniectomy for TBI in a developing country and describes the epidemiological profile. Methods: A retrospective study was performed using a five-year neurosurgical database, taking a sample of patients with TBI who underwent decompressive craniectomy. Several variables were considered and a formula was developed for calculating the total cost. Results: Most patients had multiple brain lesions and the majority (69.0%) developed an infectious complication. The general mortality index was 68.8%. The total cost was R$ 2,116,960.22 (US$ 661,550.06) and the mean patient cost was R$ 66,155.00 (US$ 20,673.44). Conclusions: Decompressive craniectomy for TBI is an expensive procedure that is also associated with high morbidity and mortality. This was the first study performed in a developing country that aimed to evaluate the direct costs. Prevention measures should be a priority.
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Affiliation(s)
| | - João Luiz Vitorino Araujo
- Santa Casa de São Paulo, Brasil; Hospital Israelista Albert Einstein, Brasil; Instituto do Câncer Arnaldo Vieira de Carvalho, Brasil
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Yang NR, Song J, Yoon KW, Seo EK. How Early Can We Perform Cranioplasty for Traumatic Brain injury After Decompressive Craniectomy? A Retrospective Multicenter Study. World Neurosurg 2017; 110:e160-e167. [PMID: 29101076 DOI: 10.1016/j.wneu.2017.10.117] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is used to treat intractable intracranial hypertension after severe traumatic brain injury (TBI). Cranioplasty (CP) is typically performed weeks or months later. However, the optimal timing for CP is unknown. We aimed to determine the earliest possible time point for CP. METHODS We retrospectively reviewed brain computed tomography images from 159 patients who underwent CP after DC for TBI at 3 hospitals. We determined the earliest possible day for CP by reviewing the resolution of intracranial pressure in serial brain computed tomography images between DC and CP. The early CP group was defined as the group within the earliest possible timing of CP; other cases constituted the late CP group. We compared complications and the Glasgow Outcome Scale scores at 6 months between groups. RESULTS The mean initial Glasgow Coma Scale score was 8.33 ± 3.46. The time interval between DC and CP was 94.75 ± 143.98 days. The earliest possible timing for CP was determined to be 34.60 ± 34.36 days after DC. The incidence of complications did not differ significantly between groups, except for ventriculomegaly, which occurred more frequently in the late CP group (P = 0.026). Predictors of good outcome were revision because of infection, preoperative epidural hematoma, early cranioplasty, and no ventriculomegaly after DC. CONCLUSIONS CP can be performed at around 34 days after DC for TBI. Ventriculomegaly occurred less frequently and the 6-month Glasgow Outcome Scale score was better in the early CP group than in the late CP group.
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Affiliation(s)
- Na Rae Yang
- Department of Neurosurgery, Ewha Womans University Medical Center, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Jihye Song
- Department of Neurosurgery, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Kyeong-Wook Yoon
- Department of Neurosurgery, College of Medicine, Dankook University, Cheonan, Chungnam, Republic of Korea
| | - Eui Kyo Seo
- Department of Neurosurgery, Ewha Womans University Medical Center, College of Medicine, Ewha Womans University, Seoul, Republic of Korea.
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Gutman MJ, How E, Withers T. The floating anchored craniotomy. Surg Neurol Int 2017; 8:130. [PMID: 28713633 PMCID: PMC5502294 DOI: 10.4103/sni.sni_460_16] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 02/01/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The "floating anchored" craniotomy is a technique utilized at our tertiary neurosurgery institution in which a traditional decompressive craniectomy has been substituted for a floating craniotomy. The hypothesized advantages of this technique include adequate decompression, reduction in the intracranial pressure, obviating the need for a secondary cranioplasty, maintained bone protection, preventing the syndrome of the trephined, and a potential reduction in axonal stretching. METHODS The bone plate is re-attached via multiple loosely affixed vicryl sutures, enabling decompression, but then ensuring the bone returns to its anatomical position once cerebral edema has subsided. RESULTS From the analysis of 57 consecutive patients analyzed at our institution, we have found that the floating anchored craniotomy is comparable to decompressive craniectomy for intracranial pressure reduction and has some significant theoretical advantages. CONCLUSIONS Despite the potential advantages of techniques that avoid the need for a second cranioplasty, they have not been widely adopted and have been omitted from trials examining the utility of decompressive surgery. This retrospective analysis of prospectively collected data suggests that the floating anchored craniotomy may be applicable instead of decompressive craniectomy.
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Affiliation(s)
- Matthew J. Gutman
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Australia
| | - Elena How
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Australia
| | - Teresa Withers
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Australia
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Moon JW, Hyun DK. Decompressive Craniectomy in Traumatic Brain Injury: A Review Article. Korean J Neurotrauma 2017; 13:1-8. [PMID: 28512611 PMCID: PMC5432443 DOI: 10.13004/kjnt.2017.13.1.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/05/2017] [Accepted: 04/17/2017] [Indexed: 11/23/2022] Open
Abstract
The importance of treating traumatic brain injury (TBI) is well known worldwide. Although many studies have been conducted in this topic, there is still much uncertainty about the effectiveness of surgical treatment in TBI. Recently, good randomized controlled trial (RCT) papers about the effectiveness of decompressive craniectomy (DC) in TBI has been published. In this article, we will review the overall contents of the DC (historical base, surgical technic, rationale, complications) and the results of the recently published RCT paper.
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Affiliation(s)
- Ji Won Moon
- Department of Neurosurgery, Inha University School of Medicine and Hospital, Incheon, Korea
| | - Dong Keun Hyun
- Department of Neurosurgery, Inha University School of Medicine and Hospital, Incheon, Korea
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Complications following cranioplasty and relationship to timing: A systematic review and meta-analysis. J Clin Neurosci 2016; 33:39-51. [DOI: 10.1016/j.jocn.2016.04.017] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/28/2016] [Accepted: 04/02/2016] [Indexed: 11/21/2022]
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Management of the Repeatedly Failed Cranioplasty Following Large Postdecompressive Craniectomy. J Craniofac Surg 2016; 27:1971-1977. [DOI: 10.1097/scs.0000000000003043] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Yu SH, Kim BC, Choi JY, Lee JI, Cho WH, Choi HJ. Addition of Resection of Temporal Muscle and Fascia in Decompressive Craniectomy in the Treatment of Traumatic Brain Injury. Korean J Neurotrauma 2016; 12:84-88. [PMID: 27857913 PMCID: PMC5110924 DOI: 10.13004/kjnt.2016.12.2.84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/31/2016] [Accepted: 09/13/2016] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Seung Han Yu
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Byung Chul Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jae Young Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Won Ho Cho
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Busan, Korea
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Outcome in patient-specific PEEK cranioplasty: A two-center cohort study of 40 implants. J Craniomaxillofac Surg 2016; 44:1266-72. [DOI: 10.1016/j.jcms.2016.07.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/24/2016] [Accepted: 07/01/2016] [Indexed: 11/18/2022] Open
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Stoner KE, Abode-Iyamah KO, Grosland NM, Howard MA. Volume of Brain Herniation in Patients with Ischemic Stroke After Decompressive Craniectomy. World Neurosurg 2016; 96:101-106. [PMID: 27591100 DOI: 10.1016/j.wneu.2016.08.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/22/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Decompressive craniectomy procedures are performed in patients with malignant intracranial hypertension. A bone flap is removed to relieve pressure. Later, a second operation is performed to reconstruct the skull after brain swelling has resolved. This surgical treatment would be improved if it were possible to perform a single operation that decompressed the brain acutely and eliminated the need for a second operation. To design a device and procedure that achieve this objective, it is essential to understand how the brain swells after a craniectomy procedure. METHODS We identified 20 patients with ischemic stroke who underwent a decompressive hemicraniectomy operation. Skull defect morphology and postoperative brain swelling were measured using computed tomography scan data. Additional intracranial volume created by placing a hypothetical cranial plate implant offset from the skull surface by 5 mm was measured for each patient. RESULTS The average craniectomy area and brain herniation volume was 9999 ± 1283 mm2 and 30.48 ± 23.56 mL, respectively. In all patients, the additional volume created by this hypothetical implant exceeded the volume of brain herniation observed. CONCLUSIONS These findings show that a cranial plate with a 5-mm offset accommodates the brain swelling that occurs in this patient population.
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Affiliation(s)
- Kirsten E Stoner
- Department of Biomedical Engineering, University of Iowa, Seamans Center for the Engineering Arts and Sciences, Iowa City, Iowa, USA
| | | | - Nicole M Grosland
- Department of Biomedical Engineering, University of Iowa, Seamans Center for the Engineering Arts and Sciences, Iowa City, Iowa, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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Borger V, Schuss P, Kinfe TM, Vatter H, Güresir E. Decompressive Craniectomy for Stroke: Early Cranioplasty Is a Predictor for Postoperative Complications. World Neurosurg 2016; 92:83-88. [PMID: 27157285 DOI: 10.1016/j.wneu.2016.04.113] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous clinical studies assumed that early cranioplasty (CP) was mandatory for a favorable neurologic recovery after decompressive craniectomy (DC) for malignant stroke. However, the appropriate timing of the CP procedure after DC remains controversial. This study assessed patients who underwent DC because of cerebral ischemia to determine the appropriate time point of CP and surgical-associated complications. METHODS Data from the period 2007-2014 were retrospectively evaluated. CP was performed in 75 patients who previously underwent DC because of supratentorial cerebral infarction. Patients were divided into 2 groups (early CP vs. late CP) according to the time from DC to CP (<3 months vs. ≥3 months). Patient characteristics, timing of CP, and postoperative complications associated with CP were analyzed. RESULTS CP was performed early in 12 patients (16%) and late in 63 patients (84%). The complication rate after CP was 18%; complications included wound healing disturbance in 8 patients (11%), epidural hematoma or subdural hematoma in 4 patients (4%), and others in 2 patients (3%). Patients with early CP experienced significantly more complications compared with patients with late CP after initial DC (5 of 12 patients [42%] vs. 8 of 63 patients [13%]; P = 0.02). In multivariate analysis, early CP was a significant predictor of postoperative complications after CP (odds ratio = 6.04; 95% confidence interval, 1.4-24.9; P = 0.01). CONCLUSIONS The present data suggest that patients who underwent DC for stroke might benefit from CP performed >3 months after DC owing to a lower rate of wound infection.
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Affiliation(s)
- Valeri Borger
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany.
| | - Patrick Schuss
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Thomas M Kinfe
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
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Zhang K, Jiang W, Ma T, Wu H. Comparison of early and late decompressive craniectomy on the long-term outcome in patients with moderate and severe traumatic brain injury: a meta-analysis. Br J Neurosurg 2016; 30:251-7. [PMID: 26828333 DOI: 10.3109/02688697.2016.1139052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Several studies have searched whether early decompressive craniectomy (DC) can improve the long-term outcome of patients with moderate and severe traumatic brain injury (TBI). However, the effects of early DC remain unclear. The purpose of this meta-analysis was to assess whether early DC (time to surgery after injury <24 h) is better than late DC (>24 h) after moderate and severe TBI. METHOD Two reviewers independently searched Pubmed, Embase, ISI web of science, the Cochrane Library and Scopus databases from inception to 4 November 2014. Studies comparing the long-term outcome of patients following early and late DC after TBI were included. The long-term outcomes were evaluated by Glasgow Outcome Score, Extended Glasgow Outcome Score. Newcastle-Ottawa Scale was used to assess the methodological quality of included studies. Characteristics of the selected studies were extracted. Pooled results were presented by odds ratios (ORs) with 95% CIs. I(2) was used to test heterogeneity. Pearson correlation coefficient was used to detect the relationship between bilateral pupil abnormality and unfavourable outcome. RESULTS Five articles were eligible for this meta-analysis. The pooled results of comparison of unfavourable outcome and mortality revealed no significant difference in the early and late groups (ORs: 1.469; 95% CIs: 0.495-4.362; p > 0.05; I(2 )=70.5% and ORs: 1.262; 95% CIs: 0.385-4.137; p > 0.05; I(2 )=77.6%, respectively). Pearson correlation coefficient indicated that bilateral pupil abnormality was positive related to the unfavourable outcomes and mortality (r = 0.833; p < 0.05) (0.829; p < 0.05). CONCLUSION Bilateral pupil abnormality is positive related to unfavourable outcome and mortality in the patients following DC after moderate and severe TBI. Early DC may be more helpful to improve the long-term outcome of patients with refractory raised intracranial cerebral pressure after moderate and severe TBI. However, more RCTs with better control of patients with bilateral pupil abnormality divided into the early and late groups are needed in the future.
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Affiliation(s)
- Kai Zhang
- a Department of General Surgery , the Second Affiliated Hospital of Soochow University , Soochow , Jiangsu , P.R. China ;,b Department of Hepatobiliary Surgery , the Affiliated Yixing Hospital of Jiangsu University , Yixing , Jiangsu , P.R. China
| | - Wenjie Jiang
- c Department of Anesthesiology , the Affiliated Yixing Hospital of Jiangsu University , Yixing , Jiangsu , P.R. China
| | - Tieliang Ma
- d Central Laboratory , the Affiliated Yixing Hospital of Jiangsu University , Yixing , Jiangsu , P.R. China
| | - Haorong Wu
- a Department of General Surgery , the Second Affiliated Hospital of Soochow University , Soochow , Jiangsu , P.R. China
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Rosseto RS, Giannetti AV, de Souza Filho LD, Faleiro RM. Risk Factors for Graft Infection After Cranioplasty in Patients with Large Hemicranial Bony Defects. World Neurosurg 2015; 84:431-7. [DOI: 10.1016/j.wneu.2015.03.045] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/24/2015] [Accepted: 03/25/2015] [Indexed: 11/28/2022]
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Xu H, Niu C, Fu X, Ding W, Ling S, Jiang X, Ji Y. Early cranioplasty vs. late cranioplasty for the treatment of cranial defect: A systematic review. Clin Neurol Neurosurg 2015; 136:33-40. [PMID: 26056810 DOI: 10.1016/j.clineuro.2015.05.031] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 05/18/2015] [Accepted: 05/25/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cranioplasty is considered as a routine procedure in everyday neurosurgical practice for the patient with cranial defect, however, there is no established consensus on optimal surgical timing. OBJECTIVE To compare the effect of early cranioplasty (1-3 months after DC) and late cranioplasty (3-6 months after DC) on the complications and recovery of neurological function in the management of patients who received decompressive craniotomy. METHODS In this paper, the authors report a systematic review and meta-analysis of operative time, complications and neurological function outcomes on different timing of cranioplasty. Randomized or non-randomized controlled trials of early cranioplasty and late cranioplasty surgery were considered for inclusion. RESULTS Nine published reports of eligible studies involving 1209 participants meet the inclusion criteria. Compared with late cranioplasty, early cranioplasty had no significant difference in overall complications [RR=1.14, 95%CI (0.83, 1.55), p>0.05], infection rates [RR=0.87, 95%CI (0.47, 1.61), p>0.05], intracranial hematoma [RR=1.09, 95%CI (0.53, 2.25), p>0.05]; subdural fluid collection [RR=0.47, 95%CI (0.15, 1.41), p>0.05]. However, early CP significantly reduced the duration of cranioplasty [mean difference=-13.46, 95%CI (-21.26, 5.67), p<0.05]. The postoperative hydrocephalus rates were significant higher in the early cranioplasty group [RR=2.67, 95%CI (1.24, 5.73), p<0.05]. CONCLUSION Early CP can only reduce the duration of operation, but cannot reduce the complications of patients and even increase the risk of hydrocephalus. More evidence from advanced multi-center studies is needed to provide illumination for the timing selection of CP surgery.
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Affiliation(s)
- Hao Xu
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, PR China.
| | - Chaoshi Niu
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Xianming Fu
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Wanhai Ding
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Shiying Ling
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Xiaofeng Jiang
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Ying Ji
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, PR China
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Martin AG, Abdullah JY, Jaafar A, Ghani ARI, Rajion ZA, Abdullah JM. Addition of zygomatic arch resection in decompressive craniectomy. J Clin Neurosci 2015; 22:735-9. [DOI: 10.1016/j.jocn.2014.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 09/19/2014] [Indexed: 11/25/2022]
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O'Reilly EB, Barnett S, Madden C, Welch B, Mickey B, Rozen S. Computed-tomography modeled polyether ether ketone (PEEK) implants in revision cranioplasty. J Plast Reconstr Aesthet Surg 2015; 68:329-38. [DOI: 10.1016/j.bjps.2014.11.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 09/23/2014] [Accepted: 11/01/2014] [Indexed: 11/25/2022]
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El Ghoul W, Harrisson S, Belli A. Autologous cranioplasty following decompressive craniectomy in the trauma setting. Br J Neurosurg 2014; 29:64-69. [PMID: 25284308 DOI: 10.3109/02688697.2014.957157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) is an option for the treatment of increased intracranial pressure resulting from an acute neurological insult, including insults caused by trauma. When the brain swelling has receded, the skull is reconstructed with a wide choice of materials, each with its own advantages and disadvantages in terms of cost, cosmetic appearance, biocompatibility, implant strength and complication rate. Autologous cranioplasty (AC), where the patient's own bone flap is stored and reutilised, is common in many countries. No outcome studies have, however, been published on this technique for traumatic injuries. METHODS A retrospective study was conducted including all AC operations performed following DC due to traumatic brain injury. All operations were performed in one institution during a 4-year time period. Results were analysed for complication rates. RESULTS 44 cases were included. The mean time from craniotomy to cranioplasty was 86 (95% CI: 63-109) days. Complications severe enough to warrant readmission or further surgery were found in 13 cases (30%). No statistically significant predictor of complication from cranioplasty was detected. The complication rate was similar to published data on cranioplasty using artificial prosthetic materials. CONCLUSIONS AC in the trauma setting is a valid treatment option with a complication rate that seems no worse than other alternatives.
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Affiliation(s)
- Wessam El Ghoul
- a Department of Neurosurgery , Skane University Hospital , Lund , Sweden
| | - Stuart Harrisson
- b Department of Neurosurgery , Wessex Neurological Centre, Southampton Hospital University Trust , Southampton , UK
| | - Antonio Belli
- c NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham , Birmingham , UK
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Singla N, Parkinson Singh S, Gupta SK, Karthigeyan M, Radotra BD. Histopathology of subcutaneously preserved autologous bone flap after decompressive craniectomy: a prospective study. Acta Neurochir (Wien) 2014; 156:1369-73. [PMID: 24752721 DOI: 10.1007/s00701-014-2071-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 03/14/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Limited reports are available regarding the viability of subcutaneously preserved autologous bone flaps after decompressive craniectomy. The present study was undertaken to evaluate the histopathological changes in these autologous bone flaps. METHODS Between January 2011 and July 2012, 50 patients were prospectively studied at the time of cranioplasty. Bone flap retrieved from the abdominal wall was subjected to histopathological examination to look for mononuclear cell infiltration into the Haversian system, presence of osteocytes, osteoblastic activity, angiogenesis and new bone formation. Microbiological culture of bone specimens was also done. RESULTS Of the 50 patients, there were 40 cases of trauma, 6 of aneurysmal bleed, 2 of tumor, and a single case of intracerebral hemorrhage and middle cerebral artery infarct, respectively. Mean age of the patients was 35.8 years (range, 10-64 years). Histopathological examination revealed the presence of osteocytes in 86 %, which indicates the viability of bone flaps. Osteoblastic activity was noted in 38 % and angiogenesis in 14 % of bone flaps, respectively. New bone formation was found in 6 %, and all had underlying osteoblastic activity. No significant correlation was found between the presence of osteocytes, osteoblasts, angiogenesis and duration of preservation of bone flaps. Acinetobacter species were cultured in a single patient. However, there was no evidence of clinical infection. CONCLUSIONS Subcutaneously preserved bone flap in the anterior abdominal wall remains viable and retains its osteogenic potential, and it is a simple, cost-effective option for storage of bone flaps during decompressive craniotomy. It has a negligible infection rate.
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Affiliation(s)
- Navneet Singla
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India,
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An In Situ Repositioning Bone Flap in Retrosigmoid Craniotomy for Cranial Reconstruction. J Craniofac Surg 2014; 25:135-9. [DOI: 10.1097/scs.0000000000000368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Management of decompressive craniectomy defects: modern military treatment strategies. J Craniofac Surg 2013; 23:2042-5. [PMID: 23154344 DOI: 10.1097/scs.0b013e318258ba36] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Decompressive craniectomy has become a critical and standard life-saving maneuver in the theater of war. The high number of patients returning with large cranial defects and complex craniofacial injuries often involving the upper orbits or associated with the sunken skin flaps are a reconstructive challenge. We present a review of our treatment protocol highlighting the evolution of decompressive craniectomy and the development of a modern cranial defect treatment algorithmic approach to reconstruct these difficult clinical cases. METHODS A review of previously published data and current data from our warfare treatment unit that reported the treatment of decompressive cranial defects from 2004 to 2011 was performed. Reported data included mechanism of injury, evacuation time, initial Glasgow Coma Scale (GCS), GCS on arrival to the continental United States, type of decompressive craniectomy, type of implants used for reconstruction, and complications such as implant infections, exposures, and removals. Secondary reconstruction techniques used to salvage failed cranioplasty cases with free tissue transfers and cranial bone or dermal fat grafts as indicated were also reviewed and outcomes were reported. RESULTS From March 2003 to July 2011, more than 200 patients were identified who underwent cranioplasty after decompressive craniectomy. Patient average age was approximately 25 years (range, 18-53 y), and all patients were male. Average follow-up was 870 days (2.4 y). Average GCS at initial presentation was 7 and was 9 on arrival to the continental United States. Average time to evacuation to the continental United States was 6 days. Of all injuries, 46% were associated with an improvised explosive device blast. Of the patients, 90% underwent hemicraniectomies with the remaining 10% having received bifrontal craniectomies. Successful reconstruction and retention of the implant was present in 95% of the overall cohort. Contour abnormalities were the most common adverse outcome encountered (10% of patients after cranioplasty), whereas infections resulting in implant loss (5%) and seizures (<5%) were the most common complications that occurred after cranioplasty reconstruction. CONCLUSIONS Warfare-related decompressive craniectomy defects can be safely reconstructed using custom alloplastic implants with low morbidity and mortality. Risk factors that increase the rate of infection and require implant removal included orbital extension of the craniectomy defect, proximity to facial sinuses, and large contour abnormalities with corresponding large dead spaces. Staging reconstruction of high-risk cranial defects followed by definitive cranial defect reconstruction improved the likelihood of implant retention and successful cranioplasty outcome.
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Wiggins A, Austerberry R, Morrison D, Ho KM, Honeybul S. Cranioplasty with custom-made titanium plates--14 years experience. Neurosurgery 2013; 72:248-56; discussion 256. [PMID: 23149967 DOI: 10.1227/neu.0b013e31827b98f3] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There is no consensus on which material is best suited for repair of cranial defects. OBJECTIVE To investigate the outcomes following custom-made titanium cranioplasty. METHODS The medical records for all patients who had titanium cranioplasty at 2 major neurosurgical centers in Western Australia were retrieved and analyzed for this retrospective cohort study. RESULTS Altogether, 127 custom-made titanium cranioplasties on 113 patients were included. Two patients had 3 titanium cranioplasties and 10 patients had 2. Infected bone flap (n = 61, 54%), either from previous craniotomy or autologous cranioplasty, and contaminated bone flap (n = 16, 14%) from the initial injury were the main reasons for requiring titanium cranioplasty. Complications attributed to titanium cranioplasty were common (n = 33, 29%), with infection being the most frequent complication (n = 18 patients, 16%). Complications were, on average, associated with an extra 7 days of hospital stay (interquartile range 2-17). The use of titanium as the material for the initial cranioplasty (P = .58), the presence of skull fracture(s) (P > .99) or scalp laceration(s) (P = .32) at the original surgery, and proven local infection before titanium cranioplasty (P = .78) were not significantly associated with an increased risk of infection. Infection was significantly more common after titanium cranioplasty for large defects (hemicraniectomy [39%] and bifrontal craniectomy [28%]) than after cranioplasty for small defects (P = .04). CONCLUSION Complications after using titanium plate for primary or secondary cranioplasty were common (29%) and associated with an increased length of hospital stay. Infection was a major complication (16%), and this suggested that more vigorous perioperative infection prophylaxis is needed for titanium plate cranioplasty.
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Affiliation(s)
- Anthony Wiggins
- Department of Neurosurgery, Royal Perth Hospital, Perth, Western Australia, Australia.
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Beez T, Sabel M, Ahmadi SA, Beseoglu K, Steiger HJ, Sabel M. Scanning electron microscopic surface analysis of cryoconserved skull bone after decompressive craniectomy. Cell Tissue Bank 2013; 15:85-8. [PMID: 23673469 DOI: 10.1007/s10561-013-9378-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 05/03/2013] [Indexed: 10/26/2022]
Abstract
Bone flaps removed during decompressive craniectomy are commonly frozen at -80 °C and stored until cranioplasty. Histological integrity and regenerative capacity have been shown for cryoconserved bone. The effects of cryoconservation on the surface structure are unknown, although these might cause mechanical instability or facilitate bacterial adhesion. This study evaluates the surface structure of cryoconserved bone by scanning electron microscopy. Five patients were identified who could not receive their autologous bone flaps after decompressive craniectomy. These redundant bone specimens were obtained after cryoconservation for 6-8 months and the outer surface was analyzed by scanning electron microscopy. We found varying surface structures which did not correlate with any variables, such as patient age, gender or duration of freezing, and probably reflect physiological interindividual variation. Pathological findings, such as microscopic crack formation, were not observed. Cryoconservation for up to 8 months does not appear to alter the surface structure of skull bone on scanning electronic microscopy.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Heinrich-Heine-Universität, Düsseldorf, Germany,
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El Ahmadieh TY, Adel JG, El Tecle NE, Daou MR, Aoun SG, Nanney AD, Bendok BR. Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring. Neurosurg Clin N Am 2013; 24:375-91. [PMID: 23809032 DOI: 10.1016/j.nec.2013.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, McGaw Medical Center, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 2210, Chicago, IL 60611, USA
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Tuzgen S, Kucukyuruk B, Aydin S, Ozlen F, Kizilkilic O, Abuzayed B. Decompressive craniectomy in patients with cerebral infarction due to malignant vasospasm after aneurysmal subarachnoid hemorrhage. J Neurosci Rural Pract 2012. [PMID: 23188970 PMCID: PMC3505309 DOI: 10.4103/0976-3147.102598] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIM The authors present their experience and the clinical results in decompressive craniectomy (DC) in patients with vasospasm after aneurysmal subarachnoid hemorrhage (SAH). MATERIALS AND METHODS Between 2002 and 2010, six patients underwent DC due to cerebral infarct and edema secondary to vasospasm after aneurysmal SAH. Four patients were male, and two were female. The age of patients ranged between 33 and 60 (mean: 47,6 ± 11,4). The follow up period ranged between 12 to 104 months (mean: 47,6 ± 36,6). The SAH grading according World Federation of Neurosurgeons (WFNS) score ranged between 3 to 5. RESULTS Last documented modified Rankin Score (mRS) ranged between 2 to 6. One patient died in the following year after decompression due to pneumonia and sepsis. Two patients had moderate disability (mRS of 4) and three patients continue their life with minimal deficit and no major dependency (mRS score 2 and 3). CONCLUSION DC can be a life-saving procedure which provides a better outcome in patients with cerebral infarction secondary to vasospasm and SAH. However, the small number of the patients in this study is the main limitation of the accuracy of the results, and more studies with larger numbers are required to evaluate the efficiency of DC in this group of patients.
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Affiliation(s)
- Saffet Tuzgen
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Cerebral blood flow, brain tissue oxygen, and metabolic effects of decompressive craniectomy. Neurocrit Care 2012; 16:478-84. [PMID: 22396191 DOI: 10.1007/s12028-012-9685-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Decompressive craniectomy (DC) is used for patients with traumatic brain injury (TBI), malignant edema from middle cerebral artery infarction, aneurysmal subarachnoid hemorrhage, and non-traumatic intracerebral or cerebellar hemorrhage. The objective of the procedure is to relieve intractable intracranial hypertension and/or to prevent or reverse cerebral herniation. Decompressive craniectomy has been shown to decrease mortality in selected patients with large hemispheric infarction and to control intracranial pressure in addition to improving pressure-volume compensatory reserve after TBI. The clinical effectiveness of DC in patients with TBI is under evaluation in ongoing randomized clinical trials. There are several unresolved controversies regarding optimal candidate selection, timing, technique, and post-operative management and complications. The nature and temporal progression of alterations in cerebral blood flow, brain tissue oxygen, and microdialysis markers have only recently been researched. Elucidating the pathophysiology of pressure-flow and cerebral hemodynamic consequences of DC could assist in optimizing clinical decision making and further defining the role of decompressive craniectomy.
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Morrison DA, Guy DT, Day RE, Lee GYF. Simultaneous repair of two large cranial defects using rapid prototyping and custom computer-designed titanium plates: a case report. Proc Inst Mech Eng H 2012; 225:1108-12. [PMID: 22292209 DOI: 10.1177/0954411911422766] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Custom titanium cranioplasty plates, manufactured by a variety of techniques, have been used to repair a range of cranial defects. The authors present a case where two relatively large, adjacent cranial defects were repaired by custom computer-designed titanium plates. The two plates were designed and fabricated simultaneously using a unique methodology. A 28-year-old woman underwent a corpus callosotomy for medically intractable epilepsy. The surgery was complicated by unexpected haemorrhage which necessitated a second craniotomy. Subsequent deep infection required the removal of bilateral bone flaps, presenting a challenge in the reconstruction of extensive, bilateral but asymmetrical cranial defects. The patient underwent a head computed tomography scan, from which a rapid-prototype model of the skull was produced. The surfaces for the missing cranial segments were generated virtually using a combination of software products and two titanium plates that followed these virtual contours were manufactured to cover the defects. The cranioplasty procedure to implant both titanium cranial plates was performed efficiently with no intra-operative complications. Intra-operatively, an excellent fit was achieved. The careful planning of the plates enhanced the relative ease with which the cranial defects were repaired with an excellent cosmetic outcome.
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Affiliation(s)
- D A Morrison
- Department of Medical Engineering and Physics, Royal Perth Hospital, Perth, Australia.
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Klein A, Kuehner C, Schwarz S. Attitudes in the General Population Towards Hemi-Craniectomy for Middle Cerebral Artery (MCA) Infarction. A Population-Based Survey. Neurocrit Care 2012; 16:456-61. [DOI: 10.1007/s12028-012-9677-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Oluigbo CO, Wilkinson CC, Stence NV, Fenton LZ, McNatt SA, Handler MH. Comparison of outcomes following decompressive craniectomy in children with accidental and nonaccidental blunt cranial trauma. J Neurosurg Pediatr 2012; 9:125-32. [PMID: 22295915 DOI: 10.3171/2011.11.peds09449] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to compare clinical outcomes following decompressive craniectomy performed for intracranial hypertension in children with nonaccidental, blunt cranial trauma with outcomes of decompressive craniectomy in children injured by other mechanisms. METHODS All children in a prospectively acquired database of trauma admissions who underwent decompressive craniectomy over a 9-year span, beginning January 1, 2000, are the basis for this study. Clinical records and neuroimaging studies were systematically reviewed. RESULTS Thirty-seven children met the inclusion criteria. Nonaccidental head trauma was the most common mechanism of injury (38%). The mortality rate in patients with abusive brain injury (35.7%) was significantly higher (p < 0.05) than in patients with other causes of traumatic brain injury (4.3%). Children with inflicted head injuries had a 12-fold increase in the odds of death and 3-fold increase in the odds of a poor outcome (King's Outcome Scale for Closed Head Injury score of 1, 2, or 3). CONCLUSIONS Children with nonaccidental blunt cranial trauma have significantly higher mortality following decompressive craniectomy than do children with other mechanisms of injury. This understanding can be interpreted to mean either that the threshold for decompression should be lower in children with nonaccidental closed head injury or that decompression is unlikely to alter the path to a fatal outcome. If decompressive craniectomy is to be effective in reducing mortality in the setting of nonaccidental blunt cranial trauma, it should be done quite early.
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Affiliation(s)
- Chima O Oluigbo
- Department of Neurosurgery, The Children's Hospital and University of Colorado, Aurora, Colorado 80045, USA
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Schwarz S, Kühner C. Prognose und Lebensqualität nach Entlastungstrepanation. DER NERVENARZT 2011; 83:731-40. [DOI: 10.1007/s00115-011-3402-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Decompressive craniectomy (DC) is the surgical management removing part of the skull vault over a swollen brain used to treat elevated intracranial pressure that is unresponsive to maximal medical therapy. The commonest indication for DC is traumatic brain injury (TBI) or middle cerebral artery (MCA) infarction, though DC has been reported to have been used for treatment of aneurysmal subarachnoid haemorrhage and venous infarction. 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 are retrospective, the recent publication of several randomised prospective studies prompts a re-evaluation of the use of DC. We review the literature concerning the pathophysiology, indication, surgical techniques and timing, complications and long-term effects of DC (including reversal with cranioplasty), in order to rationalise its use. We conclude that at the time of this review, though we cannot support the routine use of DC in TBI or MCA stroke, there is evidence that early and aggressive use of DC in TBI patients with intracranial haematomas or younger malignant MCA stroke patients may improve outcome. Though the results of the DECRA trial suggest that primary DC may worsen outcome, the decision to perform DC after diffuse TBI is still individualised. We await the results of the RESCUEicp trial to ascertain whether an evidence-based protocol for its use can be agreed in the future.
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Affiliation(s)
| | - A Tarnaris
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, UK
| | - J Wasserberg
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, UK
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