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

Resection of swollen temporal muscles in patients with intractable intracranial hypertension after decompressive craniectomy

BACKGROUND

Decompressive craniectomy is employed as treatment for traumatic brain swelling in selected patients. We discussed the effect of temporal muscle resection in patients with intractable intracranial hypertension and temporal muscle swelling after craniectomy.

METHODS

Records of 280 craniectomies performed on 258 patients who were admitted with severe head injury were retrospectively reviewed. Eight patients developed intractable increased intracranial pressure with temporal muscle swelling within 24 h after craniectomy and were treated by muscle resection.

RESULTS

The initial Glasgow Coma Scale score was 7 ± 1. The mean intracranial pressure was 41.7 ± 8.59 mmHg before muscle resection and 14.81 ± 8.07 mmHg immediately after surgery. Five patients had skull fracture and epidural hematoma at the craniectomy site. The mean intensive care unit stay was 11.25 ± 5.99 days. Glasgow Outcome Scale-Extended scoring performed during the 12-month follow-up visit showed that 6 patients (75%) had a favorable outcome.

CONCLUSIONS

Our study findings indicate that a direct impact on the temporal region during trauma may lead to subsequent temporal muscle swelling. Under certain circumstances, muscle resection can effectively control intracranial pressure.

Aggressive internal and external decompression as a life-saving surgery in a deeply comatose patient with fixed dilated pupils after severe traumatic brain injury: A case report

Background:

To maximize control of the intracranial pressure in deeply comatose patients with malignant cerebral swelling, combination of the surgical techniques for internal and external brain decompression may be reasonable, as demonstrated in the presented case.

Case Description:

A 55-year-old man was admitted with Glasgow Coma Scale (GCS) score 4, maximally dilated pupils, and absence of the pupillary light and vestibulo-ocular reflexes. Head CT revealed massive acute subdural hematoma, prominent brain shift with subfalcine and transtentorial herniation, and diffuse subarachnoid hemorrhage. Large size decompressive craniectomy and evacuation of subdural hematoma were done, however, prominent swelling of the brain and its protrusion through the bone defect remained. Therefore, extensive temporal lobectomy and removal of the bulk of temporal muscle were additionally attained followed by lax duraplasty. Gradual recovery of the patient was noted from the 1^st postoperative day, and on the 70^th day, his GCS score was 4T4. Three months later, his condition corresponded to the Glasgow Outcome Scale score 3 (severe disability).

Conclusion:

Aggressive internal and external decompression with combination of large size craniectomy, extensive temporal lobectomy, removal of the bulk of temporal muscle, and lax duraplasty should be considered as possible life-saving option in cases of neurosurgical emergencies with malignant cerebral swelling.

Relationship between Clinical Outcomes and Superior Sagittal Sinus to Bone Flap Distance during Unilateral Decompressive Craniectomy in Patients with Traumatic Brain Injury: Experience at a Single Trauma Center

Objective

This retrospective study was conducted to investigate the relationship between the superior sagittal sinus (SSS) to bone flap distance and clinical outcome in patients with traumatic brain injury (TBI) who underwent decompressive craniectomy (DC).

Methods

A retrospective review of medical records identified 255 adult patients who underwent DC with hematoma removal to treat TBI at our hospital from 2016 through 2017; of these, 68 patients met the inclusion criteria and underwent unilateral DC. The nearest SSS to bone flap distances were measured on postoperative brain computed tomography images, and patients were divided into groups A (distance ≥20 mm) and B (distance <20 mm). The estimated blood loss (EBL) and operation time were evaluated using anesthesia records, and the time spent in an intensive care unit (ICU) was obtained by chart review. The clinical outcome was rated using the extended Glasgow Outcome Scale (GOS-E) at 3 and 6 months postoperatively.

Results

The male to female ratio was 15:2 and the mean subject age was 55.12 years (range, 18–79 years). The mean EBL and operation times were significantly different between groups A and B (EBL: 655.26 vs. 1803.33 mL, p<0.001; operation time: 125.92 vs. 144.83 min, p<0.001). The time spent in the ICU and GOS-E scores did not differ significantly between the groups.

Conclusion

We recommend that when DC is indicated due to TBI, an SSS to bone flap distance of at least 20 mm should be maintained, considering the EBL, operation time, and other outcomes.

Decompressive Craniectomy in Traumatic Brain Injury: A Review Article

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.