Incidence of Intracranial Hemorrhage After a Cranial Operation

Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy

OBJECTIVE

Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy.

MATERIALS AND METHODS

We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes.

RESULTS

We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04).

CONCLUSION

Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.

Reoperation-requiring postoperative intracranial haemorrhage after posterior fossa craniotomy: Retrospective case-series

Introduction

Studies report rates of treatment-requiring postoperative intracranial haemorrhage after craniotomy around 1-2%, but do not distinguish between supratentorial and posterior fossa operations. Reports about intracranial haemorrhages' temporal occurrence show conflicting results. Recommendations for duration of postoperative monitoring vary.

Research question

To determine the rate, temporal pattern and clinical presentation of reoperation-requiring postoperative intracranial posterior fossa haemorrhage.

Material and methods

This retrospective case-series identified cases operated with posterior fossa craniotomy or craniectomy between January 1, 2007 and December 31, 2021 by an electronic search in the patient administrative database, and collected data about patient- and treatment-characteristics, postoperative monitoring, and the occurrence of haemorrhagic and other serious postoperative complications.

Results

We included 62 (n = 34, 55% women) cases with mean age 48 (interquartile range 50) years operated for tumours (n = 34, 55%), Chiari malformations (n = 18, 29%), ischemic stroke (n = 6, 10%) and other lesions (n = 3, 5%). One (2%) 66-year-old woman who was a daily smoker operated with decompressive craniectomy and infarct resection, developed a reoperation-requiring postoperative intracranial haemorrhage after 25.5 h. In four (6%) cases, other serious complications requiring reoperation or transfer from the post anaesthesia care unit or regular bed wards to the intensive care unit occurred after 0.5, 6, 9 and 54 h, respectively.

Discussion and conclusion

Treatment-requiring postoperative intracranial haemorrhage and other serious complications after posterior fossa craniotomies occur over a wide timespan and are difficult to capture with a standardized postoperative monitoring time. This indicates that the duration of monitoring should be individualized based on assessment of risk factors.

Recurrent Subdural Hematoma: An Institutional Experience

Background Chronic subdural hematoma (CSDH) is a common neurosurgical problem, which offers a good outcome following surgery. In many cases, burr hole irrigation and drainage under local anesthesia can provide satisfactory results. However, recurrence can be a cause for concern for both the surgeon and the patient. While recurrence is not a frequent phenomenon, studies have reported rates of up to 31.6%. Aims and objectives In this study, our objective is to examine a comprehensive range of potential risk factors and provide valuable insights into identifying patients at a higher risk of recurrence to aid in surgical decision-making. Methodology This study employed a prospective and retrospective design, conducted between 2017 and 2021, at Sri Ramachandra Institute of Higher Education and Research. The study received ethical approval from the Institutional Ethics Committee. The research aimed to assess patients who underwent surgery for CSDH, with a particular focus on those who experienced recurrence. Results The average age of patients with recurrence was 71.5 years compared to 65.2 years in the no-recurrence group, but this difference did not show a significant statistical correlation. A significant male predominance was observed, with 27 men and four women affected (out of a total of 147 men and 73 women in the study), resulting in a statistically significant p-value of 0.01. On multivariate analysis, heterogenous subtypes were a significant predictor of recurrence (OR: 8.88, 95% CI: 6.96-16.54, p = 0.01). The mean midline shift in those with recurrence was 11.4 mm compared to 7.09 mm in those without recurrence. This was a statistically significant correlation with a p-value of 0.02. Regarding those with recurrence, 24 patients underwent evacuation using two burr holes, with one placed in the frontal region and another in the parietal region. All of these patients had a subdural drain placed, which was removed on postoperative day 2. The remaining eight patients underwent a mini-craniotomy for evacuation. We had four cases of refractory CSDH, all of whom underwent the second evacuation using burr holes. Three of them underwent evacuation via craniotomy, while the family of the fourth patient did not give consent for the procedure. Conclusion Patient-related factors such as gender, bilateral presentation, and the presence of hypertension and radiological factors such as the presence of heterogenous subtype and a significant midline shift are clues toward a higher chance of recurrence.

Multiple different remote epidural hematomas after craniotomy: A case report

BACKGROUND

Epidural hematoma is one of the common postoperative complications after craniotomy. However, multiple remote epidural hematomas in different sites, including supratentorial and infratentorial regions, are exceedingly rare.

CASE SUMMARY

We present a rare case in which three remote epidural hematomas occurred after craniotomy. A 21-year-old woman was admitted with a headache for 1 mo, vomiting, and rapid vision loss for 1 wk. Brian magnetic resonance imaging indicated a right thalamic tumor. The intraoperative diagnosis was a cystic tumor, posterior cerebral artery aneurysm, and vascular malformation. The operation was successful. Unfortunately, the patient developed three extradural hematomas within 48 h. Family members consented to the first two hematoma evacuations but refused the third.

CONCLUSION

More attention should be paid to this kind of rare complication. Adequate preoperative evaluation is important, especially for acute patients. Monitoring neural function and early computed tomography scanning of the brain after surgery should be highlighted.

PINK1 antagonize intracerebral hemorrhage by promoting mitochondrial autophagy

BACKGROUND

Intracerebral hemorrhage (ICH) causes neurotransmitter release, oligemia, membrane depolarization, mitochondrial dysfunction, and results in the high rate of mortality and functional disability. Here, we focus on PTEN-induced kinase 1 (PINK1), a mitochondrial-targeted protein kinase, and explore its role in ICH progression.

METHODS

The qPCR and Western blot were performed to examine the expression of PINK1 in ICH patients and mouse model. PINK1 gain- and loss-of-function mice were used to evaluate their protective role on brain injury and behavioral disorders. Flow cytometry was carried out, mitochondrial membrane potential and reactive oxygen species production were detected to explore the distribution and neuroprotective function of PINK1.

RESULTS

PINK1 mRNA was upregulated, however, its protein was downregulated in ICH patients. The reduction of PINK1 was mainly happened in microglial cells in ICH model. Overexpression of PINK1 is able to rescue ICH-induced behavioral disorders. PINK1 protects ICH-induced brain injury by promoting mitochondrial autophagy in microglia.

CONCLUSION

PINK1 possesses a neuroprotective role and antagonizes ICH by promoting mitochondrial autophagy, which may be of value as a therapeutic target for ICH treatment.

Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a 5-year experience

PURPOSE

Decompressive craniectomy is an effective measure to reduce a pathologically elevated intracranial pressure. Patients' survival and life quality following this surgery have been a subject of several studies and significantly differ according to the primary diagnosis. Since this operation is often associated with a wide spectrum of possibly serious complications, we aimed to describe their incidence and possible associated risk factors.

METHODS

We evaluated 118 patients who underwent decompressive craniectomy at our clinic during years 2013-2017. The indications included traumatic brain injuries, ischaemic or haemorrhagic strokes and postoperative complications of planned neurosurgical procedures. Subsequently, we assessed the incidence of early postoperative complications (occurring during the first 3 postoperative weeks). The results were statistically analysed with relation to a wide selection of possible risk factors.

RESULTS

At least one early surgical postoperative complication occurred in 87 (73.73%) patients, the most frequent being a development of an extraaxial fluid collection in 41 (34.75%) patients. We were able to identify risk factors linked with extraaxial fluid collections, subcutaneous and extradural haematomas, postoperative seizures and meningitis. An overall need for reoperation was 13.56%. Neither the duration of the surgery nor the qualification of the operating surgeon had any effect on the complications' occurrence.

CONCLUSIONS

Decompressive craniectomy is associated with numerous early postoperative complications with a various degree of severity. Most cases of complications can, however, be managed in a conservative way. The risk factors linked with postoperative complications should be taken into account during the indication process in each individual patient.

Postoperative subdural hematoma with blood flow from an epidural hematoma through a tear at the suture point of an artificial dura substitute

OBJECTIVE

We have recently seen cases of postoperative epidural and subdural hematomas after duraplasty with an artificial dura substitute. In these cases, the epidural hematoma flowed into the subdural space through a tear at the suture point of the artificial dura substitute. In this study, whether such hematomas are specific to a certain artificial dura substitute was investigated, and the cause and risk factors were examined.

METHODS

In our institute, 46 patients underwent brain tumor extirpation with duraplasty with an artificial dura substitute; Gore-Tex and SEAMDURA were used as the artificial dura substitutes. Patients with postoperative hemorrhage after brain tumor extirpation with duraplasty with an artificial dura substitute were retrospectively analyzed. Moreover, suture strength was compared experimentally between Gore-Tex and SEAMDURA.

RESULTS

In patients who underwent brain tumor extirpation with duraplasty with an artificial dura substitute, the rate of postoperative hemorrhage was 8.6%. Epidural and subdural hematomas were seen in four patients after tumor extirpation with duraplasty with SEAMDURA, but there were none with Gore-Tex. Exposure of the superior sagittal sinus at craniotomy, older age, and longer operative time were seen more frequently in patients with hematoma than in patients without hematoma. The strength of the suture point was significantly weaker with SEAMDURA than with Gore-Tex (P = 0.00016).

CONCLUSIONS

Postoperative epidural and subdural hematomas seem to be specific for SEAMDURA and may be caused by the weak suture strength of SEAMDURA. In cases of duraplasty, a nonabsorbable artificial dura substitute may be suitable.

Post-operative complications of craniotomy and craniectomy

Craniotomy and craniectomy are widely performed emergent neurosurgical procedures and are the prescribed treatment for a variety of conditions from trauma to cancer. It is vital for the emergency radiologist to be aware of expected neuroimaging findings in post-craniotomy and craniectomy patients in order to avoid false positives. It is just as necessary to be familiar with postsurgical complications in these patients to avoid delay in lifesaving treatment. This article will review the commonly encountered normal and abnormal findings in post-craniotomy and craniectomy patients. The expected postoperative CT and MRI appearance of these procedures are discussed, followed by complications. These include hemorrhage, tension pneumocephalus, wound/soft tissue infection, bone flap infection and extradural abscesses. Complications specifically related to craniectomies include extracranial herniation, external brain tamponade, paradoxical herniation, and trephine syndrome.

Mild hemophilia A presaged by recurrent postoperative hemorrhagic complications in an elderly patient

Background:

Mild hemophilia without spontaneous bleeding can remain undiagnosed for a lifetime. However, intracranial hemorrhage is one of the most serious complications for patients with hemophilia. In addition, hemorrhagic complications after emergency surgery tend to arise from coagulopathy.

Case Description:

An 80-year-old man was admitted with left hemiparesis and disturbed consciousness. He had no history of trauma, fever, or drug and alcohol intake. Computed tomography imaging upon admission disclosed a hemispheric subdural hematoma with a midline shift. No vascular abnormalities were identified as a source of the hemorrhage. The hematoma was removed on an emergency basis with external decompression. However, a large subcutaneous hematoma was again evident on the following day. Insufficient hemostatic maneuvers during surgery were considered the cause of this hemorrhagic complication. A second operation was performed to achieve hemostasis of the subcutaneous and muscle tissue. Thereafter, he was rehabilitated without treatment for hemophilia as he had no bleeding episodes. Cranioplasty proceeded using artificial bone at 40 days after the first operation. However, epidural hematoma developed again on postoperative day 1. His neurological status did not worsen so a repeat procedure was unnecessary. Close scrutiny uncovered a diagnosis of mild hemophilia A.

Conclusions:

Accurate diagnosis is important for the management of postoperative hemorrhagic complications caused by pathologies of the coagulation system. Sufficient hemostasis of hemorrhage from subcutaneous and muscle tissue is essential even during emergency surgery to avoid postoperative complications. A diagnosis of hemophilia should be considered in the face of prolonged activated partial thromboplastin time (APTT).