External decompressive craniectomy including resection of temporal muscle and fascia in malignant hemispheric infarction

Decompressive craniectomy procedures are used for malignant hemispheric infarctions. However, the temporal muscle and fascia are significant limiting factors for external herniation of an edematous brain. Therefore, the authors performed a decompressive craniectomy and expansive duraplasty combined with resection of the temporal muscle and fascia for 15 patients with a malignant hemispheric infarction. The volume of the maximum external herniation that was measured on the basis of a CT volumetry study ranged from 130 to 300 ml (mean +/- standard deviation, 200 +/- 64 ml) on postoperative Day 3.2 +/- 1.5 (range 2-5 days postoperatively). The mean value represented a 2-fold volume expansion in comparison with the conventional decompressive craniectomy, and the greater the external herniation obtained by external decompression, the smaller the midline brain shift after surgery. The mortality rate, favorable outcomes (modified Rankin Scale Scores 1-3), and unfavorable outcomes were 20, 60, and 20%, respectively, and the masticatory function was only minimally affected. Furthermore, a cranioplasty involving reconstruction of the temporal muscle defect performed using a MEDPOR implant resulted in good cosmetic outcomes with no temporal hollow. Resection of the temporal muscle in a decompressive craniectomy was shown to provide greater decompression and better clinical outcomes for malignant hemispheric infarctions at an acceptable cost of minimal masticatory dysfunction and cosmetic disfigurement.     

不同时机行去骨瓣减压加颞肌粘贴术治疗急性大脑中动脉区梗死效果的比较

目的探讨不同手术时机去骨瓣减压加颞肌粘贴术对急性大脑中动脉系脑梗死的疗效。方法对25例急性大脑中动脉脑梗死病人行开颅去骨瓣减压、加带血管蒂颞肌肌瓣粘附术，并观察不同手术时机的治疗效果。结果25例病例中生存18例，死亡7例，死亡率28％。早期手术组14例死亡2例。死亡率为14．3％：晚期手术组11例死亡5例，死亡率为45．5％；早期手术明显降低了死亡率（P〈0．01）。生存者术后半年Barthel Index评分早期手术组明显优于晚期手术组（P〈0.05）。结论对于急性大脑中动脉脑梗死，早期行开颅去骨瓣减压、加带血管蒂颞肌肌瓣粘附术，可迅速缓解颅内高压、促进神经功能恢复、减少死亡率．并能改善生存质量。     

Decompressive craniectomy for massive infarction of middle cerebral artery territory

There is continuing controversy about the benefits of decompressive craniectomy for the treatment of massive infarction of middle cerebral artery (MCA) territory. Under conservative therapy, the mortality rate for this stroke is reported to be up to 80%. So the authors have actively carried out decompressive craniectomy since 1997, and have compared the outcome with patients who were admitted before 1997 and, consequently treated with conservative therapy. Fifteen consecutive victims of massive infarction of MCA territory were studied. Seven patients (male: 1, female: 6, mean age: 79.8 years) were treated with conservative therapy, and 8 patients (male: 3, female: 5, mean age: 71.8 years) were treated with decompressive craniectomy. There were no significant differences in age and consciousness level distribution between the two groups. Mortality rate in the conservative therapy group was 85.7% against 12.5% in the surgery group (p < 0.05). Functional performance, which was evaluated by activity in daily life (ADL), was also better in the surgery group e.g. 3 patients in ADL 3, and 3 in ADL 4 (1 patient died from a non-neurological cause). Even among the patients with speech-dominant hemispheric stroke, all except one were able to communicate in some way and understand language. Even though patients in this study were elderly, decompressive craniectomy reduced mortality and improved functional performance, so it seems that this surgery should be aggressively considered for massive infarction of MCA territory.     

Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction

BACKGROUND: Early surgical decompressive craniectomy (less than 24 hours) for malignant middle cerebral artery infarction (MCA) provides life-saving benefits. Detection of the infarction territory with computed tomography (CT) scan is usually less sensitive and delayed than diffusion-weighted imaging (DWI) that is capable of defecting the infarction territory in as little as 5 minutes after onset. Based on the DWI and clinical neurologic evaluations, ultra-early (less than 6 hours) decompressive craniectomy for malignant MCA infarction may be very helpful in improving mortality and morbidity rates. METHODS: We treated 52 patients with malignant MCA infarction. Clinical neurologic presentation was evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS). The infarction territory was evaluated by either DWI or CT. Patients were divided into three groups (Group A: ultra-early, Group B: craniectomy beyond 6 hours, and Group C: no operation). Anterior temporal lobectomy was performed according to the ICP levels (ICP >30 mm Hg) after decompressive craniectomy. RESULTS: Group A had statistically lower mortality rates than Groups B and C (8.7% in Group A, 36.7% in Group B and 80% in Group C). Group A patients also had better prognosis of conscious recovery on the 7th day of onset (91.7% in Group A, 55% in Group B and 0% in Group C). Group A had statistically better Barthel Indexes than Group B, p < 0.05. Group A and Group B had better GOS levels than Group C, p < 0.001. Diagnosis by CT was accurate in only 33% of patients while the accuracy of DWI to detect malignant MCA infarction was 100% within 6 hours of onset. In surgical Group A and B, thirteen patients underwent anterior temporal lobectomy, and 67% survived. All patients with ICP levels of more than 30 mm Hg who did not undergo further anterior temporal lobectomy died. CONCLUSIONS: Patients who underwent decompressive surgery had better outcomes than patients who did not have the operation. Ultra-early intervention with decompressive craniectomy with ICP monitoring before neurologic conditions become worse may reduce the mortality rate, increase the conscious recovery rate, and improve neurologic sequels for malignant MCA infarction. DWI with clinical neurologic evaluation (NIHSS, hemiplegia, down-hill GCS) provides for early diagnosis and treatment of malignant MCA infarction. Anterior temporal lobectomy may further reduce intraoperative ICP and reduce mortality, especially when the infarction is at multiple arterial territories.     

Aggressive decompressive surgery in patients with massive hemispheric embolic cerebral infarction associated with severe brain swelling

Summary  Massive hemispheric cerebral infarction, also known as malignant infarction, is characterized by rapid clinical deterioration due to brain swelling and downward transtentorial herniation, and is associated with a mortality of 80%. Early patient selection and establishment of the optimum therapeutic modality are important to improve the outcome. Early clinical, computed tomography (CT), and angiographic characteristics were analysed to identify patients with malignant infarction and external and internal decompression was performed, with unco-parahippocampectomy if needed, and the outcomes were compared with those of conservative treatment.  Thirty-four of 55 patients admitted with large cerebral infarctions due to embolism showed rapid clinical deterioration due to brain swelling and herniation. These 34 patients were treated under a diagnosis of malignant infarction by decompressive surgical treatment (19 cases) or conservative treatment (15 cases).  CT showed significantly higher infarction volume in patients with malignant infarction (288±62 cm³) compared to patients with non-malignant infarction (200±57 cm³, P<0.001) and angiography showed a higher incidence of recanalization of the occluded vessels in patients with malignant infarction (58%) compared to patients with non-malignant infarction (15%, P<0.05). Discriminant analysis revealed that an infarction volume of more than 240 cm³ was predictive of malignant infarction with 76.4% accuracy. Basic clinical characteristics on admission and deterioration were not statistically different between the surgically treated and conservatively treated groups of patients with malignant infarction. The shift of midline structures was significantly improved (14±3.5 to 10±4.7 mm) after surgical treatment (P<0.05), compared to deterioration (12±5.8 to 15±4.5 mm) after conservative treatment. The mortality was 67% in the conservative group and 16% in the surgical group. Surgical treatment significantly improved the mortality and Glasgow Outcome Scale score (P<0.01). However, the mean Barthel Index scores of the survivors were not significantly different.  An infarct volume of more than 240 cm ³ on CT and angiographic recanalization of the occluded artery are predictors of fatal brain swelling after massive cerebral infarction. Decompressive surgical treatment dramatically improves the mortality of massive hemispheric infarction.     

Decompressive craniectomy for intractable cerebral edema: experience of a single center

Several case reports and small clinical series have reported benefits of decompressive hemicraniectomy in patients with intractable cerebral edema and early clinical herniation. Specific indications and timing for this intervention remain unclear. We present our experience with this procedure in a subset of 18 patients with massive cerebral edema refractory to medical management, treated with decompressive craniectomy over a 3-year period (1997 to 2000). Computerized tomography (CT) scans were independently analyzed by a neuroradiologist blinded to clinical outcome. Eleven male and seven female patients, ages 20 to 69 years (mean +/- SEM, 46 +/- 14 years), underwent hemicraniectomy for the following diagnoses: 12 hemispheric infarcts, 3 traumatic intracerebral hemorrhages/contusions, 2 nontraumatic intraparenchymal hemorrhages (ICH), and 1 subdural empyema. This population included four patients with aneurysmal subarachnoid hemorrhage (SAH). Patients were followed for a mean of 10 months. Clinical factors including age, side of lesion, preoperative herniation signs, and early surgery (<12 or <24 hours) were not significantly associated with mortality or Glasgow outcome score (GOS). Preoperative CT evidence of transtentorial herniation (present in 5/17 patients) was associated with mortality ( = 0.04), while preoperative uncal herniation (8/17 patients) was associated with poor outcome (GOS > 1) ( = 0.01). Favorable outcome (GOS > 3) occurred in six patients, three with spontaneous or traumatic focal hematomas. Of four patients with SAH, one died while the others were severely disabled (GOS 3). Seven of nine patients with malignant MCA infarctions unrelated to SAH had poor outcomes. The overall mortality was 4/18 (22%). Patients with refractory cerebral swelling secondary to focal hematomas may have better outcomes following decompressive craniectomy. Patients with preexisting SAH seem to have poor outcomes, possibly related to other neurologic comorbidities. Hemicraniectomy requires definition of proper timing. Preoperative CT findings, especially transtentorial and uncal herniation may be useful in defining when decompressive surgery should not be performed.     

Comparison of the effect of decompressive craniectomy on different neurosurgical diseases

Background  Many previous studies have reported that decompressive craniectomy has improved clinical outcomes in patients with intractable increased intracranial pressure (ICP) caused by various neurosurgical diseases. However there is no report that compares the effectiveness of the procedure in the different conditions. The authors performed decompressive craniectomy following a constant surgical indication and compared the clinical outcomes in different neurosurgical diseases. Materials and methods  Seventy five patients who underwent decompressive craniectomy were analysed retrospectively. There were 28 with severe traumatic brain injury (TBI), 24 cases with massive intracerebral haemorrhage (ICH), and 23 cases with major infarction (MI). The surgical indications were GCS score less than 8 and/or a midline shift more than 6 mm on CT. The clinical outcomes were assessed on the basis of mortality and Glasgow Outcome Scale (GOS) scores. The changes of ventricular pressure related to the surgical intervention were also compared between the different disease groups. Findings  Clinical outcomes were evaluated 6 months after decompressive craniectomy. The mortality was 21.4% in patients with TBI, 25% in those with ICH and 60.9% in MI. A favourable outcome, i.e. GOS 4–5 (moderate disability or better) was observed in 16 (57.1%) patients with TBI, 12 (50%) with ICH and 7 (30.4%) with MI. The change of ventricular pressure after craniectomy and was 53.2 (reductions of 17.4%) and further reduced by 14.9% (with dural opening) and (24.8%) after returning to its recovery room, regardless of the diseases group. Conclusions  According to the mortality and GOS scores, decompressive craniectomy with dural expansion was found to be more effective in patients with ICH or TBI than in the MI group. However, the ventricular pressure change during the decompressive craniectomy was similar in the different disease groups. The authors thought that decompressive craniectomy should be performed earlier for the major infarction patients.     

Functional recovery after decompressive craniectomy for cerebral infarction

There is continuing controversy about the benefits of decompressive craniectomy in the treatment of lesions causing increased intracranial pressure (ICP) and brain edema. Laboratory work has shown a decrease in ICP after craniectomy, but also a paradoxical enhancement in the formation of underlying cerebral edema, which may act to the detriment of the patient. Since Rengachary et al. advocated craniectomy for massive cerebral infarction and reported their group of three patients, we have managed five patients with acute supratentorial cerebral infarction who progressed to uncal herniation and impending death from raised ICP and brain stem compression. All were treated with frontotemporal craniectomy after conventional medical therapy failed to achieve a response. All patients survived and are walking, despite a paresis appropriate to their original stroke. Two have returned to work. Good results with supratentorial craniectomy after infarction show that this procedure is life-saving and can also give acceptable functional recovery.     

Aspects on decompressive craniectomy in patients with traumatic head injuries

In patients with traumatic brain injury (TBI), intracranial hypertension secondary to cerebral edema is a major problem. A last-tier treatment in these cases is decompressive craniectomy. The aim of the present retrospective investigation was to (1) study the long-time outcome in patients with traumatic head injuries with intracranial hypertension treated with decompressive craniectomy; (2) examine the effects on intracranial pressure (ICP) by the craniectomy; and (3) investigate the possible relationship between the size of the removed bone-flap and the effects on ICP. Among the about 150 patients with severe TBI treated at our neurointensive care unit during 1997-2002, 19 patients were treated with decompressive craniectomy. All patients were young (mean 22 +/- 11 years, range 7-46 years), and 68% were male. The mean ICP was reduced from 29.2 +/- 3.5 before to 11.1 +/- 6.0 mm Hg immediately after the craniectomy; at 24 h after the craniectomy, the mean ICP was 13.9 +/- 9.7 mm Hg. Paired-samples t-test revealed a statistically significant decrease, both when comparing the preoperative values to the values immediately postoperative as well as to the values after 24 h (p < 0.01). A significant correlation between the size of the craniectomy and the decrease in ICP was found using Pearson regression analysis. The outcome of all patients could be assessed. The survival rate was 89%. Two patients died (both day 4 after the trauma); 68% of the patients had a favorable outcome (Glasgow Outcome Scale [GOS] score of 4 or 5); 16% were severely disabled (GOS score of 3); and one patient (5%) was left in a vegetative state.     

Quality of life after decompressive craniectomy in patients suffering from supratentorial brain ischemia

Summary Background. Decompressive craniectomy in patients suffering from severe ischemic stroke in the middle cerebral artery territory (MCA) decreases mortality to near 30%. Additionally functional outcome in patients after early craniectomy seems to be better than in patients without surgery. The aim of this study was to investigate the quality of life of patients who were treated with a decompressive craniectomy for severe ischemic stroke. Methods. We retrospectively investigated the patient records of 48 patients (26 men, mean age 48 years) suffering from ischemic strokes who underwent craniectomy since 1993. We registrated the preoperative neurological status, the diagnostic data as well as the operative procedure. The outcome was assessed using the Barthel Index, the Glasgow outcome score and a questionnaire to assess the quality of life according to Blau consisting of eleven items at follow-up. Findings. The mortality rate was 26%, age correlated to mortality (44.5 versus 60.3 years GOS 1, mean, p<0.0006). Craniectomy without dura patch correlated to mortality (58% versus 14% GOS 1 with dura patch, p<0.005). The quality of life index was 6 points mean. The quality of life index did neither differ significantly between patients with left or right sided lesions nor in patients with and without aphasia. 83% of the surviving patients and/or dependents would agree to surgery in the future. Conclusion. Despite the fact that some patients remain in a poor neurological condition, quality of life after decompressive surgery for ischemic stroke seems to be acceptable to the patients.     

Role of decompressive craniectomy in the management of severe head injury with refractory cerebral edema and intractable intracranial pressure. Our experience with 48 cases

BACKGROUND: The effects of decompressive craniectomy in the treatment of severe head injury remain unclear. Only very few randomized studies relating to this topic exist in the literature, including a very small number of patients with no class I evidence. METHODS: We rretrospectively reviewed a series of 221 patients operated on for a head injury during a 25-month period. Of these, 48 patients underwent a decompressive craniectomy. All data available on patients' Glasgow Coma Scale score, pupil size and reaction, and intracranial pressure were collected and analyzed. The patients' outcome was evaluated by the Glasgow Outcome Scale (GOS) and the results compared with the data available in the Traumatic Coma Data Bank. Furthermore, the results were analyzed in respect of the time of surgical intervention (early or late), age, and the preoperative Glasgow Coma Score. RESULTS: Decompressive craniectomy reduced the midline shift in all patients with monolateral diffuse brain edema and contusions having a median value of 7 mm; in the remaining, it ameliorated the basal cisterns effacement. At a mean follow-up of 14 months, 6 (12.5%) patients died, 7 (15%) were discharged home with a GOS of 5, 18 (40%) showed a favorable outcome after rehabilitation with a GOS of 4 and 5, 6 (12.5%) had a severe disability (GOS 3), 9 (20%) were in a vegetative state (GOS 2), and 2 were lost to follow-up. The younger age, earlier surgery, and higher preoperative Glasgow Coma Scale score were related to better outcome (P < .001, P < .05, and P < .034, respectively). CONCLUSION: Our results seem to support the idea that decompressive craniectomy coupled with neurointensive care may be an effective way to reduce intractable raised intracranial pressure, and probably to improve patients outcome. However, it should be obvious that our results and those available in the literature can not be considered conclusive.     

Outcome following decompressive craniectomy for malignant swelling due to severe head injury

OBJECT: The aim of this study was to assess outcome following decompressive craniectomy for malignant brain swelling due to closed traumatic brain injury (TBI). METHODS: During a 48-month period (March 2000-March 2004), 50 of 967 consecutive patients with closed TBI experienced diffuse brain swelling and underwent decompressive craniectomy, without removal of clots or contusion, to control intracranial pressure (ICP) or to reverse dangerous brain shifts. Diffuse injury was demonstrated in 44 patients, an evacuated mass lesion in four in whom decompressive craniectomy had been performed as a separate procedure, and a nonevacuated mass lesion in two. Decompressive craniectomy was performed urgently in 10 patients before ICP monitoring; in 40 patients the procedure was performed after ICP had become unresponsive to conventional medical management as outlined in the American Association of Neurological Surgeons guidelines. Survivors were followed up for at least 3 months posttreatment to determine their Glasgow Outcome Scale (GOS) score. Decompressive craniectomy lowered ICP to less than 20 mm Hg in 85% of patients. In the 40 patients who had undergone ICP monitoring before decompression, ICP decreased from a mean of 23.9 to 14.4 mm Hg (p < 0.001). Fourteen of 50 patients died, and 16 either remained in a vegetative state (seven patients) or were severely disabled (nine patients). Twenty patients had a good outcome (GOS Score 4-5). Among 30-day survivors, good outcome occurred in 17, 67, and 67% of patients with postresuscitation Glasgow Coma Scale scores of 3 to 5, 6 to 8, and 9 to 15, respectively (p < 0.05). Outcome was unaffected by abnormal pupillary response to light, timing of decompressive craniectomy, brain shift as demonstrated on computerized tomography scanning, and patient age, possibly because of the small number of patients in each of the subsets. Complications included hydrocephalus (five patients), hemorrhagic swelling ipsilateral to the craniectomy site (eight patients), and subdural hygroma (25 patients). CONCLUSIONS. Decompressive craniectomy was associated with a better-than-expected functional outcome in patients with medically uncontrollable ICP and/or brain herniation, compared with outcomes in other control cohorts reported on in the literature.     

Long-term complications of decompressive craniectomy for head injury

There is currently much interest in the use of decompressive craniectomy for intracranial hypertension. Though technically straightforward, the procedure is not without significant complications. A retrospective analysis was undertaken of 164 patients who had had a decompressive craniectomy for severe head injury in the years 2004 to 2009 at the two major hospitals in Western Australia. Eighty-six patients had a bifrontal decompression and seventy-eight had a unilateral decompression. Two patients died due to post-operative care issues. Complications attributable to the decompressive surgery were: herniation of the cortex through the bone defect (42 patients, 25.6%), subdural effusion (81 patients, 49.4%), seizures (36 patients, 22%), hydrocephalus (23 patients, 14%), and syndrome of the trephined (2 patients, 1.2%). Complications attributable to the subsequent cranioplasty included: sudden death due to massive cerebral swelling in 3 patients (2.2%), infection requiring removal of the bone flap in 16 patients (11.6%), and bone flap resorption requiring augmentation in 10 patients (7.2%). After excluding simple complications such as subdural effusion and brain herniation through the skull defect and some patients who died as a direct consequence of traumatic brain or extracranial injury, 81 patients (55.5%) had at least one complication after decompressive craniectomy. The occurrence of at least one complication after decompressive craniectomy was significantly associated with an increased risk of prolonged stay in the hospital or rehabilitation facility (odds ratio 2.54, 95%confidence interval 1.22,5.24, p=0.013), after adjusting for predicted risk of unfavorable outcome.     

Is decompressive craniectomy for malignant middle cerebral artery territory infarction of any benefit for elderly patients?

BACKGROUND: Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients who present with malignant MCA territory infarction and to compare functional outcome in elderly patients with younger patients. METHODS: Patients with malignant MCA territory infarction treated in our hospital between January 1997 and March 2003 were included in this retrospective analysis. The National Institutes of Health Stroke Scale (NIHSS) assessed neurologic status at admission, operation, and at 1 week after surgery. All patients were followed up for assessment of functional outcome by the Barthel Index (BI) and the modified Rankin Scale (RS) at 3 to 9 months after infarction. RESULTS: Twenty-five patients underwent decompressive craniectomy. The mortality was 7.7% in younger patients (ages <60 years) compared with 33.3% in elderly patients (ages >/=60 years) (P > .05). All patients had significant decrease of NIHSS after surgery (P < .001). At follow-up, younger patients who received surgery had significantly better outcome with mean BI of 75.42 and Rankin score of 3.00; however, none of the elderly survivors had a BI score above 60 or a Rankin score below 4. CONCLUSION: Decompressive craniectomy in younger patients with malignant MCA territory infarction improves both survival rates and functional outcomes. Although survival rates were improved after surgery in elderly patients, functional outcome and level of independence were poor.     

Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction

OBJECT: Whether decompressive hemicraniectomy is an appropriate treatment for space-occupying middle cerebral artery (MCA) infarction is still a controversial issue. Previous studies are in agreement on a reduction of the mortality rate, but the reported functional outcome was highly variable. The authors sought to determine functional impairment, disability, and health-related quality of life (QOL) outcome in long-term survivors who had undergone this procedure, and tried to identify factors related to functional outcome. METHODS: The study included 36 consecutive patients (mean age 58.8 +/- 12.7 years, 20 men and 16 women) who underwent decompressive hemicraniectomy for treatment of malignant MCA infarction (29 on the right and seven on the left side; mean time to surgery 37.8 +/- 20 hours). The survival rate was determined at 6 months: 13.7 +/- 6.7 months after the stroke, a cross-sectional personal investigation of survivors was performed to assess functional impairment, disability, and health-related QOL. Survival rates were 78% at 6 months and 64% at the time of the follow-up investigation; one patient was lost to follow up. Sixteen of 22 long-term survivors lived at home. The median Barthel Index (BI) was 45 (25th and 75th percentile 19 and 71) and the BI correlated negatively with patient age (r = -0.58, p = 0.005). Three patients reached a BI of at least 90. Older age, more severe neurological deficit on admission, and longer duration of intensive care treatment and mechanical ventilation were significantly associated with worse disability (BI < 50). The health-related QOL was considerably impaired in the subscales of mobility, household management, and body care. CONCLUSIONS: Decompressive hemicraniectomy improves survival in patients with malignant MCA infarction when compared with earlier reports of conservative treatment alone. Functional outcome and QOL remain markedly impaired, especially among elderly patients and in those with a severe neurological deficit at admission.     

Cerebral oxygenation, vascular reactivity, and neurochemistry following decompressive craniectomy for severe traumatic brain injury

OBJECT: This study addresses the changes in brain oxygenation, cerebrovascular reactivity, and cerebral neurochemistry in patients following decompressive craniectomy for the control of elevated intracranial pressure (ICP) after severe traumatic brain injury (TBI). METHODS: Sixteen consecutive patients with isolated TBI and elevated ICP, who were refractory to maximal medical therapy, underwent decompressive craniectomy over a 1-year period. Thirteen patients were male and 3 were female. The mean age of the patients was 38 years and the median Glasgow Coma Scale score on admission was 5. RESULTS Six months following TBI, 11 patients had a poor outcome (Group 1, Glasgow Outcome Scale [GOS] Score 1-3), whereas the remaining 5 patients had a favorable outcome (Group 2, GOS Score 4 or 5). Decompressive craniectomy resulted in a significant reduction (p < 0.001) in the mean ICP and cerebrovascular pressure reactivity index to autoregulatory values (< 0.3) in both groups of patients. There was a significant improvement in brain tissue oxygenation (PbtO(2)) in Group 2 patients from 3 to 17 mm Hg and an 85% reduction in episodes of cerebral ischemia. In addition, the durations of abnormal PbtO(2) and biochemical indices were significantly reduced in Group 2 patients after decompressive craniectomy, but there was no improvement in the biochemical indices in Group 1 patients despite surgery. CONCLUSIONS: Decompressive craniectomy, when used appropriately in protocol-driven intensive care regimens for the treatment of recalcitrant elevated ICP, is associated with a return of abnormal metabolic parameters to normal values in patients with eventually favorable outcomes.     

Combined internal uncusectomy and decompressive craniectomy for the treatment of severe closed head injury: experience with 80 cases

OBJECTIVES: Transtentorial brain herniation is a major cause of morbidity and death following severe closed head injury. The purpose of this study was to evaluate the efficacy of selective uncoparahippocampectomy and tentorial splitting as an adjuvant method of treating otherwise uncontrollable elevated intracranial pressure (ICP) while attempting to prevent or minimize the devastating consequences caused by transtentorial herniation. METHODS: The authors retrospectively reviewed data from a series of 80 consecutive cases of severe closed head injury (Glasgow Coma Scale [GCS] score < 8) treated in their neurosurgical unit. All patients had elevated ICP and downward tentorial herniation, as documented with ICP monitoring, and clinical examination and computed tomography, respectively. Given the evidence of acute and ongoing neurological deterioration, all patients were treated with selective uncoparahippocampectomy and tentorial edge incision followed by wide decompressive craniectomy and duraplasty. RESULTS: All injuries were caused by blunt trauma with signs of acute and/or progressive increased ICP causing downward transtentorial herniation. Fifty-eight patients were male and 22 were female with a mean age of 35 years and a mean preoperative GCS score of 5. Based on the current American Association of Neurological Surgeons guidelines for head trauma, an intraparenchymal ICP device (Camino, Integra) was placed in all patients who had a GCS score < 8, and ICP was consistently > 20 cm H2O. Whenever possible, risks and benefits were explained to family members, and then surgery was performed within 3-16 hours (median 6 hours). At a mean follow-up of 30 months, the outcome was favorable (Glasgow Outcome Scale [GOS] score of 4 or 5) in 60 patients (75%) and unfavorable (GOS score of 3) in 8 (10%), whereas the remaining 12 patients (15%) died at some point during the postoperative course. There was no survivor patient in a vegetative state. A younger age had a significant effect on positive outcome (p < 0.0005), as did an earlier operation (p < 0.04). The preoperative neurological status as assessed using the GCS as well as pupillary reactivity had no significant effect on outcome (p = 0.054 and p > 0.05, respectively). CONCLUSIONS: A selective uncoparahippocampectomy with a tentorial edge incision and a wide decompressive craniectomy with duraplasty can be an effective adjuvant form of aggressive treatment to improve outcome in patients with severe closed head injury, especially in those who are younger if they are treated promptly.     

Decompressive craniectomy for severe intracranial hypertension due to cerebral infarction or meningoencephalitis

We describe the clinical course and outcome following decompressive craniectomy in six patients. Five patients suffered from severe intracranial hypertension due to middle cerebral artery infarction. In one patient the cause was bacterial meningoencephalitis. Acute clinical and neuroradiological signs of intracranial hypertension were seen in all cases. Following ineffective conventional brain edema therapy, decompressive craniectomy was undertaken. In five cases intracranial pressure was sufficiently lowered. One patient developed transtentorial herniation with subsequent brain death. Four patients with middle artery infarction showed moderate neurological disorders and one patient with bacterial meningoencephalitis recovered completely after treatment. Craniectomy in malignant middle artery infarction should be taken into consideration if conventional brain edema therapy does not sufficiently reduce critically raised intracranial pressure. Craniectomy provides development of brain herniation. This treatment may reduce high lethality rate and high frequency of severe neurological disorders.