Brainstem hemorrhage following decompressive craniectomy

Decompressive craniectomy (DC) is used for the management of refractory raised intracranial pressure, but the impact of DC on surgical outcome is still controversial. We report a 21-year-old man admitted to our hospital after a road traffic accident. The brain CT scan revealed a left hemispheric acute subdural hematoma. After DC, he developed a brainstem hemorrhage. Recovery was, however, good.     

Orthostatic mesodiencephalic dysfunction after decompressive craniectomy

An extreme syndrome of the trephined after decompressive craniectomy is reported here. The most extensive clinical syndrome observed was established over 4 weeks and consisted of bradypsychia, dysartria, and limb rigidity with equine varus feet predominating on the right. The syndrome was aggravated when the patient was sitting with the sequential appearance over minutes of a typical parkinsonian levodopa-resistant tremor starting on the right side, extending to all four limbs, followed by diplopia resulting from a left abducens nerve palsy followed by a left-sided mydriasis. All signs recovered within 1-2 h after horizontalisation. It was correlated with an orthostatic progressive sinking of the skin flap, MRI and CT scan mesodiencephalic distortion without evidence of parenchymal lesion. Brain stem auditory evoked potential wave III latency increases were observed on the right side on verticalisation of the patient. EEG exploration excluded any epileptic activity. Symptoms were fully recovered within 2 days after cranioplasty was performed. The cranioplasty had to be removed twice due to infection. Bradypsychia, speech fluency, limb rigidity and tremor reappeared within a week after removal of the prosthesis. While waiting for sterilisation of the operative site, the symptoms were successfully prevented by a custom-made transparent suction-cup helmet before completion of cranioplasty.     

Tumefactive demyelinating disease treated with decompressive craniectomy

Background:  Tumefactive demyelinating disease (TDD) is a rare primary demyelinating disease with diagnostic and therapeutic challenges.
Methods and results:  We report a 50-year old woman with TDD successfully treated with decompressive craniectomy and corticosteroids. The patient presented with seizures, subacute progressive hemispheric syndrome, and a tumourlike abnormality on MRI. Demyelinating disease was initially considered unlikely. Due to a rapidly evolving herniation syndrome hemicraniectomy was performed. Outcome was favourable with only very mild neurological deficits 6 weeks later.
Conclusion:  TDD should be considered as a differential diagnosis in tumour-like presentations, and appears to have distinctive neuroimaging features. In the advent of treatement failure from high dose corticosteroids and plasmapheresis and development of severe mass effect, decompressive hemicraniectomy is an important treatment option.     

Bifrontal decompressive craniectomy for acute subdural empyema

INTRODUCTION: Subdural empyema is an uncommon but serious complication of sinusitis. Despite the use of advanced imaging facilities, modern antibiotic therapy and aggressive neurosurgical protocols, this condition still carries significant morbidity and mortality. CASE REPORT: We report an unusual case of sinusitis-associated acute subdural empyema in a 13-year-old patient, presenting in a catastrophic manner with acutely raised intracranial pressure. Emergency bifrontal decompressive craniectomy was necessary both to reduce the intracranial pressure and to drain the subdural empyema. RESULTS: The full range of intracranial complications subsequently occurred, including brain abscesses, recurrent subdural empyema and ventriculitis. Despite this, the patient's outcome was good, with minimal intellectual deficits. CONCLUSION: In cases of severe intracranial infection, we therefore advocate an aggressive surgical approach coupled with appropriate antibiotics to ensure a good outcome.     

Complications of decompressive craniectomy for head injury

There is much interest in the use of decompressive craniectomy for intracranial hypertension. Whilst technically straightforward, the procedure is not without significant complications. A retrospective analysis was undertaken of 41 patients who had had a decompressive craniectomy for severe head injury in the years 2006 and 2007 at the two major hospitals in Western Australia, Sir Charles Gairdner Hospital and Royal Perth Hospital. Complications attributable to the decompressive surgery were: herniation of the cortex through the bone defect, 18 patients (51%); subdural effusion, 22 patients (62%); seizures, five patients (14%) and hydrocephalus, four patients (11%). Complications attributable to the subsequent cranioplasty were: infection, four patients (11%) and bone flap resorption, six patients (17%). Syndrome of the trephined occurred in three (7%) of those patients whose bone flap had significantly resorbed. Two deaths (5.5%) occurred as a direct complication of the craniectomy or cranioplasty procedure. I attempted to define what may be regarded as a complication of the decompressive procedure rather than what may be a consequence of the primary pathological process of traumatic brain injury.     

Hydrocephalus after decompressive craniectomy for hemispheric cerebral infarction

The aim of the present study was to investigate the risk factors for hydrocephalus after decompressive craniectomy (DC) for hemispheric cerebral infarction. This study selected 28 patients who underwent DC for malignant hemispheric cerebral infarction. The patients’ clinical and radiologic findings were retrospectively reviewed. Fourteen of the 28 patients were male and 14 were female, with an age range from 34 to 80 years (mean, 63.5 years). Eighteen patients (64.3%) underwent DC within 48 hours of stroke onset. The superior limit of DC was <25 mm from the midline in 16 patients (57.1%). Twenty-two patients underwent cranioplasty, and the interval from DC to cranioplasty was within 60 days in 14 patients. Pre- and post-cranioplasty hydrocephalus were observed in 13 and nine patients, respectively. Two patients required shunt procedures for post-cranioplasty hydrocephalus. Patients with DC whose superior limit was <25 mm from the midline had a significantly increased risk of developing not only pre-cranioplasty but also post-cranioplasty hydrocephalus (p = 0.008, p = 0.010, respectively). In addition, the presence of pre-cranioplasty hydrocephalus was significantly associated with the development of post-cranioplasty hydrocephalus (p = 0.001). The presence of pre- and post-cranioplasty hydrocephalus was significantly associated with a poor outcome (p = 0.031, p = 0.049, respectively). DC with a superior limit <25 mm from the midline should be avoided to prevent the development of hydrocephalus.     

大骨瓣减压对重型颅脑创伤治疗作用的临床研究

目的 探讨大骨瓣减压术(DC)对重度颅脑损伤(STBI)的治疗价值.方法 纳入132例STBI患者,分两组采用大骨瓣减压术或常规骨瓣开颅,每组各66人.随访6个月,首要结局评价指标为临床疗效,次要结局评价指标为术后并发症的发生.结果 6个月时,大骨瓣减压术组死亡10例(15.2％)、长期昏迷2例(3.0％)、重等残疾13例(19.7％)、中等残疾6例(9.1％)、良好35例(53.0％);常规骨瓣开颅组分别为14例(21.2％)、4例(6.1％)、20例(30.3％)、18例(27.3％)、10例(15.2％).大骨瓣减压术组疗效好于常规骨瓣开颅组(,=37.998,P=0.000).6个月内,大骨瓣减压术组发生急性脑膨出7例(10.6％)、迟发性血肿5例(7.6％)、外伤癫痫6例(9.1％)、颅内感染3例(4.5％)、切口脑脊液漏3例(4.5％),总共并发症24例(36.4％);常规骨瓣开颅组分别为20例(30.3％)、5例(7.6％)、7例(10.6％)、2例(3.0％)、2例(3.0％)和36例(54.5％).大骨瓣减压术组术后并发症少于常规骨瓣开颅组(x2=4.400,P=0.036).经多因素凋整后,大骨瓣减压术疗效良好的机会是常规骨瓣开颅的2.173倍(p=0.011).结论 大骨瓣减压术对重度颅脑损伤的治疗效果优于常规骨瓣开颅,预后好、并发症少.     

Unilateral decompressive craniectomy in left transverse and sigmoid sinus thrombosis

Cerebral venous and dural sinus thrombosis is a rare cause of stroke. We explore the controversial issue of anticoagulation therapy and indication for decompressive craniectomy in association with severe sinus thrombosis. The 62-year-old female patient was admitted to hospital, because of first generalized seizure. A computed tomographic (CT) scan of the brain revealed a left occipital hemorrhage. Digital subtraction angiogram showing thrombosis of the left transverse and sigmoid sinus. An intravenously administered regimen of heparin was begun, because of a protein S deficiency. On the 6th day the patients level of consciousness deteriorated, necessitating intubation, hyperventilation, and mannitol. Repeat CT scan revealed increasing edema with midline shift and obliteration of the basal cisterns, although the hemorrhagic lesion was unchanged. The patient developed signs of diencephalic dysfunction. A large left temporoparietooccipital craniectomy was performed and the dura was opened. The multiloculated intraparenchymatous hemorrhage portion of the brain was not removed. In addition, the patient was treated postoperatively with heparin therapy for three months, than a regimen of phenprocoumon was begun. Twelve months later the hemianopsia had not improved and she had an incomplete Wernicke's dysphasia. When, despite adequate anticoagulation therapy and intensive care, neurological deterioration occurs in sigmoideus and/or transversus dural sinus thrombosis with unilateral edema, a decompressive craniectomy should be considered especially in young patients.     

Neurological recovery after decompressive craniectomy for massive ischemic stroke

Introduction: Decompressive craniectomy has demonstrated efficacy in reducing morbidity and mortality in critically ill patients with massive hemispheric cerebral infarction. However, little is known about the patterns of functional recovery that exist in patients after decompressive craniectomy, and controversy still exists as to whether craniotomy and infarct resection (“strokectomy”) are appropriate alternatives to decompression alone. We therefore used functional magnetic resonance imaging (f-MRI) to assess the extent and location of functional recovery in patients after decompressive craniectomy for massive ischemic stroke. Methods: f-MRI was obtained in three patients with massive nondominant cerebral infarction who had undergone decompressive craniectomy for severe cerebral edema 13 to 26 months previously. Brain activation was triggered by hand-gripping or foot-movement tasks. Imaging results were combined with periodic clinical follow-up to determine the extent of neurological recovery. Results: Activation of the contralateral hemisphere was seen in the sensorimotor cortex, premotor, and supplementary motor areas. Lesser activation patterns were seen in equivalent regions of the infarcted hemisphere. Peri-infarct activation foci were seen in two of the three patients, but no activation occurred within the area of infarction as defined by the initial stroke seen on diffusion-weighted MRI. All three patients demonstrated some corresponding neurological improvement. Conclusion: After massive hemispheric cerebral infarction requiring decompressive craniectomy, patients may experience functional recovery as a result of activation in both the infarcted and contralateral hemispheres. The evidence of functional recovery in peri-infarct regions suggests that decompression alone may be preferable to strokectomy where the risk of damage to adjacent nonischemic brain may be greater.     

Hydrocephalus after decompressive craniectomy for malignant hemispheric cerebral infarction

Purpose: Several studies have investigated the incidence and risk factors of hydrocephalus after decompressive craniectomy (DC) for malignant hemispheric cerebral infarction. However, the results are controversial. Therefore, the following is a retrospective cohort study to determine the incidence and risk factors of hydrocephalus after DC for malignant hemispheric cerebral infarction. Materials and methods: From January 2004 to June 2014, patients at two medical centres in south-west China, who underwent DC for malignant hemispheric cerebral infarction, were included. The patients’ clinical and radiologic findings were retrospectively reviewed. A chi-square test, Mann–Whitney U-test and logistic regression model were used to identify the risk factors. Results: A total of 128 patients were included in the study. The incidence of ventriculomegaly and shunt-dependent hydrocephalus were 42.2% (54/128) and 14.8% (19/128), respectively. Lower preoperative Glasgow Coma Scale (GCS) score and presence of subarachnoid haemorrhage (SAH) were factors significantly associated with the development of post-operative hydrocephalus after DC. Conclusions: Cerebral infarction patients receiving DC have a moderate tendency to suffer from post-operative hydrocephalus. A poor GCS score and the presence of SAH were significantly associated with the development of hydrocephalus after DC.     

单纯颅骨修补对去骨瓣后脑积水的影响

目的 探讨单纯颅骨修补对去骨瓣后脑积水患者的影响。方法 选取2017年9月—2020年9月南华大学附属第二医院神经外科收治的112例颅骨修补患者行双向队列研究,根据术前脑积水的情况分为观察组（有积水）40例和对照组（无积水）72例,比较两组术前状态、术后并发症情况、脑室变化、Barthel生活量表指数、简明精神状态量表（MMSE）评分等。结果 观察组年龄、缺损面积及动脉瘤患者人数均高于对照组（P＜0.05）,两组并发症发生率并无差异（P＞0.05）;术后随访结果显示,观察组术后脑室缩小人数比率多于对照组,但缩小程度不足以使其脱离脑积水的范畴（P＜0.05）;两组Barthel评分及MMSE评分均有提高（P＜0.05）,评分改善率无差异（P＞0.05）。相关性分析发现,脑积水患者术后评分改善与脑室变化无相关性（P＞0.05）。结论 对去骨瓣后脑积水患者实施单纯颅骨修补是安全的,尽管脑室扩大无法变回正常,但多数脑积水患者的神经功能及生活质量可得到改善。     

Treatment of cerebellar infarction by decompressive suboccipital craniectomy.

BACKGROUND AND PURPOSE: We present an anecdotal series of 11 patients without past history of stroke with progressive neurological deterioration while on medical therapy for large cerebellar infarctions. Clinical signs of brain stem compression developed in these patients. Computerized tomography of the head confirmed mass effect from brain edema. It was the clinical judgment of the neurologists and neurosurgeons that each of these 11 patients would expire without surgical intervention. METHODS: All 11 patients (seven men, four women; mean age, 54 years) were treated with suboccipital craniectomy for decompression and temporary ventriculostomy for cerebrospinal fluid pressure monitoring and drainage. RESULTS: Seven patients demonstrated neurological improvement on the first postoperative day. Two patients returned to their previous jobs 3 months after surgery. The Barthel Index indicated that six individuals were functioning with minimal assistance within a follow-up period of 16-60 months. The remaining three were functionally dependent. No mortality was noted in this series. CONCLUSIONS: These results suggest that decompressive suboccipital craniectomy may be an effective, lifesaving procedure for malignant cerebellar edema after a large infarction.     

Cost‐effectiveness of decompressive craniectomy in traumatic brain injuries

Background and purpose: Decompressive craniectomy (DC) is used regularly in traumatic brain injury (TBI). There are, however, no cost‐effectiveness studies of the procedure. Methods: We evaluated the outcomes and treatment costs of all decompressive craniectomies performed between the 2000 and 2006 in a single institution to lower intractable intracranial pressure after TBI. The health‐related quality of life was evaluated on the Euroqol (EQ‐5D) questionnaire and on the visual‐analogue scale (VAS), and cost of a quality‐adjusted life year (QALY) was calculated. Results: In this study of 54 patients, the median follow‐up time was 5.6 years. Overall mortality rate was 41%. Of the 22 non‐survivors, 73% died within 30 days. For 32 survivors, the median EQ‐5D index value was 0.85, which is equal to the normal population. The median VAS value was 73, whilst normal population’s value is 80. Of the survivors, 81% (26/32) were able to live at home and 31% (10/32) returned to work. The cost of neurosurgical treatment for one QALY was 2400€. Estimation for all medical costs, including rehabilitation and anticipated future costs, resulted cost of a QALY 17 900 €. Conclusion Mortality after severe TBI leading to DC was high, but amongst the survivors, the health‐related quality of life was equal to normal population. Most survivors were able to live at home and were almost as satisfied with their health as in general people are. Cost of neurosurgical treatment was low, and also including all evaluated costs, cost of a QALY gained was acceptable.     

Complications in cranioplasty after decompressive craniectomy: timing of the intervention

Journal of Neurology - To prevent complications following decompressive craniectomy (DC), such as sinking skin flap syndrome, studies suggested early cranioplasty (CP). However, several groups...