Intracranial Haemorrhage After Decompressive Craniectomies for Trauma: Role of the Skull Clamp

Abstract

Background: High Intracranial Pressure (ICP) is the most frequent cause of death and disability after severe Traumatic Brain Injury (TBI); in Europe, 33% of patients with TBI require neurosurgical intervention. Decompressive Craniectomy (DC) represents the extreme surgical treatment; although it is regarded as a relatively simple surgical procedure, it is often accompanied by many complications, including Extradural Hematoma (EDH) associated with an overlying fracture on the contralateral side. It presents an incidence of 5-12%, but Singh et al., analysing 2108 DC performed without the skull clump, estimate it to be about 0.48%. Any authors have indicated the relationship between EDH after DC for trauma in patients showing skull fractures and the use of this Head Immobilisation Device (HID). Materials and methods: We have retrospectively analysed all patients who underwent frontotemporoparietal DC and bifrontal DC after TBI at Venice Angel Hospital during a 5-year and six-month period (January 2017-June, 2022). All patients showed skull bone fractures at CT brain scan, associated with clinical and neuroradiological signs of increasing ICP. For each patient, we analysed: age and sex, neurological status: GCS at the moment of trauma and before surgery, pupillary size and form before and after surgery; neuroimaging evolution; the timing and DC. DORO© Mayfield skull clump was used in all cases. Results: Our surgical cohort counts 20 patients with M/F 3:2 and an average age of 47±17. 16 patients underwent urgent surgery (primary DC), and 4 were operated on after an overage of 50 hours of observation (secondary DC): 90% of patients experienced frontotemporoparietal DC and 10% bifrontal DC. Postoperative CT brain scan showed enlargement of brain contusion in 4 patients (20%); EDH in 4 patients: 2 in the side of skull fracture contralateral at DC, 1 contralateral at DC and skull fracture, 1 occipital in the side of fracture homolateral at DC; SDH in 2 cases, both homolateral at DC. For 3 patients, surgical treatment of EDH was necessary following DC. Conclusion: Our patients showed a higher probability of developing remote-site EDH; other typical complications presented the same or slightly higher frequency of occurrence. Considering the high risk-benefit ratio of skull bone application, we suggest adopting safer HID, such as surgical adhesive tape or a horseshoe headrest.