Craniectomy Group Research Articles

Morphological and surgical results in sagittal synostosis: early craniectomy versus later cranioplasty.

Morphological correction is one of the main aims of surgery for sagittal synostosis (SSO). Different surgical techniques have been developed; however, few studies have compared the different surgical protocols. The morphological outcome is poorly documented, because a consensual evaluation tool is lacking. We performed a prospective study of children operated for SSO in our institution. Children were operated whenever possible at 4 months for craniectomy; by default, children underwent cranioplasty at or after 9 months. The morphological outcome of all children was evaluated using traditional craniometry with head circumference (HC) and the cephalic index (CI), and with the Rotterdam scaphocephaly morphology score (RSMS), a total of semi-quantitative assessments of morphological hallmarks. Craniectomy was significantly associated with a shorter operation time and hospital stay, and a better impact on HC and CI measurements, compared with cranioplasty. The RSMS was markedly improved after surgery in both groups; however, we found no significant difference in improvement between the two groups. Although the transfusion rate and the prevalence of developmental delay were lower in the craniectomy group, and reoperations for calvarial lacunae or complex craniosynostosis occurred only this group, these differences were not significant. Our results support early surgery with craniectomy whenever possible; however, cranioplasty at a later age is a very acceptable by-default indication. In addition to classical craniometry, morphological evaluation using the RSMS or a similar quantitative scale appears highly desirable for future studies.

Management of sagittal synostosis in the Synostosis Research Group: baseline data and early outcomes.

Sagittal synostosis is the most common form of isolated craniosynostosis. Although some centers have reported extensive experience with this condition, most reports have focused on a single center. In 2017, the Synostosis Research Group (SynRG), a multicenter collaborative network, was formed to study craniosynostosis. Here, the authors report their early experience with treating sagittal synostosis in the network. The goals were to describe practice patterns, identify variations, and generate hypotheses for future research. All patients with a clinical diagnosis of isolated sagittal synostosis who presented to a SynRG center between March 1, 2017, and October 31, 2019, were included. Follow-up information through October 31, 2020, was included. Data extracted from the prospectively maintained SynRG registry included baseline parameters, surgical adjuncts and techniques, complications prior to discharge, and indications for reoperation. Data analysis was descriptive, using frequencies for categorical variables and means and medians for continuous variables. Two hundred five patients had treatment for sagittal synostosis at 5 different sites. One hundred twenty-six patients were treated with strip craniectomy and 79 patients with total cranial vault remodeling. The most common strip craniectomy was wide craniectomy with parietal wedge osteotomies (44%), and the most common cranial vault remodeling procedure was total vault remodeling without forehead remodeling (63%). Preoperative mean cephalic indices (CIs) were similar between treatment groups: 0.69 for strip craniectomy and 0.68 for cranial vault remodeling. Thirteen percent of patients had other health problems. In the cranial vault cohort, 81% of patients who received tranexamic acid required a transfusion compared with 94% of patients who did not receive tranexamic acid. The rates of complication were low in all treatment groups. Five patients (2%) had an unintended reoperation. The mean change in CI was 0.09 for strip craniectomy and 0.06 for cranial vault remodeling; wide craniectomy resulted in a greater change in CI in the strip craniectomy group. The baseline severity of scaphocephaly was similar across procedures and sites. Treatment methods varied, but cranial vault remodeling and strip craniectomy both resulted in satisfactory postoperative CIs. Use of tranexamic acid may reduce the need for transfusion in cranial vault cases. The wide craniectomy technique for strip craniectomy seemed to be associated with change in CI. Both findings seem amenable to testing in a randomized controlled trial.

Does the Size of Unilateral Decompressive Craniectomy Impact Clinical Outcomes in Patients with Intracranial Mass Effect after Severe Traumatic Brain Injury?

ObjectiveDecompressive craniectomy (DC) is one of the treatment modalities in severe traumatic brain injury (TBI), however, there was a lack of evidence for optimal craniectomy size. The authors aimed to investigate optimal DC size and analyze clinical outcome according to craniectomy size.MethodsWe retrospectively reviewed the medical data of 87 patients with a space occupying lesion following TBI who underwent unilateral DC. Craniectomy size was measured by anterior-posterior (AP) diameter and surface estimate (SE). Mortality, clinical outcome, and complications were collected and analyzed according to craniectomy size.ResultsNineteen patients (21.8%) died and 35 patients (40.2%) had a favorable outcome at last follow-up (a mean duration, 30.3±39.4 months; range, 0.2–132.6 months). Receiver operating curve analyses identified AP diameter more than 12.5 cm (area under the curve [AUC]=0.740; p=0.002) and SE more than 98.0 cm2 (AUC=0.752; p=0.001) as cut-off values for survival, and AP diameter more than 13.4 cm (AUC=0.650; p=0.018) and SE more than 107.3 cm2 (AUC=0.685; p=0.003) for favorable outcome. Large craniectomy resulted in a significantly lower mortality rate and a higher rate of favorable outcome than small craniectomy (p=0.005 and p=0.014, respectively). However, procedure related bleeding occurred more frequently in the large craniectomy group (p=0.044).ConclusionUnilateral DC size is associated with clinical outcome of patients with a space occupying lesion following severe TBI. Large craniectomy is needed for survival and favorable outcome.

Early versus late decompressive craniectomy in traumatic brain injury: A retrospective comparative case study

Objectives Decompressive craniectomy is a last-tier therapy in the treatment of raised intracranial pressure after traumatic brain injury. We report the association of demographic, radiographic, and injury characteristics with outcome parameters in early (<24 h) and late (≥24 h) decompressive craniectomy following traumatic brain injury. Methods We retrospectively identified 204 patients (158 (early decompressive craniectomy) and 46 (late decompressive craniectomy)), with a median age of 34 years (range 2–78 years) between 2015 and 2018. The primary endpoint was Glasgow Outcome Scale Extended (GOSE) at 60 days, while secondary endpoints included Glasgow Coma Score (GCS) at discharge, mortality at 30 days, and length of hospital stay. Regression analysis was used to assess the independent predictive variables of functional outcome. Results With a clinical follow-up of 60 days, the good functional outcome (GOSE = 5–8) was 73.5% versus 74.1% (p = 0.75) in early and late decompressive craniectomy, respectively. GCS ≥ 9 at discharge was 82.2% versus 91.3% (p = 0.21), mortality at 30 days was 10.8% versus 8.7% (p = 0.39), and length of stay in the hospital was 21 days versus 28 days (p = 0.20), respectively, in early and late decompressive craniectomy groups. Univariate analysis identified that GCS at admission (0.07 (0.32–0.18; < 0.05)) and indication for decompressive craniectomy (3.7 (1.3–11.01; 0.01)) are significantly associated with good functional outcome. Multivariate regression analysis revealed that GCS at admission (<9/≥9) (0.07 (0.03–0.16; <0.05)) and indication for decompressive craniectomy (extradural alone/ other hematoma) (1.75 (1.09–3.25; 0.02)) were significant independent predictors of good functional outcome irrespective of the timing of surgery. Conclusions Our results corroborate that the timing of surgery does not affect the outcome parameters. Furthermore, GCS ≥ 9 and/or extra dural hematoma are associated with relatively good clinical outcome after decompressive craniectomy.

Patient Outcomes at Twelve Months after Early Decompressive Craniectomy for Diffuse Traumatic Brain Injury in the Randomized DECRA Clinical Trial.

Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension.In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients.We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model.At 12 months, the odds ratio (OR) for worse functional outcomes in the craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes.Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased.Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive craniectomy did not improve outcomes and increased vegetative survivors.

Role of surgical modality and timing of surgery as clinical outcome predictors following acute subdural hematoma evacuation.

Background & Objective:A Craniotomy (CO) or decompressive craniectomy (DC) are the two main surgical procedures employed for evacuation of acute traumatic subdural hematoma (ASDH). However, the optimal surgical procedure remains controversial. The beneficial effect of early surgical evacuation of acute subdural hematoma in improving outcome also remains unclear. Our objective was to study the role of these two parameters in determining the outcome in patients undergoing surgical evacuation of acute traumatic subdural hematoma.Methods:A retrospective analysis of 58 patients presenting with acute traumatic subdural hematoma and with presenting Glasgow Coma Scale (GCS) ≤ 8 that had been operated in Lahore General Hospital between June 2014 and July 2015 was performed. The demographic data, preoperative GCS, type of surgical procedure performed and timing of surgery were analysed.Results:Forty (69%) patients underwent CO, and eighteen (31%) patients underwent DC. The CO and DC groups showed no difference in the demographic data and preoperative GCS. Six patients survived in the craniotomy group, while none survived in the decompressive craniectomy group (p=0.083). The relationship of timing of surgery with survival in the craniotomy group was found not to be clinically significant (p=0.87).Conclusion:In this study craniotomy was associated with a better outcome as compared to decompressive craniectomy, however, the difference did not reach statistical significance. Early surgery was also found not to be associated with an improved outcome.

In-hospital mortality and length of hospital stay with craniotomy versus craniectomy for acute subdural hemorrhage: a multicenter, propensity score-matched analysis.

The optimal surgical treatment for acute subdural hemorrhage (ASDH) remains controversial. The purpose of this study was to compare outcomes in patients who underwent craniotomy with those in patients who underwent decompressive craniectomy for the treatment of ASDH. Using the Japan Trauma Data Bank, a nationwide trauma registry, the authors identified patients aged ≥ 18 years with ASDH who underwent surgical evacuation after blunt head trauma between 2004 and 2015. Logistic regression analysis was used to estimate a propensity score to predict decompressive craniectomy use. They then used propensity score-matched analysis to compare patients who underwent craniotomy with those who underwent decompressive craniectomy. To identify the potential benefits and disadvantages of decompressive craniectomy among different subgroups, they estimated the interactions between treatment and the subgroups using logistic regression analysis. Of 236,698 patients who were registered in the database, 1788 were eligible for propensity score-matched analysis. The final analysis included 514 patients who underwent craniotomy and 514 patients who underwent decompressive craniectomy. The in-hospital mortality did not differ significantly between the groups (41.6% for the craniotomy group vs 39.1% for the decompressive craniectomy group; absolute difference -2.5%; 95% CI -8.5% to 3.5%). The length of hospital stay was significantly longer in patients who underwent decompressive craniectomy (median 23 days [IQR 4-52 days] vs 30 days [IQR 7-60 days], p = 0.005). Subgroup analyses demonstrated qualitative interactions between decompressive craniectomy and the patient subgroups, suggesting that patients who were more severely injured (Glasgow Coma Scale score < 9 and probability of survival < 0.64) and those involved in high-energy injuries may be good candidates for decompressive craniectomy. The results of this study showed that overall, decompressive craniectomy did not appear to be superior to craniotomy in ASDH treatment in terms of in-hospital mortality. In contrast, there were significant differences in the effectiveness of decompressive craniectomy between the subgroups. Thus, future studies should prioritize the identification of a subset of patients who will possibly benefit from the performance of each of the procedures.

Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score-based analysis.

Traumatic intracerebral hemorrhage (TICH) represents approximately 13%-48% of the lesions after a traumatic brain injury (TBI), and hemorrhagic progression (HP) occurs in 38%-63% of cases. In previous studies, decompressive craniectomy (DC) has been characterized as a risk factor in the HP of TICH; however, few studies have focused exclusively on this relationship. The object of the present study was to analyze the relationship between DC and the growth of TICH and to reveal any correlation with the size of the craniectomy, degree of cerebral parenchymal herniation (CPH), or volumetric expansion of the TICH. The authors retrospectively analyzed the records of 497 adult patients who had been consecutively admitted after suffering a severe or moderate closed TBI. An inclusion criterion was presentation with one or more TICHs on the initial or control CT. Demographic, clinical, radiological, and treatment variables were assessed for associations. Two hundred three patients presenting with 401 individual TICHs met the selection criteria. TICH growth was observed in 281 cases (70.1%). Eighty-two cases (20.4%) underwent craniectomy without TICH evacuation. In the craniectomy group, HP was observed in 71 cases (86.6%); in the noncraniectomy group (319 cases), HP occurred in 210 cases (65.8%). The difference in the incidence of HP between the two groups was statistically significant (OR 3.41, p < 0.01). The mean area of the craniectomy was 104.94 ± 27.5 cm2, and the mean CPH distance through the craniectomy was 17.85 ± 11.1 mm. The mean increase in the TICH volume was greater in the groups with a craniectomy area > 115 cm2 and CPH > 25 mm (16.12 and 14.47 cm3, respectively, p = 0.01 and 0.02). After calculating the propensity score (PS), the authors followed three statistical methods-matching, stratification, and inverse probability treatment weighting (IPTW)-thereby obtaining an adequate balance of the covariates. A statistically significant relationship was found between HP and craniectomy (OR 2.77, p = 0.004). This correlation was confirmed with the three methodologies based on the PS with odds greater than 2. DC is a risk factor for the growth of TICH, and there is also an association between the size of the DC and the magnitude of the volume increase in the TICH.

Dural Sandwich Technique for Hemicraniectomy and Benefits During Cranioplasty

Hemicraniectomy is a commonly performed neurosurgical procedure used in the setting of medically refractory malignant intracranial hypertension. Complications from cranioplasty after hemicraniectomy can be significant, including infection and wound issues. Difficulty with scar tissue during exposure for cranioplasty can be challenging and can lead to prolonged surgical time and increased bleeding. We describe a surgical technique, termed the "dural sandwich," that could provide a significant benefit during cranioplasty as compared with traditional single-layered dural closure. A retrospective analysis was conducted that included 14 patients who underwent a hemicraniectomy procedure over a 4-year period. Seven patients were identified who received a cranioplasty after dural sandwich technique during craniectomy. They were compared with a similar patient group of 7 patients who received a cranioplasty after conventional hemicraniectomy with single-layered dural closure. Surgical time, estimated blood loss, and complication rates were compared between the 2 groups. Analysis of variance measures were performed to assess for statistically significant differences in blood loss and operative time between the dural sandwich and control groups. Statistical significance was defined as P < 0.05. The mean estimated blood loss was 82.1 mL in the dural sandwich craniectomy group versus 150 mL in the conventional hemicraniectomy group (P < 0.05). The mean estimated surgical time was 91.7 minutes in the dural sandwich craniectomy group versus 127.5 minutes in the conventional craniectomy group (P < 0.05). There was no evidence of neurologic deterioration, cerebral spinal fluid leak, or postoperative hematoma requiring evacuation in either group. In the conventional craniectomy group, a single report of a wound infection was noted that was treated conservatively with antibiotics. By layering bovine pericardium above and below the dura during initial hemicraniectomy, an artificial plane is created that improves ease of exposure during cranioplasty. This technique could reduce surgical time and blood loss during subsequent cranioplasty, and potentially reduce recovery time and postoperative complications.

Craniectomy Effects on Resting State Functional Connectivity and Cognitive Performance in Immature Rats.

Experimental models have been proven to be valuable tools to understand downstream cellular mechanisms of Traumatic Brain Injury (TBI). The models allow for reduction of confounding variables and tighter control of varying parameters. It has been recently reported that craniectomy induces pro-inflammatory responses, which therefore needs to be properly addressed given the fact that craniectomy is often considered a control procedure for experimental TBI models. The current study aims to determine whether a craniectomy induces alterations in Resting State Network (RSN) in a developmental rodent model. Functional Magnetic Resonance Imaging (fMRI) data-driven RSN show clusters of peak differences (left caudate putamen, somatosensory cortex, amygdala and piriform cortex) between craniectomy and control group, four days post-craniectomy. In addition, the Novel Object Recognition (NOR) task revealed impaired working memory in the craniectomy group. This evidence supports craniectomy-induced neurological changes which need to be carefully addressed, considering the frequent use of craniectomy as a control procedure for experimental models of TBI.

Decompressive Craniectomy in Spontaneous Intracerebral Hemorrhage: ACase-Control Study.

Decompressive craniectomy is performed to relieve intracranial pressure as an emergency procedure. There is no large study to systematically evaluate the benefit of decompressive craniectomy versus best medical therapy. This study evaluates the survival and long-term functional outcomes of decompressive craniectomy for spontaneous intracranial hemorrhage. A total of 54 eligible patients with spontaneous supratentorial hemorrhage (median age, 55 years; interquartile range, 47-64 years) who underwent decompressive craniectomy were retrospectively matched to 72patients managed with best medical treatment (median age, 58 years; interquartile range, 32-74 years). Glasgow Outcome Scale (GOS) scores were dichotomized into favorable and unfavorable outcomes. Survival and functional outcomes were analyzed at discharge, 3, 6, and 12months. Survival in the craniectomy group was significantly higher compared with the medical treatment group at 30 days, 6, and 12 months (76%, 70%, and 70% vs. 60%, 57%, and 52% respectively; all P ≤ 0.05). There was no difference in functional outcomes at discharge, 3, 6, or 12 months after hemorrhage (all P > 0.05). Decompressive craniectomy was associated with longer hospital stay (median of 30 days vs. 7 days in the control group; P<0.001). Hospital adverse events were more frequent in the craniectomy group than in the control group (76% vs. 33%; P < 0.001), the commonest adverse events being pneumonia and urinary tract infections. We showed that decompressive craniectomy significantly improved survival compared with medical treatment with lasting benefits. This improvement came at a cost of increased length of hospital stay and related adverse events. There was no improvement in functional outcome.

Primary decompressive craniectomy is associated with worse neurological outcome in patients with traumatic brain injury requiring acute surgery.

Background:The role of decompressive craniectomy in treating raised intracranial pressure (ICP) after traumatic brain injuries (TBI) is controversial. The aim of this study was to assess the differences in prognosis of patients initially treated by decompressive craniectomy, craniotomy, or conservatively.Methods:We conducted a single-center retrospective study on adult blunt TBI patients admitted to a neurosurgical intensive care unit during 2009–2012. Patients were divided into three groups based on their initial treatment – decompressive craniectomy, craniotomy, and conservative. Primary outcome was 6-month Glasgow Outcome Scale (GOS) dichotomized to favorable outcome (independent) and unfavorable outcome (dependent). The association between initial treatment and outcome was assessed using a logistic regression model adjusting for case-mix using known predictors of outcome.Results:Of the 822 included patients, 58 patients were in the craniectomy group, 401 patients in the craniotomy group, and 363 patients in the conservatively treated group. Overall, 6-month unfavorable outcome was 48%. After adjusting for case-mix, patients in the decompressive craniectomy group had a statistical significantly higher risk for poor neurological outcome compared to patients in the conservative group (OR 3.06, 95% CI 1.45–6.42) and craniotomy group (OR 3.61, 95% CI 1.74–7.51).Conclusion:In conclusion, patients requiring primary decompressive craniectomy had a higher risk for poor neurological outcome compared to patients undergoing craniotomy or were conservatively treated. It is plausible that the poor prognosis is related to the TBI severity itself rather than the intervention. Further prospective randomized trials are required to establish the role of decompressive craniectomy in the treatment of patients with TBI.

Mechanism of death after early decompressive craniectomy in traumatic brain injury

Background Decompressive craniectomy in devastating traumatic brain injury is controversial. The impact of decompressive craniectomy on mechanism of death is unclear in the literature to date. Our goal was to determine the mechanism of death between those receiving early decompressive craniectomy and those managed medically. Methods We performed an institutional retrospective review, from June 2003 to June 2013, of adult patients with devastating blunt traumatic brain injury undergoing early decompressive craniectomy who subsequently died. We compared this group to a retrospectively matched group based on: age, pre-hospital KPS, Marshall diffuse computed tomography grades, Injury Severity Scores, and admission laboratory values. Results Forty patients were analyzed; 20 with decompressive craniectomy and 20 without. The two groups were similar based on admission demographics, with the only statistically significant difference being platelet levels. Upon analysis, through both univariate and multivariate regression analysis, the mechanism of death was significantly different (p = 0.003; OR: 0.07 (0.01–0.41) and p = 0.04; OR: 0.08 (0.01–0.87)) with the decompressive craniectomy and non-decompressive craniectomy groups displaying neurological death rates of 10.0% versus 60.0%, respectively, with all other patients in both groups dying secondary to circulatory arrest after withdrawal of life-sustaining therapy. Time to death was significantly longer in the decompressive craniectomy group (2.83 vs. 9.21 days, respectively) (p = 0.01; OR: 0.65 (0.46–0.91). Conclusions Progression to neurological death appears to be more common in those devastating blunt traumatic brain injury patients treated medically compared to those undergoing early decompressive craniectomy. Given the implications of end-of-life care and societal implications, the mechanism of death determination and organ donation should be reported as relevant outcomes in devastating traumatic brain injury studies.

Posterior Fossa Craniectomy with Endovascular Therapy of Giant Fusiform Basilar Artery Aneurysms: A New Approach to Consider?

The prognosis of unruptured giant basilar artery (BA) aneurysms is very poor. No treatment has shown efficacy in survival. This pilot case-control study examines the overall survival (OS) benefit of combined surgical and endovascular management of giant BA aneurysms. Combined treatment including posterior fossa craniectomy followed by endovascular treatment was performed in 3 patients with giant BA aneurysms. OS of the 3 patients was compared with a control group of 6 patients (ratio 1:2) treated with the endovascular procedure only. The mean survival time was 32.6 months in the craniectomy group (SD 9.01, 95% confidence interval [14.9, 50.3]) and 3.5 months in the control group (SD= 2.08, 95% confidence interval [0.001, 7.6]; Mantel-Cox test P < 0.04). At mean follow-up of 36.5 months (SD 10.2), 2 of 3 patients had a favorable outcome with a Glasgow Outcome Scale score of 5. Univariate analysis determined that women had a statistically higher OS than men (33.7 months vs. 3.058 months for men; log-rank test P= 0.011). A similar outcome was obtained in the presence of a circulating posterior communicating artery (P= 0.03) and in the presence of an endovascular right vertebral artery occlusion (P= 0.022). Our study suggests that preventive posterior fossa craniectomy increases significantly OS of patients with giant BA aneurysms.

Reversibility of Murine Motor Deficits Following Hemi-Craniectomy and Cranioplasty.

Hemi-craniectomy is a common surgical procedure which allows the brain to swell and herniate and is often utilized to treat traumatic brain injury. When left untreated the scalp skin typically sinks on the side of the craniectomy creating a phenotype termed "sinking skin flap syndrome." In addition, these same patients often develop long-term neurocognitive deficits termed "syndrome of the trephined" as a result of their craniectomy which reverse when the cranial skull is replaced. The authors hypothesize that a mouse animal model can be developed demonstrating long-term neurologic deficits attributed to hemi-craniectomy skull defects similar to humans with syndrome of the trephined. Thirty C57 mice were randomized among 3 groups: Group 1 = control group (sham surgery), Group 2 = hemi-craniectomy only, and Group 3 = hemi-craniectomy with immediate cranioplasty. Motor deficits were studied using a beam walk test. Statistical comparison of differences among the 3 groups was performed. Beam walk test results demonstrated the craniectomy group had a statistically higher contralateral footfault slip/step ratio when compared with the control group (P <0.05). Comparison of the control group and the cranioplasty group demonstrated contralateral footfault slip/step ratio that was statistically different for 7 days postoperative but no statistical differences thereafter. Comparison of the craniectomy group and the cranioplasty group demonstrated statistically significant differences for 14 days; however, motor deficits were not statistically different than baseline thereafter. No ipsilateral footfault deficits were detected in this study. Motor deficits that are attributed to hemi-craniectomy bone defects alone are demonstrated in a mouse animal model. These motor deficits resemble some symptoms associated with human syndrome of the trephined.

Revised CT angiography venous score with consideration of infratentorial circulation value for diagnosing brain death.

BackgroundComputed tomography angiography (CTA) is largely performed in European countries as an ancillary test for diagnosing brain death. However, CTA suffers from a lack of sensitivity, especially in patients who have previously undergone decompressive craniectomy. The aim of this study was to assess the performance of a revised four-point venous CTA score, including non-opacification of the infratentorial venous circulation, for diagnosing brain death.MethodsA preliminary study of 43 control patients with normal CTAs confirmed that the infratentorial superior petrosal vein (SPV) was consistently visible. Therefore, 76 patients (including ten with decompressive craniectomy) who were investigated with 83 CTAs to confirm clinical brain death were consecutively enrolled between July 2011 and July 2013 at a university centre. The image analysis consisted of recording non-opacification of the cortical segment of the middle cerebral artery and internal cerebral vein (ICV), which were used as the reference CTA score, as well as non-opacification of the SPV. The diagnostic performance of the revised four-point venous CTA score based on the non-opacification of both the ICV and SPV was assessed and compared with that of the reference CTA score.ResultsThe revised four-point venous CTA score showed a sensitivity of 95 % for confirming clinical brain death versus a sensitivity of 88 % with the reference CTA score. Non-opacification of the SPV was observed in 95 % of the patients. In the decompressive craniectomy group, the revised four-point CTA score showed a sensitivity of 100 % compared with a sensitivity of 80 % using the reference CTA score.ConclusionCompared with the reference CTA score, the revised four-point venous CTA score based on ICV and SPV non-opacification showed superior diagnostic performance for confirming brain death, including for patients with decompressive craniectomy.

377 Craniectomy Versus Craniotomy in Traumatic Brain Injury

Abstract Surgery for patients with traumatic brain injury (TBI) remains controversial. Studies suggest that craniectomy (CE) may be superior to craniotomy (CO) by reducing intracranial pressure and limiting postoperative brain swelling. Few studies report comprehensive long-term functional and quality-of-life outcomes. All patients with TBI who underwent CE or CO were extracted from the TBI Model Systems database from 2000 to 2012. A 1:1 propensity matching with replacement technique was used to match baseline characteristics including age, Glasgow Coma Score, Marshall CT score, TBI subtype, and intracranial hypertension across groups. The matched sample was analyzed for outcomes during hospitalization, acute rehabilitation, and up to 2 years of follow-up. We identified 1470 patients in both CE and CO groups. Baseline characteristics were well-matched between groups (standardized mean difference

Effect of Decompressive Craniectomy on Perihematomal Edema in Patients with Intracerebral Hemorrhage

BackgroundPerihematomal edema contributes to secondary brain injury in the course of intracerebral hemorrhage. The effect of decompressive surgery on perihematomal edema after intracerebral hemorrhage is unknown. This study analyzed the course of PHE in patients who were or were not treated with decompressive craniectomy.MethodsMore than 100 computed tomography images from our published cohort of 25 patients were evaluated retrospectively at two university hospitals in Switzerland. Computed tomography scans covered the time from admission until day 100. Eleven patients were treated by decompressive craniectomy and 14 were treated conservatively. Absolute edema and hematoma volumes were assessed using 3-dimensional volumetric measurements. Relative edema volumes were calculated based on maximal hematoma volume.ResultsAbsolute perihematomal edema increased from 42.9 ml to 125.6 ml (192.8%) after 21 days in the decompressive craniectomy group, versus 50.4 ml to 67.2 ml (33.3%) in the control group (Δ at day 21 = 58.4 ml, p = 0.031). Peak edema developed on days 25 and 35 in patients with decompressive craniectomy and controls respectively, and it took about 60 days for the edema to decline to baseline in both groups. Eight patients (73%) in the decompressive craniectomy group and 6 patients (43%) in the control group had a good outcome (modified Rankin Scale score 0 to 4) at 6 months (P = 0.23).ConclusionsDecompressive craniectomy is associated with a significant increase in perihematomal edema compared to patients who have been treated conservatively. Perihematomal edema itself lasts about 60 days if it is not treated, but decompressive craniectomy ameliorates the mass effect exerted by the intracerebral hemorrhage plus the perihematomal edema, as reflected by the reduced midline shift.

Prospective randomized evaluation of therapeutic decompressive craniectomy in severe traumatic brain injury with mass lesions (PRECIS): study protocol for a controlled trial.

BackgroundFor cases of severe traumatic brain injury, during primary operation, neurosurgeons usually face a dilemma of whether or not to remove the bone flap after mass lesion evacuation. Decompressive craniectomy, which involves expansion of fixed cranial cavity, is used to treat intra-operative brain swelling and post-operative malignant intracranial hypertension. However, due to indefinite indication, the decision to perform this procedure heavily relies on personal experiences. In addition, decompressive craniectomy is associated with various complications, and the procedure lacks strong evidence of better outcomes. In the present study, we designed a prospective, randomized, controlled trial to clarify the effect of decompressive craniectomy in severe traumatic brain injury patients with mass lesions.MethodsPRECIS is a prospective, randomized, assessor-blind, single center clinical trial. In this trial, 336 patients with traumatic mass lesions will be randomly allocated to a therapeutic decompressive craniectomy group or a prophylactic decompressive craniectomy group. In the therapeutic decompressive craniectomy group, the bone flap will be removed or replaced depending on the emergence of brain swelling. In the prophylactic decompressive craniectomy group, the bone flap will be removed after mass lesion evacuation. A stepwise management of intracranial pressure will be provided according to the Brain Trauma Foundation guidelines. Salvage decompressive craniectomy will be performed for craniotomy patients once there is evidence of imaging deterioration and post-operative malignant intracranial hypertension. Participants will be assessed at 1, 6 and 12 months after randomization. The primary endpoint is favorable outcome according to the Extended Glasgow Outcome Score (5–8) at 12 months. The secondary endpoints include quality of life measured by EQ-5D, mortality, complications, intracranial pressure and cerebral perfusion pressure control and incidence of salvage craniectomy in craniotomy patients at each investigation time point.DiscussionThis study will provide evidence to optimize primary decompressive craniectomy application and assess outcomes and risks for mass lesions in severe traumatic brain injury.Trial registrationISRCTN20139421

Surgery for Acute Subdural Hematoma: Replace or Remove the Bone Flap?

In surgery for acute subdural hematoma (ASDH), the bone flap can be fixed onto the skull, left riding to provide partial skull decompression, or removed. This study assessed whether removing the bone flap improved outcome. We conducted an observational study on consecutive patients who were operated for ASDH in our hospital from July 2011 to June 2014. We retrospectively collected data on demographics, injury severity, and predicted and observed outcomes at 6 months. The cohort was divided into 2 groups based on whether the bone flap was replaced (fixed and riding flap craniotomy) or removed (decompressive craniectomy). The differences in functional status, postoperative control of intracranial hypertension, and number of cranial reoperations were analyzed. A subgroup analysis compared decompressive craniectomy with riding flap craniotomy alone. Data were obtained for 99 patients; 69 had decompressive craniectomy, 17 had riding flap craniotomy, and 13 had fixed flap craniotomy. The decompressive craniectomy group had statistically worse injuries, more predicted poor outcomes (69% vs. 57%, P= 0.013), more observed poor outcomes (59% vs. 37%, P= 0.037), equivalent control of intracranial hypertension, and a similar number of reoperations compared with the craniotomy groups. Subgroup analysis between decompressive craniectomy and riding flap craniotomy showed no significant difference in baseline characteristics and outcomes. Our study concluded that removing the bone flap after ASDH evacuation was not associated with a better outcome. We recommend replacing the bone flap if brain conditions allow. Further research is required to evaluate the role of skull decompression in surgery for ASDH.