Craniectomy Procedure Research Articles

Decompressive Craniectomy in Postpartum Cortical venous Thrombosis Masquerading as Postspinal Headache: What the Obstetrician should know - A Case Report

Introduction: Cerebral venous sinus thrombosis is commonly seen during pregnancy or in the postpartum period due to multiple physiological changes resulting in an altered state of homeostasis and a hypercoagulable state. Cortical vein thrombosis is a subgroup of cerebral venous thrombosis where there is an involvement of the superficial cerebral veins and may occur with or without coexisting sinus venous thrombosis. Early identification of the diagnosis is of utmost importance to reduce morbidity and mortality. Differentiation from postspinal headache may be difficult until the occurrence of neurological features and a high level of suspicion for this condition is required. Contrast magnetic resonance imaging venography or computed tomography venography can confirm the diagnosis. Methods: We report a case of postpartum cortical venous thrombosis with malignant cerebral sinus venous thrombosis (CSVT). Results: The patient was managed with a lifesaving decompressive craniectomy (DC) procedure and anticoagulants with a favorable response. Conclusion: Obstetricians should be aware of this medical complication of pregnancy and of its management. Medical treatment with anticoagulants is the mainstay of therapy. Patients with malignant CSVT presenting with rapid and severe neurological decline carry a high mortality, and early DC in this subgroup can be lifesaving. Contraceptive agents containing estrogens should not be administered in patients with a previous history of CSVT, and prophylactic low-molecular-weight heparin should be administered throughout a subsequent pregnancy and continued into the puerperium.

Craniotomies at an overseas military treatment facility: Maintaining readiness for the unit and the surgeon

IntroductionCraniotomy and craniectomy are common neurosurgical procedures with wide applications in both civilian and military practice. Skill maintenance for these procedures is required for military providers in the event they are called to support forward deployed service members suffering from combat and non-combat injuries. The presents investigation details the performance of such procedures at a small, overseas military treatment facility (MTF). Materials and methodsA retrospective review of craniotomy procedures performed at an overseas military treatment facility (MTF) over a 2-year period (2019–2021) was performed. Patient and procedural data were collected for all elective and emergent craniotomies including surgical indications, outcomes, complications, military rank, and impact on duty status and tour curtailment. ResultsA total of 11 patients underwent a craniotomy or craniectomy procedure with an average follow-up of 496.8 days (range 103–797). Seven of the 11 patients were able to undergo surgery, recovery, and convalesce without transfer to a larger hospital network or MTF. Of the 6 patients that were active duty (AD), one returned to full duty while three separated and two remain in partial duty status at latest follow-up. There were four complications in four patients with one death. ConclusionsIn this series, we demonstrate that cranial neurosurgical procedures can be performed safely and effectively while at an overseas MTF. There are potential benefits to the AD service members, their unit, and family as well as to the hospital treatment team and surgeon as this represents a clinical capability requisite to maintain trauma readiness for future conflicts.

14-Day Mortality Predictive Factors in Surgically Treated Supratentorial Spontaneous Intracerebral Hemorrhage: A Retrospective Analysis of 44 Patients

Background: Spontaneous intracerebral hemorrhage accounts for 10-15% of cerebrovascular events. Various modalities of patient management, both conservatively and surgical. Despite its deadly nature and extensive studies, there is no standard model for predictive factors in intracerebral hemorrhage-related mortality. Methods: A retrospective cohort analysis on patients with supratentorial spontaneous intracerebral hemorrhage who received surgical treatment for clot evacuation. Factors including age, sex, initial Glasgow Coma Scale score, the volume of the clot, existing intraventricular hemorrhage, existing subarachnoid hemorrhage, signs of cerebral herniation from head CT-Scan, duration of the surgery, and surgical technique were analyzed. Results: Data for 44 patients were included in this study. The mean age was 54.68 ±12.79 years old, with 64.6% of the sample being males. The mean GCS score of the sample is 9.3 ± 3.15. Subarachnoid hemorrhage was noticed in 34.1% of cases. Intraventricular hemorrhage extension was found in 27.3% of cases. Cerebral herniation on CT-scan was noticed in 50% of cases. Based on surgical characteristics, the mean surgical time is 194.84 ± 54.84 mins. Almost two-thirds of the cases performed craniectomy procedure 28 (63.6%). We found that subarachnoid hemorrhage (OR 5.77 [1.12 – 29.7]; p = 0.036) and cerebral herniation (OR 8.26 [1.91- 35.7]; p = 0.005) were considered as significant factors in predicting 14-day mortality after multivariate analysis. Conclusions: Subarachnoid hemorrhage and cerebral herniation are good predictors of 14-day mortality in patients with sICH who are surgically treated. Earlier and shorter duration of the surgery showed no correlation to the outcome.

Novel CT-based parameters assessing relative cross-sectional area to guide surgical management and predict clinical outcomes in patients with acute subdural hematoma.

Acute subdural hematoma (aSDH) is one of the most devastating entities secondary to traumatic brain injury (TBI). Even though radiological computed tomography (CT) findings, such as hematoma thickness (HT), midline shift (MLS), and MLS/HT ratio, have an important prognostic role, they suffer from important drawbacks. We hypothesized that relative cross-sectional area (rCSA) of specific brain regions would provide valuable information about brain compression and swelling, thus being a key determining factor governing the clinical course. We performed an 8-year retrospective analysis of patients with moderate to severe TBI with surgically evacuated, isolated, unilateral aSDH. We investigated the influence of aSDH rCSA and ipsilateral hemisphere rCSA along the supratentorial region on the subsequent operative technique employed for aSDH evacuation and patient's clinical outcomes (early death and Glasgow Outcome Scale [GOS] at discharge and after 1-year follow-up). Different conventional radiological variables were also assessed. The study included 39 patients. Lower HT, MLS, hematoma volume, and aSDH rCSA showed a significant association with decompressive craniectomy (DC) procedure. Conversely, higher ipsilateral hemisphere rCSA along the dorso-ventral axis and, specifically, ipsilateral hemisphere rCSA at the high convexity level were predictors for DC. CT segmentation analysis exhibited a modest relationship with early death, which was limited to the basal supratentorial subregion, but could not predict long-term outcome. rCSA is an objectifiable and reliable radiologic parameter available on admission CT that might provide valuable information to optimize surgical treatment.

Cranial defect and pneumocephalus are associated with significant postneurosurgical positional brain shift: evaluation using upright computed tomography

Only few studies have assessed brain shift caused by positional change. This study aimed to identify factors correlated with a large postneurosurgical positional brain shift (PBS). Sixty-seven patients who underwent neurosurgical procedures had upright computed tomography (CT) scan using settings similar to those of conventional supine CT. The presence of a clinically significant PBS, defined as a brain shift of ≥ 5 mm caused by positional change, was evaluated. The clinical and radiological findings were investigated to identify factors associated with a larger PBS. As a result, twenty-one patients had a clinically significant PBS. The univariate analysis showed that supratentorial lesion location, intra-axial lesion type, craniectomy procedure, and residual intracranial air were the predictors of PBS. Based on the multivariate analysis, craniectomy procedure (p < 0.001) and residual intracranial air volume (p = 0.004) were the predictors of PBS. In a sub-analysis of post-craniectomy patients, PBS was larger in patients with supratentorial craniectomy site and parenchymal brain injury. A large craniectomy area and long interval from craniectomy were correlated with the extent of PBS. In conclusion, patients who undergo craniectomy and those with residual intracranial air can present with a large PBS. In post-craniectomy patients, the predisposing factors of a large PBS are supratentorial craniectomy, presence of parenchymal injury, large skull defect area, and long interval from craniectomy. These findings can contribute to safe mobilization among postneurosurgical patients and the risk assessment of sinking skin flap syndrome.

Abstract P267: Healthcare Resource Utilization and Costs of US Patients With Possible Large Hemispheric Infarction: A Real-World Assessment of Burden Associated With Cerebral Edema

Introduction: Severe cerebral edema further compromises survival and functional outcomes in patients suffering from large hemispheric infarction (LHI). This study aims to compare the healthcare resource use and costs during the acute hospitalization and post-discharge, in a cohort of US patients with possible LHI with and without cerebral edema (CED). Methods: Using IBM MarketScan Commercial, Medicaid, and Medicare databases (2016Q1-2018Q4), a cohort of patients aged 18-85 were identified using ICD10 codes for hospitalization due to occlusion of the carotid or middle cerebral arteries, which are most closely associated with LHI. We classified patients with ICD10 codes G93.5 (compression of brain), G93.6 (cerebral edema), or a craniectomy procedure as having had CED. In addition to the inpatient resource use and outcomes, annualized frequency of resource utilization and costs during the follow-up period were reported in those who survived and continued to be enrolled in their health plan post-index hospitalization. Logistic regression was used to estimate the odds ratio of mortality, generalized linear models for mean in healthcare utilization and costs between those with and without CED, adjusting for age, sex, and comorbidity. Results: Of the 7,336 commercial, 1,946 Medicaid, and 5,015 Medicare patients with possible LHI, we found 7.8%, 6.9%, and 4.3% had CED, respectively. Those with CED had higher length of stay, mortality, and costs during the index hospitalization across the populations examined (Table). CED was also consistently associated with higher post-discharge resource utilization and costs in the commercially-insured population (Table). Conclusions: This real-world evidence from private and public health plans highlights the substantial clinical and economic burden during the index hospitalization and post-discharge in patients who develop cerebral edema after LHI.

SURG-41. BLOOD-BRAIN BARRIER DISRUPTION WITH HIGH-FREQUENCY ELECTROPORATION IN VIVO: A PRELIMINARY INVESTIGATION DEMONSTRATING THE EFFECTS OF VARIED PULSE WIDTHS AND INTRA-PHASE DELAYS

Abstract OBJECTIVE Treatment of CNS disorders suffer from the inability to deliver large therapeutic agents to the brain parenchyma due to protection from the blood-brain barrier (BBB). High-frequency electroporation (HFE) employs a series of high voltage pulsed electric fields to disrupt the BBB and/or ablate tumor tissue while sparring proteinaceous structures. Pulsing parameters pulse width and intra-phase delay can be modulated to reduce excitation of muscle and nervous tissues, though this is inherently accompanied by an increase in thresholds for ablation in non-CNS tissues. Here, we investigate the effects of pulse width and intra-phase delay on intracranial tissue for BBB disruption (BBBD) in an in vivo healthy rodent model. METHODS 18 male Fisher rats underwent craniectomy procedure and two blunt tipped monopolar electrodes were advanced into the brain for HFE therapy. 200 bursts of HFE were delivered at a voltage-to-distance ratio 600 V/cm. BBBD was verified with contrast enhanced T1W MRI (gadopentetate dimeglumine) and pathologically (Evans blue dye). RESULTS Gross pathological sections and contrast enhanced T1W scans demonstrated BBBD for 2-2-2 µs (n = 4, 36.6 ± 9.4 mm3, 36.7 ± 13.0 mm3), 2-5-2 µs (n = 4, 74.1 ± 7.7 mm3, 74.7 ± 9.8 mm3), 5-2-5 µs (n = 4, 53.9 ± 8.1 mm3, 59.2 ± 10.8 mm3), 5-5-5 µs (n = 4, 81.2 ± 7.9 mm3, 84.1 ± 8.7 mm3), and 10-1-10 µs (n = 2, 61.0 ± 2.8 mm3, 60.0 ± 4.2 mm3) HFE. Histologically, tissue damage was restricted to electrode insertion tracks. BBBD was induced with minimal muscle contractions and minimal cell death attributed to HFE. Numerical modeling indicated the threshold for HFE-mediated BBBD as low magnitude electric fields (&amp;lt; 201 V/cm). These data suggest HFE-mediated BBBD is only modestly affected by changes in pulse width and intra-phase delay.

Linear oblique craniectomy: A novel method of minimally invasive subdural grid insertion

Background: Many countries rely upon subdural grid electroencephalography in the planning of epilepsy surgeries. However, craniotomy for subdural grid implantation is known to result in a variety of complications and requires diligence from the surgical team. We describe a minimally invasive method of subdural grid insertion, termed the linear oblique craniectomy, designed to mitigate complications and increase ease of subdural grid insertion. Objective: To demonstrate feasibility of minimally invasive subdural grid insertion utilizing skull anatomy. Methods: Three fresh frozen and embalmed human cadavers underwent surface landmarking and craniectomy to introduce a 4 × 5 cm2 subdural grid over the Sylvian fissure. Anteroposterior lens-shaped craniectomy measured 5 cm in length with 1 cm maximal width. The dura mater was longitudinally incised, and subdural grids were introduced over the Sylvian fissure. Results: The total area of the craniectomy created by the linear oblique approach consists of only approximately 20% of the total area removed by the traditional approach to access the Sylvian fissure for mesial temporal epilepsy monitoring/preoperative planning. The locations of the grids were evaluated by MRI and computed tomography scans postoperatively to ensure accurate alignment with the Sylvian fissure. Conclusion: In this cadaveric study, we demonstrate the linear oblique craniectomy procedure that provides an alternative approach to subdural grid implantation with significantly decreased invasiveness. This surgical approach has the potential of reducing complication rates of subdural grid insertion for surface monitoring of the brain activity and/or neuromachine interface analysis and is associated with significant reduction of surgical time.

Abstract WP370: Inpatient Outcomes and Resource Utilization Among Patients With Large Hemispheric Infarction Who Developed Cerebral Edema: An Analysis of U.S. Real-World Data

Introduction: Patients with large hemispheric infarction (LHI) may suffer from life-threatening complications, including cerebral edema. Published data among these patients in real-world settings are limited. This study describes inpatient outcomes and resource utilization associated with cerebral edema among hospitalized patients with LHI. Methods: A retrospective cohort study was conducted using the MarketScan Hospital Drug Database (2015Q3-2017Q4). As infarct volume is not captured in the data, patients were included based on diagnosis codes for infarction of the middle cerebral artery or carotid artery, which are most closely associated with LHI. Within this group, cerebral edema was determined based on a diagnosis code of cerebral edema (ICD-10-CM G93.6) or herniation (G93.5), or a craniectomy procedure. Logistic regressions, comparing patients with edema vs. those without edema, were used to estimate the odds ratio of death, ICU admission, and tracheostomy/intubation during the hospital stay. Linear regression models were used to estimate the mean difference in length of hospital stay, length of ICU stay, and hospital charges. All models controlled for age, sex, and admission type. Results: A total of 11,772 patients were designated as likely LHI cases; 869 (7%) were identified with cerebral edema. Table 1 compares inpatient outcomes and resource utilization in patients with vs. without cerebral edema. Patients with cerebral edema had significantly higher odds of death, ICU admission and tracheostomy/intubation. They also had longer hospital stays, longer stays in the ICU, and higher hospital charges. Conclusion: This study provides evidence in a real-world setting, highlighting the substantial clinical and economic burden associated with cerebral edema among patients hospitalized with LHI. Given the unmet needs, management strategies and interventions focusing on reducing cerebral edema among patients with LHI are warranted.

Design and evaluation of a biosynthesized cellulose drug releasing duraplasty.

Decompressive craniectomy (DC) is a standard surgical procedure performed on stroke patients in which a portion of a skull is removed and a duraplasty membrane is applied onto the brain. While DC can significantly reduce the risk of death, it does not reverse the stroke damage. In this study, a novel biosynthesized cellulose (BC)-based drug releasing duraplasty was developed and studied. The BC duraplasty fabrication process allowed readily incorporation of growth factors (GFs) in a sterile manner and control of physical and mechanical properties of the resulting duraplasty. Our results showed that BC duraplasty containing the highest amount of dry cellulose presented swelling ratio of 496±27%, Young's modulus of 0.37±0.02MPa, ultimate tensile strength of 0.96±0.02MPa, while releasing GFs for over 10days. In addition, neural stem/progenitor cell (NSPC) cultures demonstrated that the GFs released from the BC duraplasty promoted NSPC proliferation and differentiation in vitro. Finally, animal studies revealed that the BC duraplasty did not cause any inflammatory reactions after the DC procedure in vivo. In summary, this newly developed GF loaded BC membrane demonstrates a promising potential as drug releasing duraplasty, not only for stroke treatments but also for traumatic brain injuries and spinal cord injuries.

Abstract WP21: Successful Reperfusion With Thrombectomy in Patients With Large Dwi Lesion is Associated With Reduced Occurrence of Malignant Stroke

Introduction: Malignant middle cerebral artery infarction (MMI) is a severe complication of ischaemic stroke (IS), with a mortality rate up to 80%. Diffusion-weighted imaging (DWI) lesion volume larger than 82 millilitres on cerebral MRI performed within the six first hours is known to be predictive of MMI. These patients, with “malignant profile”, were mostly excluded of endovascular therapy (EVT) randomised trials. The aim of our study was to evaluate whether successful reperfusion after EVT in patients presenting IS with large DWI lesion decreased occurrence of malignant stroke. Methods: We analysed data collected between 2014 and 2018, in a monocentric prospective IS patients registry treated with EVT. Patients were selected if they had a malignant profile and could be eligible to a craniectomy. Thus, selected patients were less than 65-years old, with a severe stroke defined by National Institutes of Health Stroke Scale (NIHSS) score &gt; 15 and with DWI lesion larger than 82ml. We compared patients with successful recanalization (defined by Thrombolysis in Cerebral Ischemia (TICI) 2b or 3) and poor recanalization (TICI 0, 1 or 2A). Primary end point was malignant stroke rate. Secondary end points were craniectomy, haemorrhagic complications, 90-days all-cause mortality rates and 90-days favourable outcome (defined by modified Rankin Scale 0-2). Results: From 2014 to 2018, 66 patients were selected. MMI occurred in 27 patients (42%), and 22 (33%) had effectively craniectomy. Successful recanalization was observed for 46 patients (69.7%). MMI occurrence was significantly lower in the latter patients compared to the poor recanalization group (14/44(31.8%) vs 13/20(65.0%); OR=0.25 (0.08-0.77), p = 0.015). Less craniectomies were performed in the successful recanalization group (12/46 (26.1%) vs 10/20 (50.0%); OR=0.35 (011-1.06), p=0.063).There was no significant difference in symptomatic intracranial haemorrhage rate; in 90-days favourable outcome and all causes mortality rate between the two groups. Conclusion: Successful recanalization performed in IS patients with large DWI lesion decreases the occurrence of malignant strokes and the need for craniectomy procedure. Further data with a larger sample or from randomized studies are needed.

Volume of Brain Herniation in Patients with Ischemic Stroke After Decompressive Craniectomy

Decompressive craniectomy procedures are performed in patients with malignant intracranial hypertension. A bone flap is removed to relieve pressure. Later, a second operation is performed to reconstruct the skull after brain swelling has resolved. This surgical treatment would be improved if it were possible to perform a single operation that decompressed the brain acutely and eliminated the need for a second operation. To design a device and procedure that achieve this objective, it is essential to understand how the brain swells after a craniectomy procedure. We identified 20 patients with ischemic stroke who underwent a decompressive hemicraniectomy operation. Skull defect morphology and postoperative brain swelling were measured using computed tomography scan data. Additional intracranial volume created by placing a hypothetical cranial plate implant offset from the skull surface by 5 mm was measured for each patient. The average craniectomy area and brain herniation volume was 9999 ± 1283 mm2 and 30.48 ± 23.56 mL, respectively. In all patients, the additional volume created by this hypothetical implant exceeded the volume of brain herniation observed. These findings show that a cranial plate with a 5-mm offset accommodates the brain swelling that occurs in this patient population.

Alteration of the Circadian Network after Traumatic Brain Injury (TBI)

RESULTS: Sixty patients (83 procedures) were included in the study. Fifty-seven patients (95.0%) underwent previous craniotomy, craniectomy, or other trans-galeal procedure. Of the total 60 patients, 35 patients received preoperative radiation. Sixteen patients received bevacizumab prior to their index case, while 12 received bevacizumab postoperatively. Ten patients (16.7%) required additional plastic surgical intervention for wound complications after their index plastic surgery procedure. Plastic surgery was consulted prophylactically in 34 patients (38 procedures). When plastic surgery was consulted prophylactically, 4 patients (11.8%) required further wound revision. None of the 14 patients who underwent prophylactic plastic surgery closure for previous scalp incision, preoperative bevacizumab, and radiation administration required re-intervention.

Importance of Early Cranioplasty in Reversing the "Syndrome of the Trephine/Motor Trephine Syndrome/Sinking Skin Flap Syndrome".

The "Motor Trephine Syndrome (MTS)" also known as the "Sunken brain and Scalp Flap Syndrome" or the "Sinking Skin Flap Syndrome (SSFS)" or the "Syndrome of the trephined" is an unusual syndrome in which neurological deterioration occurs following removal of a large skull bone flap. This syndrome is associated with sensorimotor deficit and neurological deterioration following decompressive craniectomy which is performed for various neurosurgical conditions involving cerebral swelling causing mass effect. The neurological deterioration can be exacerbated or precipitated by CSF diversion procedures like a Ventriculo-Peritoneal shunt. It was the objective of this study to observe if any improvement in the patient's condition, or if any beneficial effects in his sensorimotor deficit could be gained by performing an early cranioplasty as against after the usual delay of one to two years normally allowed for post-craniectomy cases. A 52 year old male suffered severe head injury in a road traffic accident and underwent a craniectomy and contusectomy of the left Fronto-Temporo-Parietal (FTP) region for treatment of Acute Subdural hematoma (SDH) as well as hemorrhagic and non-hemorrhagic contusions of the brain with severe mass effect. On recovery from this acute event he was bed bound, on tracheostomy, his GCS was E4VTrM4 with residual right sided hemiparesis. Three months later, he developed Hydrocephalus for which a Right Ventriculo-Peritoneal (V-P) shunt was performed. Following this procedure, severe depression of the skin/scalp flap occurred and the neurological recovery was not as expected. He was diagnosed as a case of "Syndrome of the trephined". An immediate Cranioplasty was performed, on the third month following the craniectomy procedure, in an attempt to resolve the rapidly deteriorating neurological status of the patient. In the case presented, following the early Cranioplasty which was performed within three months of the initial craniectomy, the patient's neurological condition and cognitive functions showed a remarkable, immediate and dramatic improvement. The early Cranioplastic repair led to a remarkable clinical recovery of the patient, with improvement in the cognitive behavior and motor deficit with a rapid reversal of the sensorimotor paresis, reflecting an improvement in brain perfusion. Patients with the classical "Motor trephine syndrome/ Sinking skin flap syndrome" following large craniectomy defects, may hugely benefit from an early cranioplasty procedure, with a reversal of features of this syndrome and early recovery of their neurological and cognitive functions. Hence, an early cranioplasty can serve as a therapeutic procedure, rather than merely a cosmetic one.

Cerebellar Liponeurocytoma Mimicking Cerebellopontine Angle Epidermoid Cyst: A Case Report

Cerebellar liponeurocytoma (CL) described under many different names, is a rare WHO grade I or II well differentiated neurocytic tumor of the cerebellum with focal lipomatous differentiation. Mainly reported in adulthood, it is fought to be a posterior fossa benign tumor. In this paper, we talk about a 64-year-old woman, following up for Parkinson’s disease presented in our department for 7 months’ history of headache and gait disturbance. MRI showed a right cerebellopontine angle (CPA) heterogeneous unlimited tumor mimicking an epidermoid cyst. She underwent a lateral suboccipital craniectomy procedure that permitted obtaining the whole gross total resection of this tumor. The histopathological diagnosis was a cerebellar liponeurocytoma. She was discharged from hospital the 8th day after surgery and was free of symptoms since 5 years.

Different sham procedures for rats in traumatic brain injury experiments induce corresponding increases in levels of trauma markers

BackgroundIn traumatic brain injury animal models, sham or naïve control groups are often used for the analysis of injured animals; however, the existence and/or significance of differences in the control groups has yet to be studied. In addition, recent controversies regarding the decompressive craniectomy trial in which decompressive craniectomies in patients with severe traumatic brain injury and refractory increased intracranial pressure remains unsettled. Although the report demonstrated that the procedure may result in less favorable long-term outcomes despite the decrease in intracranial pressure and shorter length of intensive care unit stay, the study has been criticized, and the debate is still inconclusive partly because of a lack of mechanistic explanation. We have recently discovered epithelial and endothelial tyrosine kinase (Etk) to exhibit upregulation after traumatic neural injury and will compare the effects of craniectomy procedure with those of other procedures inducing different levels of severity. Materials and methodsFour groups of rats receiving different procedures (controlled cortical impact, craniectomy, bicortical drilling, and unicortical drilling [UD]) were compared. Polymerase chain reaction, Western blot analysis, and immunoflorescence staining of Etk, S100, and glial fibrillary acidic protein levels were used to analyze the results and compare the different groups. ResultsEtk upregulation was statistically significant between craniectomy and UD groups. The level of change for glial fibrillary acidic protein and S100 was only significant when cortex was impacted. ConclusionsUD may be preferable as a sham control procedure over craniectomy or bicortical drilling. Increases in the expression of Etk in the craniectomy group suggest a possible mechanism by which unfavorable outcome occurs in patients receiving craniectomy procedures.

Complications of Decompressive Craniectomy

Persistent elevation of intracranial pressure (ICP), if untreated, may lead to brain ischemia or lack of brain oxygen and even brain death.1-6,10 When standard treatments for elevated ICP are exhausted without any signs of improvement, decompressive craniectomy can be an effective alternative solution.7,19 Decompressive craniectomies (DC) have been used as a method of controlling intracranial pressure in patients with cerebral edema secondary to cerebral ischemia, subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI), among others. 8-10 Several studies over the years have demonstrated the efficacy of this procedure.7-9,11,35,36 However, consensus is still lacking in the utility of DC as an effective first tier treatment for intractable intracranial pressure due to the rudimentary neurological outcome assessments, and the many complications associated with this procedure.11,12,59 There are a limited number of studies that have looked at complications secondary to the procedure itself.13-18 The majority of these studies only investigated the impact of this procedure in patients with traumatic brain injury. The purpose of this study is to investigate the rates of various complications associated with the decompressive craniectomy procedure in patients that did not suffer from traumatic brain injury, and to determine whether the same associations between preoperative parameters and development of complications can be made.

Complications of Decompressive Craniectomy

Persistent elevation of intracranial pressure (ICP), if untreated, may lead to brain ischemia or lack of brain oxygen and even brain death.1-6,10 When standard treatments for elevated ICP are exhausted without any signs of improvement, decompressive craniectomy can be an effective alternative solution.7,19 Decompressive craniectomies (DC) have been used as a method of controlling intracranial pressure in patients with cerebral edema secondary to cerebral ischemia, subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI), among others. 8-10 Several studies over the years have demonstrated the efficacy of this procedure.7-9,11,35,36 However, consensus is still lacking in the utility of DC as an effective first tier treatment for intractable intracranial pressure due to the rudimentary neurological outcome assessments, and the many complications associated with this procedure.11,12,59 There are a limited number of studies that have looked at complications secondary to the procedure itself.13-18 The majority of these studies only investigated the impact of this procedure in patients with traumatic brain injury. The purpose of this study is to investigate the rates of various complications associated with the decompressive craniectomy procedure in patients that did not suffer from traumatic brain injury, and to determine whether the same associations between preoperative parameters and development of complications can be made.

Unilateral decompressive craniectomy for children with severe brain injury. Report of seven cases and review of the relevant literature.

Severe head injuries in children (under 15 years of age) have many features that differentiate them from head injuries in adults. In such cases, non-surgical treatment cannot always prevent fatal herniation. We report on seven cases of children with severe head injury, presenting with decorticate posturing and treated by unilateral decompressive craniectomy. The aim of the unilateral decompressive craniectomy was to decompress the midbrain and the brainstem. Post-operatively, all patients showed good recovery within 5 weeks (Glasgow Coma Scale score 15). The alternative treatment modalities are discussed critically in an attempt to determine the value of the unilateral decompressive craniectomy procedure and to define the clinical parameters that might identify those children most likely to benefit from this technique. the unilateral decompressive craniectomy has an advantage over non-surgical treatment of children with severe brain injury and should be considered in their management.

Surgical management of sagittal synostosis: a comparative analysis of strip craniectomy and calvarial vault remodeling.

Although surgical treatment of sagittal synostosis has become normative, the procedure of choice is still debated. This retrospective analysis, during a 10-year period (1986-1995) at Children's Hospital Los Angeles, compares the more conservative strip craniectomy (SC) procedure with a more extensive occipital reduction-biparietal widening calvarial vault remodeling (CVR) technique for the management of sagittal synostosis. SC was performed in 72 patients (61%) and CVR in 46 (39%). Patients undergoing CVR were older (mean 5.3 vs. 3.0 months, p < 0.01), the procedure time longer (mean 126 min vs. 72 min, p < 0.01), intraoperative blood loss greater (mean 243 vs. 54 cm3, p < 0.01), and the frequency of intraoperative blood transfusion increased (100 vs. 38%, p < 0.01; mean volume 357 vs. 51 cm3, p < 0.01) compared to patients undergoing SC. No significant intraoperative complications occurred in either group. The total time of hospitalization was similar (mean 4.4 vs. 3.8 days, p = 0.02). No neurological, hematological, or transfusion-related complications or deaths were encountered in either group. Cosmetic outcomes were significantly better in the CVR group with 79% rated as excellent compared to 41% in the SC group (p < 0.01). Fifty-nine percent of the SC patients manifested bony defects at last follow-up visit. Two SC patients required reoperation for poor cosmetic outcomes; CVR was successfully employed in both cases. These findings demonstrate that CVR is superior to SC in providing immediate and lasting correction of calvarial deformities secondary to sagittal synostosis. The optimal age at time of surgery is <6 months; however, CVR can be utilized throughout infancy, while SC becomes progressively less effective after 6 months of age. No significant complications were observed in either group, despite the increased operative manipulation and greater incidence of blood transfusion in the CVR patients.