Early Decompressive Craniectomy Research Articles

Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy.

Numerous studies have indicated that early decompressive craniectomy (DC) for patients with major infarction can be life-saving and enhance neurological outcomes. However, most of these studies were conducted by neurologists before the advent of intra-arterial thrombectomy (IA-Tx). This study aims to determine whether neurological status significantly impacts the final clinical outcome of patients who underwent DC following IA-Tx in major infarction. This analysis included 67 patients with major anterior circulation major infarction who underwent DC after IA-Tx, with or without intravenous tissue plasminogen activator. We retrospectively reviewed the medical records, radiological findings, and compared the neurological outcomes based on the "surgical time window" and neurological status at the time of surgery. For patients treated with DC following IA-Tx, a Glasgow coma scale (GCS) score of 7 was the lowest score correlated with a favorable outcome (p=0.013). Favorable outcomes were significantly associated with successful recanalization after IA-Tx (p=0.001) and perfusion/diffusion (P/D)-mismatch evident on magnetic resonance imaging performed immediately prior to IA-Tx (p=0.007). However, the surgical time window (within 36 hours, p=0.389; within 48 hours, p=0.283) did not correlate with neurological outcomes. To date, early DC surgery after major infarction is crucial for patient outcomes. However, this study suggests that the indication for DC following IA-Tx should include neurological status (GCS ≤7), as some patients treated with early DC without considering the neurological status may undergo unnecessary surgery. Recanalization of the occluded vessel and P/D-mismatch are important for long-term neurological outcomes.

Impact of timing of decompressive craniectomy on outcomes in pediatric traumatic brain injury

Background: Decompressive craniectomy (DC) can be utilized in the management of severe traumatic brain injury (TBI). It remains unclear if timing of DC affects pediatric patient outcomes. Further, the literature is limited in the risk assessment and prevention of complications that can occur post DC. Methods: This is a retrospective review over a 10-year period across two medical centers of patients ages 1 month–18 years who underwent DC for TBI. Patients were stratified as acute (<24 h) and subacute (>24 h) based on timing to DC. Primary outcomes were Glasgow outcome scale (GOS) at discharge and 6-month follow-up as well as complication rates. Results: A total of 47 patients fit the inclusion criteria: 26 (55.3%) were male with a mean age of 7.87 ± 5.87 years. Overall, mortality was 31.9% (n = 15). When evaluating timing to DC, 36 (76.6%) patients were acute, and 11 (23.4%) were subacute. Acute DC patients presented with a lower Glasgow coma scale (5.02 ± 2.97) compared to subacute (8.45 ± 4.91) (P = 0.030). Timing of DC was not associated with GOS at discharge (P = 0.938), 3-month follow-up (P = 0.225), 6-month follow-up (P = 0.074), or complication rate (P = 0.505). The rate of posttraumatic hydrocephalus following DC for both groups was 6.4% (n = 3). Conclusion: Although patients selected for the early DC had more severe injuries at presentation, there was no difference in outcomes. The optimal timing of DC requires a multifactorial approach considered on a case-by-case basis.

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.

Early versus late decompressive craniectomy in large middle cerebral arterial infarct- A stitch in time saves nine

Introduction: The etiology of malignant MCA infarctions is mostly due to thrombosis or embolic occlusion of either the internal carotid artery or the proximal MCA. The cornerstone of ischemic stroke diagnosis remains the history and neurological examination. A prospective study to compare outcome of early verses late decompression craniotomy was done at a tertiary care hospital in India. Materials and methods: A prospective observational study in the neurosurgical department of a tertiary care hospital of India, for a period of 3 years from 2018-2021. A total of 30 patients (15 each for early and late decompressive craniectomy respectively) were included in study after fulfilling inclusion criteria. The patients were followed up for next 6 months with neuro examination and score making done after every 1 month, 3 months and 6 months of-decompressive craniotomy. To find the significance between early and late group of patients we have used 2 independent sample t-test for age. For MRS and Barthal index at 1st month, 3rd month and 6th month, Hospital stay we have used Mann-Whitney U test (Non-parametric test) because the data type is ordinal or not following normal Distribution/ skewed. All statistical test performed at 5% level of significance so the p-value < 0.05 considered as significant. Results: The majority of patients were male in both the groups – early group 9 (60%) and late group 12 (80%). The mean age group for early and late groups was 44.07 and 42.87 years respectively. The comparison of MRS score in early and late group was not statistically significant at 1st month of follow up, however it showed significant difference at 2nd and 6th month respectively. MRS score with respect to affected side, in both the early and late group showed statistically significant difference at 6 months of follow up respectively. The Barthel index with respect to affected side showed significant difference in early group whereas in the late group significant difference was seen at 6th month of follow up only. The outcome of patients was not affected by side of involvement in both groups early as well as late. The mean hospital stay in early group was 14.8 days in comparison to late group where it was 42.47 days. Conclusion: The results of the present study indicate that early surgical intervention for decompression craniectomy in cases of MCA infarct have better outcome than late intervention with shorter hospital stay better functional outcome at discharge and 6 months post discharge.

BILATERAL DECOMPRESSIVE CRANIECTOMY IN A PATIENT WITH HEAD INJURIES DUE TO GUN PROJECTILE: A CASE REPORT

A 38-year-old male patient with multiple skull injuries caused by a small-caliber firearm projectile whose entry hole was the right eye after being attacked when leaving his home. Consequently, he presented head trauma with multifragmented fracture of the cranial vault causing exposure of the brain mass in the bilateral frontoparietal region and complete injury to the right eyeball with fracture of the orbit in its posterior, lateral, medial, roof and floor walls. He was transferred to the General Hospital of Axapusco, where the patient was received with 8 points on the Glasgow scale and a simple tomography of the skull was performed, observing injury to both hemispheres, bilateral subarachnoid hemorrhage, parasagittal hemorrhagic contusions and cerebral edema, predominantly affecting to the corpus callosum and cingulum. Therefore, hinge-type decompressive craniectomy and debridement in the first 12 hours of trauma were determined as surgical treatment. It should be noted that a favorable recovery was obtained without associated complications. It is concluded that the surgical treatment of choice is early decompressive craniectomy when the patient presents less than 9 points on the Glasgow Coma Scale at admission, the injury along the path of the wound is bihemispheric and posterior fossa, the time that elapses from the injury to the performance of the surgery is within the first 12 hours, there is pupillary reactivity and the age of the patient is greater than 35 years.

Early Decompressive Craniectomy in Acute Cerebral Infarctions

Early Decompressive Craniectomy in Acute Cerebral Infarctions

739: DECOMPRESSIVE CRANIECTOMY IN CHILDREN WITH TRAUMATIC BRAIN INJURY IN THE U.S. FROM 2000 TO 2019

Introduction: The role of decompressive craniectomy (DC) in children with TBI and intracranial hemorrhage (ICH) or refractory raised intracranial pressure (ICP) is undetermined. This study aimed to describe the prevalence of DC and outcomes associated with DC and ICH in children with TBI. Methods: A retrospective analysis of Kids’ Inpatient Database from 2000 to 2019 was performed. Hospitalized children from 28 days to 20 years were selected. ICD 9 and ICD 10 codes were used to identify diagnosis and procedure variables. Data were compared between early DC (procedure day = 0) and late DC (procedure day >0) using chi-square and Mann-Whitney U tests. Multivariable analysis was performed to determine the adjusted odds of mortality after early vs late DC and various types of ICH and raised ICP. Linear trends in the prevalence of DC were analyzed using the Extended Mantel-Haenszel test. Results: Among 23,804,204 hospitalized children, 193,456 children had TBI (8.1 per 1000 discharges). There was a decreasing trend in TBI hospitalization (p< 0.001) and associated mortality (p < 0.001). DC was documented in 9,887 (5.1%). DC procedure day was documented in 8,480 with early DC in 67.1% and late DC in 32.9%. In patients with TBI and DC, epidural hemorrhage (EH) was present in 19.6%, subdural hemorrhage (SH) in 11.4%, subarachnoid hemorrhage (SAH) in 5.1%, multiple hemorrhage in 51.8%, any hemorrhage in 83.5%, and raised ICP (presence of cerebral edema or EVD) in 6.6%. Early DC was more common in children with EH (OR=1.5; 95%CI:1.4-1.7) and late DC was common in SH (OR=0.7; 95%CI:0.6-0.8), SAH (OR=0.6; 95%CI:0.5-0.7) and raised ICP (OR=0.54; 95%CI:0.48-0.61). The overall mortality and morbidity associated with TBI children with DC was 36.6% and was higher with late DC (OR:1.59; 95%CI: 1.45-1.74). On multivariable regression analysis, morbidity-mortality rate was higher in raised ICP (aOR=6.5; 95%CI:5.5-7.6), SAH (aOR=3.0; 95%CI: 3.3-3.8), SH (aOR=1.9; 95%CI:1.6-2.2), and lower with early DC (aOR= 0.8; 95%CI:0.7-0.9), and EH (aOR=0.27; 95%CI:0.22-0.31). Conclusions: In our national study, in children with TBI, 5% underwent DC. ICH was present in over 80% of children who had DC. The morbidity-mortality was lower with early DC and EH, and higher with raised ICP, SAH, SH and late DC.

Surgical decompression for malignant cerebral oedema after ischaemic stroke.

Large territory middle cerebral artery (MCA) ischaemic strokes account for around 10% of all ischaemic strokes and have a particularly devastating prognosis when associated with malignant oedema. Progressive cerebral oedema starts developing in the first 24 to 48 hours of stroke ictus with an associated rise in intracranial pressure. The rise in intracranial pressure may eventually overwhelm compensatory mechanisms leading to a cascading secondary damage to surrounding unaffected parenchyma. This downward spiral can rapidly progress to death or severe neurological disability. Early decompressive craniectomy to relieve intracranial pressure and associated tissue shift can help ameliorate this secondary damage and improve outcomes. Evidence has been accumulating of the benefit of early surgical decompression in stroke patients. Earlier studies have excluded people above the age of 60 due to associated poor outcomes; however, newer trials have included this patient subgroup. This review follows a Cochrane Review published in 2012. To assess the effectiveness of surgical decompression in people with malignant oedema after ischaemic stroke with regard to reduction in mortality and improved functional outcome. We also aimed to examine the adverse effects of surgical decompression in this patient cohort. We searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 7 of 12), MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, Scopus databases, ClinicalTrials.gov, and the WHO ICTRP to July 2022. We also reviewed the reference lists of relevant articles. We included randomised controlled trials (RCTs) comparing decompressive craniectomy with medical management to best medical management alone for people with malignant cerebral oedema after MCA ischaemic stroke. Two review authors independently screened the search results, assessed study eligibility, performed risk of bias assessment, and extracted the data. The primary outcomes were death and death or severe disability (modified Rankin Scale (mRS) &gt; 4) at 6 to 12 months follow-up. Other outcomes included death or moderate disability (mRS &gt; 3), severe disability (mRS = 5), and adverse events. We assessed the certainty of the evidence using the GRADE approach, categorising it as high, moderate, low, or very low. We included nine RCTs with a total of 513 participants included in the final analysis. Three studies included patients younger than 60 years of age; two trials accepted patients up to 80 years of age; and one trial only included patients 60 years or older. The majority of included trials (six) mandated a time from stroke ictus to treatment of &lt; 48 hours, whilst in two of them this was &lt; 96 hours. Surgical decompression was associated with a reduction in death (odds ratio (OR) 0.18, 95% confidence interval (CI) 0.12 to 0.27, 9 trials, 513 participants, P &lt; 0.001; high-certainty evidence); death or severe disability (mRS &gt; 4, OR 0.22, 95% CI 0.15 to 0.32, 9 trials, 513 participants, P &lt; 0.001; high-certainty evidence); and death or moderate disability (mRS &gt; 3, OR 0.34, 95% CI 0.22 to 0.52, 9 trials, 513 participants, P &lt; 0.001; moderate-certainty evidence). Subgroup analysis did not reveal any significant effect on treatment outcomes when analysing age (&lt; 60 years versus ≥ 60 years); time from stroke ictus to intervention (&lt; 48 hours versus ≥ 48 hours); or dysphasia. There was a significant subgroup effect of time at follow-up (6 versus 12 months, P = 0.02) on death as well as death or severe disability (mRS &gt; 4); however, the validity of this finding was affected by fewer participant numbers in the six-month follow-up subgroup. There was no consistent reporting of per-participant adverse event rates in any of the included studies, which prevented further analysis. Surgical decompression improves outcomes in the management of malignant oedema after acute ischaemic stroke, including a considerable reduction in death or severe disability (mRS &gt; 4) and a reduction in death or moderate disability (mRS &gt; 3). Whilst there is evidence that this positive treatment effect is present in patients &gt; 60 years old, it is important to take into account that these patients have a poorer prospect of functional survival independent of this treatment effect. In interpreting these results it must also be considered that the data demonstrating benefit are drawn from a unique patient subset with profound neurological deficit, reduced level of consciousness, and no pre-morbid disability or severe comorbidity.

Complications and neurologic deterioration after bilateral decompressive craniectomy in Gunshot penetrating brain injury in children.

Introduction: Penetrating skull injuries in pediatrics (TPC) occupy a special place due to their rarity. The aim is to provide an overview of the current evidence on decompressive craniectomy in children, to describe the indications and to detail the complications. Reporte case: We present the case of a 12-year-old boy who suffered a TPC by a projectile that perforated his head, causing multiple brain injuries, and underwent early bilateral decompressive craniectomy, presenting the complications and neurological disabilities typical of the injury and surgery, with a reserved evolution and prognosis. Conclusions: Pediatric penetrating skull injuries should be of individualized management, type of injury and disease, experience of the treatment team, and the decision should always be consensual in front of the benefits and risks in the short and long term.

소뇌의 급성기 뇌졸중 환자에서 부분적 두개골 피판을 이용한 후두와 감압적 두개절개술과 두개절제술의 추적관찰 결과 비교

Background : In patients with severe cerebellar hemorrhage or infarction, life-threatening complications may occur. It is generally known that early decompressive craniectomy is superior to craniotomy, but there is no clear guideline for the procedure. Materials and Methods : From April 2014 to April 2021, patients who underwent suboccipital decompressive craniectomy for cerebellar stroke were treated surgically and followed up. Since September 2020, we have performed craniotomy with obtuse angled partial bone flap in 6 patients. We compared the results of 6 months follow-up in these patients with 9 patients who had previously had only decompressive craniectomy. Results : There were no deaths during 6 months in either group. Preoperative modified Rankin Scale (mRS) (P = 0.659), 1 month (P = 0.659), 3 months (P = 0.713), and 6 months (P &gt; 0.545) postoperative mRS showed no significant difference between them. Conclusions : The results were not inferior to those who underwent suboccipital craniotomy with obtuse-angled partial bone flap and those who underwent craniectomy.

CUT OFF VALUE OF GOOD PRONOSTIC FACTOR OUTCOMES IN LARGE TERRITORY ISCHEMIC STROKE UNDERGOING EARLY DECOMPRESSIVE CRANIECTOMY

Background: Decompressive craniectomy (DC) significantly reduces mortality in large territory ischemic strokes that develop intractable cerebral edema. However, evidence for functional benefit remains sparse and contradictory.&#x0D; Objective: This study aimed to assess cut-off value for predictor outcomes of early DC.&#x0D; Methods: We conducted a prospective, observational cohort study from December 2016 to June 2021. Patients were screened for ischemic stroke involving the middle cerebral, internal carotid artery or both using the National Institutes of Health Stroke Scale score. All patients underwent DC. Multivariate analysis was performed for an array of clinical variables in relation to functional outcomes according to the modified Rankin Scale (mRS) and Pearson’s correlation coefficient analysis. Clinical outcome was assessed after 3- and 6-month follow-up.&#x0D; Results: In total, 243 patients were included in this study. Age ≤71 years (AUC=0.955, p &lt;0.001 accuracy 89.7%), onset to DC ≤9 hours (AUC=0.824, p &lt;0.001 accuracy 78.8%), volume of infarction ≤155 cm3 (AUC=0.939, p &lt;0.001 accuracy 93.6%) and the Alberta Stroke Program Early CT Score or ASPECT score ≥6 (AUC = 1, p &lt;0.001 accuracy 100%) were significantly associated with good clinical outcomes in early DC (mRS 0 to 3).&#x0D; Conclusion: Among patients with large territory ischemic strokes undergoing early DC, age ≤71 years, onset to DC ≤9 hours, volume of infarction ≤155 cm3 and ASPECT score ≥6 was significantly associated with good clinical outcomes. All prognostic factors in early DC correlated well with functional outcomes at 6 months which could be used to predict outcome, and consider clinical indications and informed postoperative complications among patients with large territory ischemic stroke.

Abstract No.: ABS0639: A comparison of the total intraoperative fluid administered by goal directed fluid therapy and conventional fluid therapy in isolated traumatic brain injury patients undergoing early decompressive craniectomy- a prospective randomised controlled trial

Background & Aims:Traumatic brain injury patients are prone to osmotic and electrolyte disturbances, hence require a unique approach to fluid management. Primary aim of the study is to compare goal-directed therapy and conventional hemodynamic based therapy on total intra-operative fluid administered during decompressive craniectomyMethods:Prospective randomised controlled trial was conducted at PGIMER, accruing 64 adult patients with TBI undergoing decompressive craniectomy Goal directed fluid therapy (GDT) used Flo Trac, EV-1000 device (Edwards Lifesciences, Irvine, CA) to monitor Stroke volume variation, Cardiac index and mean arterial pressure Conventional fluid therapyutilisedcrystalloids infused at a rate of 2 ml/kg/hour with target MAP >70 mm of Hg. Quantitative variables were compared using unpaired t test if normally distributed, Mann Whitney U test was used for non-normally distributed quantitative and ordinal data. A P < 0.05 was considered statistically significant. The statistical analysis was done using IBM SPSS version 25.Results:There was a numerical difference in total fluid administered between both the groups but did not prove to be statistically significant (p=0.511). No significant difference in intraoperative blood loss (p=0.776), urine output (p=0.230), total ventilator days (p=0.30), total ICU days (p=0.34), total hospital days (p=0.57) and GCS at discharge (0.53). There was significant difference in levels of hematocrit (p=0.00) and levels of lactate (p=0.00) within both the groups and GCS pre- and post-surgery (p=0.04)Conclusion:No statistically significant difference between the total intraoperative fluid administered between both the groups was observed. Quest for methods to improve outcome in traumatic brain injury patients it still ongoing.

Comparative study of surgical outcomes between early decompressive craniectomy with clipping and coil embolization followed by decompressive craniectomy

Comparative study of surgical outcomes between early decompressive craniectomy with clipping and coil embolization followed by decompressive craniectomy

Decompressive Craniectomy After Traumatic Brain Injury: Incorporating Patient Preferences into Decision-Making

Decompressive craniectomy (DC) is highly effective in relieving intracranial hypertension; however, patient selection, intracranial pressure threshold, timing, and long-term functional outcomes are all subject to controversy. Recently, recommendations were made to update the Brain Trauma Foundation guidelines in regards to the use of DC based on the DECRA (Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury) and RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) clinical trials. Neither the updated recommendations, nor the aforementioned trials, provide a method in incorporating individualized patient or surrogate decision-maker preferences into decision making. In this manuscript, we aimed to redress the gap of not incorporating patient preferences in such value-laden decision making as in the case of DC for refractory post-traumatic intracranial hypertension. We proposed a decision aid based on principles of Decision Theory, and specifically of Expected Utility Theory. We showed that 1) early secondary DC as studied in DECRA, and based on the 1-year outcome data, is associated with decreased expected utility for all possible preference rankings of outcomes; and 2) recommending a late secondary DC versus tier-3 medical therapy, as studied in RESCUEicp, should be informed by individualized patient preference rankings of outcomes as elicited via shared decision-making. The 1-year outcomes from DECRA and RESCUEicp have served as the basis for updated guidelines. However, unaided interpretation of trial data may not be adequate for individualized decision-making; we suggest that the latter can be significantly supported by decision aids such as the one described here and based on expected utility theory.

Роль і місце декомпресивної краніектомії в інтенсивній терапії рефрактерної внутрішньочерепної гіпертензії при тяжкій черепно-мозковій травмі

У даній роботі поданий огляд літератури, присвячений ролі і місцю декомпресивної краніектомії (ДК) в інтенсивній терапії рефрактерної внутрішньочерепної гіпертензії при тяжкій черепно-мозковій травмі. Подано визначення первинної декомпресивної і додаткової краніектомії. Показано, що дослідження ДК охоплює такі напрямки: 1) першочерговість ДК щодо медикаментозного забезпечення; 2) порівняння ДК різних розмірів; 3) порівняння ДК із краніотомією; 4) рання або пізня ДК — з точки зору їх впливу на смертність пацієнтів і функціональні результати. Резюме доказів подано 3 класами. Для оцінки якості сукупності доказів додатково рекомендовані шкала результатів Glasgow Outcome Scale (GOS) і розширена шкала результатів Glasgow Outcome Scale Extended (GOS-E), в якій позиції 3–5 GOS поділені на дві. GOS-E — це глобальна шкала результатів, що описує функціональну незалежність, роботу, соціальну та дозвільну діяльність, особисті відносини; шкали GOS і GOS-E використовують також для порівняння ефективності застосування методів інтенсивної терапії. З огляду на Guidelines for the Management of severe Traumatic Brain Injury 4th Еdition — 2016 подано рекомендації з ДК. Детально вивчено й адаптовано дослідження з рандомізованої оцінки операції ДК при неконтрольованому наростанні внутрішньочерепного тиску (RESCUEicp) для аналізу ефективності ДК як втручання останнього рівня в пацієнтів із черепно-мозковою травмою та рефрактерною внутрішньочерепною гіпертензією. Установлено, що через 6 місяців після черепно-мозкової травми в групі з ДК смертність була на 22 % нижчою, підвищувався відсоток пацієнтів у вегетативному статусі, відмічалися істотні і незначні за тяжкістю неврологічні порушення; сприятливі наслідки домінували на 13 % порівняно з медикаментозним лікуванням. Показники помірної інвалідності і добре відновлення були однаковими в обох групах.

Management of Cerebral Edema, Brain Compression, and Intracranial Pressure.

This article reviews the pathophysiology and management of cerebral edema, brain compression, and elevated intracranial pressure (ICP). It also provides a brief introduction to the concept of the glymphatic system and select cellular contributors to cerebral edema. Cerebral edema and brain compression should be treated in a tiered approach after the patient demonstrates a symptomatic indication to start treatment. All patients with acute brain injury should be treated with standard measures to optimize intracranial compliance and minimize risk of ICP elevation. When ICP monitors are used, therapies should target maintaining ICP at 22 mm Hg or less. Evidence exists that serial clinical examination and neuroimaging may be a reasonable alternative to ICP monitoring; however, clinical trials in progress may demonstrate advantages to advanced monitoring techniques. Early decompressive craniectomy and hypothermia are not neuroprotective in traumatic brain injury and should be reserved for situations refractory to initial medical interventions. Medical therapies that acutely lower plasma osmolality may lead to neurologic deterioration from osmotic cerebral edema, and patients with acute brain injury and renal or liver failure are at elevated risk. A tiered approach to the management of cerebral edema and brain compression can reduce secondary brain injury when implemented according to core physiologic principles. However, our knowledge of the pathophysiology of acute brain injury is incomplete, and the conceptual framework underlying decades of clinical management may need to be revised in response to currently evolving discoveries regarding the pathophysiology of acute brain injury.

Early Decompressive Craniectomy: A Life Saving Option in Closed Head Trauma

Aim: To determine outcome and factors associated with outcome among patients with closed head injury who underwent decompressive craniectomy. Methodology: Cross sectional analytical study conducted in Neurosurgery Department of teaching hospital Dera Ghazi Khan from January, 2021 to June, 2021. Total 105 patients fulfilling the inclusion criteria were enrolled in the study. Approval of ethical review committee was obtained. All the patients with closed head injury which underwent decompressive craniectomy were included. Socio demographic profile, mode of injury, Glasgow Coma Scale (GCS) at admission time, pupillary reaction and timing from hospital admission to surgery, duration of surgery, length of hospital stay and occurrence of CSF leakage was noted. SPSS version 22 was used for data entry and analysis. Results: Head injury was more common in males. 43.8% cases admitted with GCS score between 3-8 and with head injury by road traffic accident. Leakage of CSF was recorded in 13.3% patients. Mortality was recorded in 18.1% patients. GCS at time of admission, time elapsed between admission and surgery and duration of surgery was significantly associated with the outcome. Conclusion: Early decompressive craniectomy significantly reduce death rate in patients with closed head injury. Keywords: Craniectomy, Outcome, Glasgow coma scale

Craniocerebral missile injuries in a combat zone: spectrum of injuries and lessons learnt

BackgroundHigh-velocity missile injuries are commonly encountered in war or war-like situations. Aggressive resuscitation, early evacuation to neurosurgical center, and application of neurosurgical principles remain tenets of success. MethodsThe spectrum of injuries and clinical profile of 14 such cases with craniocerebral missile injuries managed at our center in the northern sector were included. Site of injury, GCS at presentation, associated injuries, surgical intervention, duration of hospitalization, and recovery of the patient were analyzed. ResultsFive patients had sustained gunshot wounds, and nine patients had sustained shrapnel injuries. Thirteen patients were deeply comatose, and one patient was conscious. The entry wound was in frontal lobe in eight patients, and in four patients, it was in the faciocranial area. Ten patients had Glasgow Coma Scale (GCS) less than 8 at presentation. Surgical intervention was required in 13 patients, including 11 decompressive craniectomies and anterior skull base repair in four patients with faciocranial entry wound. One patient expired during initial resuscitation, and one patient died in the postoperative period. Location of injury was the single most important determinant of outcome. ConclusionAn early decompressive craniectomy provides a reasonable chance of recovery. Aggressive debridement involving track explorations, lobectomies, or removal of retained shrapnels is not beneficial. Injuries to the skull base and violation of sinus spaces predispose these patients to cerebrospinal fluid leaks and infective sequelae. All these patients require aggressive postoperative intensive care and rehabilitation.

Hyperdense middle cerebral artery sign predicts favorable outcome after decompressive craniectomy in patients with malignant middle cerebral artery infarction.

Malignant middle cerebral artery infarction (MMI) is a life-threatening cerebral vascular event. Early decompressive craniectomy (DC) has proven to be an effective treatment strategy. However, the ideal candidate for DC continues to be debated. To investigate whether a hyperdense middle cerebral artery sign (HMCAS) provides prognostic value after DC in patients with MMI. We reviewed clinical information and radiological parameters on computed tomography of 42 patients with MMI who underwent DC. Functional outcome was assessed according to the modified Rankin scale (mRS) at three months as follows: favorable outcome (mRS ≤ 4) versus unfavorable outcome (mRS > 4). Logistic regression analysis was used to identify predictors of functional outcome after DC in patients with MMI. Age (odds ratio [OR] = 0.87; 95% confidence interval [CI] = 0.78-0.97; P = 0.014) and HMCAS (OR = 7.40; 95% CI = 1.35-40.48; P = 0.021) were associated with functional outcome. The area under the receiver operating characteristic curve for predicting favorable outcome using the combination of age and HMCAS was 0.882, and the sensitivity and specificity were 0.947 and 0.696, respectively. Patients with MMI with HMCAS, as well as younger patients, often showed a favorable outcome after DC in this study.

Early Decompressive Craniectomy in Subdural Hematoma and Good Outcome – Case Report

A 20-year-old man presented to our Hospital with severe brain trauma, hit by a car while he was riding a bike. On the arrival at the emergency room (ER) his Glasgow Coma Scale (GCS) was 4 (eyes 1; verbal 1 and motor 2) with fixed midriatic pupils and submitted to mechanical ventilation. A CT scan was performed and revealed a subdural hematoma, midline shift greater than 5mm and a swelling, Marshall V (surgically evacuated). The patient was submitted to a decompressive craniectomy and hematoma evacuation two hours after the accident and sent to ICU with ICP monitoring. About 48 hours after surgery a new CT scan was performed and revealed a good outcome with regression of the edema, no midline shift and then we suspended the sedation and 7 days after the trauma the patient woke up without neurological deficits. Some authors did not see benefits in early surgery although the average time of surgical approach was 5 hours after the accident and in many cases the worse patients that underwent to early surgery had a poor outcome. We did not find a specific paper describing the outcome in patients with a very poor GCS ( less than 5 ) and fixed pupils, although the pupils abnormalities remains a critical feature for surgical indication. We believe that even in patient with severe brain trauma, poor GCS and non-reactive pupils, early surgery especially if it is performed before 4 hours can probable improves the outcome, considering other clinical features such as blood pressure and oxygen saturation