Emergency Decompressive Craniectomy Research Articles

Vascular anomaly at the craniocervical junction presenting with sub arachnoid hemorrhage: Dilemma in Imaging Diagnosis, Endovascular Management and Complications

We present a case of a ruptured vertebral artery dissecting aneurysm that mimicked a presumed vascular anomaly by CTA (Computerized Tomographic Angiography). A parenchymal arteriovenous malformation (AVM) or a dural arteriovenous fistula (DAVF) at the craniocervical junction can present with a subarachnoid hemorrhage and cannot be differentiated from a vertebral artery dissection by non invasive imaging. Catheter based cerebral angiography revealed a dissecting pseudoaneurysm of a diminutive right vertebral artery terminating in the posterior inferior cerebellar artery (PICA) that to our knowledge has not been previously reported. NBCA (N-Butyl Cyanoacrylate) embolization of the pseudoaneurysm lumen and sacrifice of the parent vessel resulted in cerebellar infarction, requiring an emergent decompressive craniectomy. The patient recovered to a functional neurologic status.

Emergency decompressive craniectomy for trauma patients with Glasgow Coma Scale of 3 and bilateral fixed dilated pupils.

Trauma patients with Glasgow Coma Scale (GCS) of 3 and bilateral fixed dilated pupils (BFDP) usually have dismal outcome, and neurosurgeons are less likely to treat such patients aggressively. In this work, the authors assessed whether emergency decompressive craniectomy (EDC) can change the poor outcome of these patients. We reviewed all patients with GCS of 3 and BFDP admitted to our neurosurgical unit from January 2004 to January 2008. Injury data, prehospital times, findings on brain computed tomography (CT) scan, procedures, and outcomes were recorded. During this period, 21 patients were admitted with GCS of 3 and BFDP following traumatic brain injury (TBI). Brain CT scan showed diffuse brain edema in 17 patients (81%), and in 13 patients (62%) it showed different types of intracranial hemorrhage. All patients received conservative medical treatment. Urgent decompressive bifrontal craniectomy was performed in five patients at a mean of 4.6h (range 2-6h) from time of injury. Intracranial pressure (ICP) was recorded hourly by intraparenchymal sensor (Codman, Johnson & Johnson). Although decompressive craniectomy was effective in controlling ICP, all patients with GCS of 3 and BFDP died within 30days of trauma. Despite control of ICP following emergency decompressive craniectomy in patients with severe TBI, GCS of 3, and BFDP, this did not change the dismal outcome of these patients; on the contrary, it may increase the suffering for patients and their families and add unnecessary medical burden. We propose that these patients have irreversible severe brain insult.

Unusual progression of herpes simplex encephalitis with basal ganglia and extensive white matter involvement

We report a 51-year old male with herpes simplex encephalitis (HSE) showing unusual progression and magnetic resonance (MR) findings. The initial neurological manifestation of intractable focal seizure with low-grade fever persisted for three days, and rapidly coma, myoclonic status, and respiratory failure with high-grade fever emerged thereafter. The polymerase chain reaction (PCR) result of cerebrospinal fluid (CSF) was positive for HSV-1 DNA. In the early stage, MR images (MRI) were normal. On subsequent MR diffusion-weighted (DW) and fluid-attenuated inversion recovery (FLAIR) images, high-intensity areas first appeared in the left frontal cortex, which was purely extra-temporal involvement, and extended into the basal ganglia, then the white matter, which are relatively spared in HSE. Antiviral therapy and immunosuppressive therapy did not suppress the progression of HSE, and finally severe cerebral edema developed into cerebral herniation, which required emergency decompressive craniectomy. Histological examination of a biopsy specimen of the white matter detected perivascular infiltration and destruction of basic structure, which confirmed non specific inflammatory change without obvious edema or demyelination. The present case shows both MR and pathological findings in the white matter in the acute stage of HSE.

Fatal Septic Thrombosis of the Superior Sagittal Sinus After Face-lift Surgery Caused by Community-Associated Methicillin-Resistant Staphylococcus aureus

Fatal Septic Thrombosis of the Superior Sagittal Sinus After Face-lift Surgery Caused by Community-Associated Methicillin-Resistant <i>Staphylococcus aureus</i>

Acute pulmonary edema due to phenylephrine injection in patient receiving long-term beta-blocker therapy: A case report.

During administration of anesthesia, intraoperative blood pressure control is very important. Sometimes a hypertensive or anti-hypertensive agent is used in order to maintain blood pressure at an adequate level; alpha-agonist and beta-blocker are drugs frequently used. Alpha-agonists are used in various ways including their application together with local anesthetics during an operation for the purpose of vasoconstriction, to control systemic absorption of local anesthetics, to extend the duration of action, or to reduce bleeding from the surgical site. In addition, alpha-agonists are used in cardiopulmonary resuscitation. Beta-blockers are used widely as a therapeutic agent for hypertension, angina, and arrhythmia, and to lower portal pressure in liver cirrhosis. Here, we are reporting the case of acute pulmonary edema that occurred after the administration of phenylephrine, in order to maintain blood pressure in a 52-year-old female patient with liver cirrhosis. The patient was underwent emergent decompressive craniectomy for intracranial hemorrhage without acknowledging her long-term use of a beta-blocker medication.

Emergency decompressive craniectomy for fulminating infectious encephalitis

In patients who develop fulminant cerebral edema and elevated intracranial pressures, viral encephalitis can result in devastating neurological and cognitive sequelae despite antiviral therapy. The benefits of decompressive craniectomy, if any, in this group of patients are unclear. In this manuscript, the authors report their experience with 2 patients who presented with herpes simplex virus requiring surgical decompression resulting in excellent neurocognitive outcomes. They also review the literature on decompressive craniectomy in patients with fulminating infectious encephalitis. Four published articles consisting of 13 patients were identified in which the authors had reported their experience with decompressive craniectomy for fulminant infectious encephalitis. Herpes simplex virus was confirmed in 6 cases, Mycoplasma pneumoniae in 2, and an unidentified viral infection in 5 others. All patients developed clinical signs of brainstem dysfunction and underwent surgical decompression resulting in good (Glasgow Outcome Scale [GOS] Score 4) or excellent (GOS Score 5) functional recoveries. The authors conclude that infectious encephalitis is a neurosurgical disease in cases in which there is clinical and imaging evidence of brainstem compression. Surgical decompression results in excellent recovery of functional independence in both children and adults despite early clinical signs of brainstem dysfunction.

Traumatic pseudoaneurysm of the middle meningeal artery: possible indicators for early diagnosis in the computed tomography era

Objective and ImportanceTraumatic pseudoaneurysms of the middle meningeal artery, which are associated with high mortality, are difficult to detect early by CT. We provide serial CT scans to show the steps of their formation and suggest characteristics that could be useful in the detection. Clinical PresentationA 25-year-old man was initially in deep coma had an anisocoric pupil after a traffic accident. Brain CT showed basal skull fracture and traumatic subarachnoid hemorrhage with severe brain swelling. Emergent decompressive craniectomy was performed, and 2 days later, an EDH appeared at the left temporal fossa. Careful examination of the image revealed a hypodense nodule inside the acute hematoma. He underwent craniotomy to remove the hematoma. Serial CT of the residual hematoma showed the gradual development of an organized hematoma around the hypodense nodule. The nodule had low density, which was strongly enhanced on CT after injection of contrast medium. The nodule was highly suspected to be a vascular lesion. A middle meningeal artery pseudoaneurysm was discovered through a 3-dimensional computed tomographic angiography. He underwent another craniotomy to remove the pseudoaneurysm. InterventionThe diagnostic approach was CT, 3-dimensional CT, and craniotomies. ConclusionFour CT findings may be useful for early diagnosis: (1) basal skull fracture in the temporal region; (2) hypodense nodule within an acute hematoma; (3) hypodense nodule within an organized and encapsulated hematoma; and (4) strong and homogenous enhancement of the hypodense nodule within an organized and encapsulated hematoma. Three-dimensional computed tomographic angiography is an effective and noninvasive tool to confirm this diagnosis.

Fatal spontaneous thrombosis of a cerebral arteriovenous malformation in a young patient with a rare heterozygousprothrombingene mutation

The authors report a case of fatal stroke due to thrombosis of a cerebral arteriovenous malformation (AVM) in a young patient. The patient presented with a progressive severe headache that had lasted for a few days, followed by a rapid deterioration in the level of consciousness. Computed tomography and magnetic resonance imaging were immediately performed, and the images showed a large area of venous ischemia in the left hemisphere as well as a left temporal pial AVM. An emergency decompressive craniectomy was unsuccessful in preventing deterioration in the patient's condition. An autopsy examination revealed a thrombosed AVM leading to a wide area of venous ischemia and massive brain swelling. Thrombophilia investigations identified a heterozygous mutation at position 20209 of the prothrombin gene, a recently reported rare prothrombotic defect. Acute neurological decline after spontaneous thrombosis of an intracranial AVM is rare, and an association with the prothrombin defect in this patient is likely.

Connection Between a Dural Artery and a Dural Vein in a Dural Arteriovenous Fistula of the Cranial Vault-Case Report-

A 41-year-old man presented with consciousness disturbance and right hemiparesis. Computed tomography showed a hematoma in the frontal lobe. Left carotid angiography showed a dural arteriovenous fistula (AVF) located in the cranial vault, supplied by the left middle meningeal artery, and drained directly into the cortical vein adjacent to the superior sagittal sinus. Emergency decompressive craniectomy and evacuation of the intracerebral hematoma were performed. A red vein was found on the cortex but the location of the arteriovenous shunt was not clear due to severe brain swelling. Two months later, cranioplasty was performed and a part of the dura mater, expected to have been affected by the dural AVF, was resected. Histological examination disclosed thickening of the intima of the middle meningeal artery and a few small veins around this artery. The fistula was clearly demonstrated between the dural artery and the dural vein. The non-sinal type of dural AVF may originate in similar arteriovenous connections to the sinal type.

Delayed onset massive oedema and deterioration in traumatic brain injury

A 52-year-old man fell from standing and a computed tomography (CT) scan revealed traumatic intracerebral haematoma and subarachnoid haemorrhage in the temporal cortex. He was treated without surgery and discharged. On day 30 after the accident, he had no neurological deficit. On day 37 he complained of headache and urinary incontinence, and on day 39 he was hospitalized due to progressive neurological deterioration (reduced conciousness, dilated pupils, and left hemiplegia). A CT scan revealed a diffuse low-density in the right cerebral hemisphere with marked midline shift. Emergency decompressive craniectomy and right temporal lobectomy were performed. Angiography after surgery revealed moderate vasospasm in the right middle and anterior cerebral arteries. The patient remained severely disabled. Delayed onset neurological deterioration can be caused by brain oedema and vasospasm after traumatic brain injury, despite an intervening period of improvement.

High Intracranial Pressure, Brain Herniation and Death in Cerebral Venous Thrombosis

To the Editor: Sir, the study by Canhao and colleagues made the important point that the most frequent cause of death in patients with cerebral venous thrombosis (CVT) is transtentorial herniation and that these patients may potentially have benefited from decompressive hemicraniectomy.1 We would like to corroborate this argument by providing evidence for a rise in intracranial pressure (ICP) preceding brain herniation and death in a patient with CVT. A 29-year-old pregnant woman who presented with confusion and vomiting was admitted to a district general hospital. A right-sided weakness developed within 2 days. A CT brain scan showed a left temporal hemorrhage without mass effect. Her Glasgow Coma Scale score dropped to 8/15; she was intubated and transferred to the neurocritical care …

Cranioplasty with Subcutaneously Preserved Autologous Bone Grafts

The efficacy of reconstructing a cranial defect with the craniectomy bone graft (bone flap) banked in a subcutaneous pocket of the abdominal wall after emergency decompressive craniotomy was evaluated. A retrospective study was performed on 53 of 65 consecutive patients who underwent emergency decompressive craniectomy and bone graft placement in the abdominal wall and survived to graft replacement. Clinical outcome after graft replacement was determined by the adequacy of the recovered craniectomy graft to achieve satisfactory reconstruction, the incidence of infection and the need for revisional surgery. Forty-nine of the 53 patients (92 percent) in whom delayed autogenous graft replacement was attempted achieved a satisfactory one-stage reconstruction. In 42 of these 49 patients, autogenous graft replacement alone was performed. In eight patients it was necessary to supplement the graft with alloplastic material to achieve desired contour. One patient who underwent reconstruction with the autogenous bone graft alone, underwent late revision cranioplasty to improve contour. There were three infections. One graft was found infected in the abdominal pocket at retrieval. Two were lost to operative infection after graft replacement. Histology of two stored grafts performed after abdominal pocket retrieval demonstrated a mixture of necrotic and newly formed woven bone. A bone scan performed 1 year after graft replacement showed radionuclide activity of the graft almost identical to that of intact neighboring bone. Subcutaneous storage preserves viability of portions of autogenous bone grafts. Cranioplasty performed with a subcutaneously preserved craniectomy graft has a low revision rate.

Emergency Decompressive Craniectomy for Traumatic Malignant Intracranial Hypertension

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