Emergency Decompressive Craniectomy Research Articles

Prognostic Analysis of Emergency Decompressive Craniectomy for Patients with Severe Traumatic Brain Injury with Bilateral Fixed Dilated Pupils

For patients with severe traumatic brain injury (sTBI) with bilateral fixed dilated pupils (BFDP), the value of aggressively decompressive craniectomy (DC) treatment is still controversial. The objective of this study was to analyze and validate the outcome of DC in patients with sTBI with BFDP. We retrospectively collected data from 44 patients with sTBI with BFDP who underwent DC treatment from July 2011 to June 2018. Outcomes used as indicators were mortality and favorable outcome. The analysis was based on the Glasgow Outcome Scale score recorded at discharge, 6, and 12 months after trauma. The overall survival was 36.4% (16/44) at discharge and 25.0% (11/44) at 6 and 12 months, and the favorable outcome (Glasgow Outcome Scale score= 4-5) at discharge, 6, and 12 months after injury was 9.1% (4/44), 13.6% (6/44), and 20.5% (9/44), respectively. Sex (P= 0.046), preoperative Glasgow Coma Scale (GCS) score (P= 0.031), injury-surgery intervals (P= 0.022), and tracheotomy (P= 0.017) were independent associations to 6 and 12 months follow-up survival, whereas only preoperative GCS score (odds ratio, 6.088; confidence interval, 1.172-31.612; P= 0.032) and injury-surgery intervals (odds ratio, 0.241; confidence interval, 0.065-0.893; P= 0.033) were independent associations with 12 months follow-up favorable outcome. BFDP indicates a grave prognostic sign after sTBI, but the higher preoperative GCS score and shorter injury-surgery intervals in patients who underwent DC treatment might independently predict favorable outcome for patients with sTBI with BFDP, and patients might benefit more than expected if the DC treatment were applied more aggressively and positively.

One case report of delayed severe intracerebral and intraventricular hemorrhage after cranioplasty

Background Cranioplasty is a relatively simple neurosurgical procedure, and common complications of cranioplasty include dural tears, CSF leakage, infection, epilepsy, epidural hematoma and bone flap resorption. Intracerebral hemorrhage as a complication of cranioplasty is rare, and it is often fatal. The report describes one case of delayed severe intracerebral and intraventricular hemorrhage after an uneventful cranioplasty. Case presentation A previously healthy 29-year-old man was admitted to our hospital with a traumatic left frontotemporoparietal acute subdural hematoma, an emergency decompressive craniectomy with clot removal was performed. Four months after the surgery, cranioplasty was performed with a titanium mesh, the surgery was uneventful. Six hours after the operation, a CT scan demonstrated no bleeding or edema. In the following 2 days after cranioplasty, the patient did not have any neurological deficits, normal blood pressure was recorded every day, no trauma occurred, and routine laboratory test results were within normal limits. However, on the third day after cranioplasty, the patient suffered a sudden severe headache while playing games on his mobile phone, and then rapidly fell into deep coma; both pupils were fixed and dilated at 5 mm with no response to light. An immediate CT scan revealed a massive intracerebral hematoma and intraventricular hematoma on the left side, and the midline shifted to the right side. Therefore, an ipsilateral decompressive craniectomy was performed with evacuation of the hematoma; the obvious bleeding point was not identified, and no obvious vascular abnormalities were found during the operation. A CT scan on day 3 after reoperation revealed successful decompression, and CT angiography showed no vascular abnormalities. Despite all treatment measures, the patient did not regain consciousness, his neurological situation did not improve after the operation, and the patient lived in a vegetative state. Conclusion Although intracerebral and intraventricular hemorrhage after cranioplasty is extremely rare, it is often fatal. Aside from hyperperfusion and cerebral autoregulation dysfunction, traction injuries to the fragile vessels due to posttraumatic angiogenesis may also be one of the key factors of complications after cranioplasty.

Mortality Outcome of Emergency Decompressive Craniectomy and Craniotomy in the Management of Acute Subdural Hematoma: A National Data Analysis

The purpose of the study is to evaluate the in-hospital mortality of patients who presented with acute subdural hematoma (SDH) and underwent emergency decompressive craniectomy (DC) or craniotomy (CO) within 4 hours of hospital arrival. The National Trauma Data Bank (NTDB) dataset of the calendar year of 2007 through 2010 was accessed for the study. All blunt severe head injury patients who presented with acute SDH were included in the study. Severe head injury is defined as a head Abbreviated Injury Scale (AIS) score ≥3 and a Glasgow Coma Scale (GCS) score ≤8. Univariate followed by propensity-matched analyses were performed to compare the two procedure groups: DC and CO. Out of 2370 patients, 518, (21.9%) patients underwent DC. There were significant differences found in the univariate analysis between the DC and CO groups for median age (38 (IQR: 22.0, 55.0) vs 49 (IQR: 27, 67), P < .001), mechanism of injury (fall: 33.2% vs 50.7%; motor vehicle crashes: 58.3% vs 40.9%, P < .001), and median injury severity score (ISS: 26.0 (IQR: 25, 38) vs 26 (IQR: 25.0, 33.0), P < .001). After propensity score matching and pair-matched analysis, no differences were found with any of the above characteristics. The pair-matched analysis also showed no significant difference in in-hospital mortality (42.7% vs 37.5%, P = .10) between the DC vs CO groups. The overall in-hospital mortality for emergency CO or DC for the evacuation of SDH remains high. The preference of one operative procedure over the other did not impact overall mortality.

A case of malignant cerebral infarction associated with COVID-19 infection

Stroke as a presenting feature of COVID-19 infection is being increasingly recognized. We describe a case of a 46-year-old healthcare worker with COVID-19 who developed malignant cerebral infarction requiring emergency decompressive craniectomy. This case illustrates the neurosurgical implications associated with inflammatory and pro-coagulopathic derangements in COVID-19 disease.

Acute Subdural Hematoma in a High School Football Player Requiring Emergent Decompressive Craniectomy

The purpose of this report is to present the case of a high school football player who sustained an injury during a game, resulting in an acute subdural hematoma (SDH). The patient underwent an emergent decompressive craniectomy. The uniqueness of the case is due to both rare pathology and treatment. The athlete had a positive outcome due to prompt on-field assessment and advanced surgical treatments. Athletic trainers should know how to recognize symptoms of emergent traumatic brain injuries and be prepared to implement an emergency action plan when necessary.

Case report: postpartum cerebral venous thrombosis misdiagnosed as postdural puncture headache

BackgroundCerebral venous thrombosis can be a fatal complication of the postpartum period. Pregnancy is known to be a risk factor for thromboembolism in itself.Case presentationA normal spontaneous vaginal delivery was planned for a 20-year-old primigravida patient with patient-controlled epidural analgesia. Next morning, the patient complained of an occipital headache. An epidural blood patch was performed for diagnostic and therapeutic purpose with 10 ml of autologous blood. That night, she had an episode of seizures. Endotracheal intubation was done to secure the airway. She was transferred to an intensive care unit. Brain CT angiography and MRI showed superior sagittal sinus thrombosis with acute infarct and mild subarachnoid haemorrhage. For cerebral venous thrombosis treatment, heparin was injected and for intracranial pressure control, a hypertonic solution was injected. Despite this medical treatment, intracranial pressure continued to rise. The next day, her mental state changed to stupor. Emergency decompressive craniectomy was performed. Her mental state improved rapidly after surgery. A week later, she was transferred to a general ward. Her health recovered and she was discharged.ConclusionsWe experienced postpartum cerebral venous thrombosis misdiagnosed as postdural puncture headache. We hope that this case report would be helpful in situation which a postpartum young woman complains severe headache in spite of management for headache including autologous epidural blood patch.

Factors associated with posttraumatic meningitis among traumatic head injury patients: a nationwide study in Japan

PurposePosttraumatic meningitis is one of the severe complications that can result in increased mortality and longer hospital stay among trauma patients. Factors such as cerebrospinal fluid (CSF) fistula and basilar skull fracture are associated with posttraumatic meningitis. However, it remains unclear whether procedures such as burr hole surgery in the emergency department and decompressive craniectomy are associated with posttraumatic meningitis. The aim of this study was to assess factors associated with posttraumatic meningitis with a nationwide hospital-based trauma registry in Japan.MethodsThis was a retrospective observational study with a 12-year study period from January 2004 to December 2015. We included trauma patients registered in the Japanese Trauma Data Bank, whose head Abbreviated Injury Scale score was ≥ 3 in this study. The main endpoint was the occurrence of meningitis during hospitalization. Multivariable logistic regression analysis was used to assess independent parameters associated with posttraumatic meningitis such as CSF fistula, burr hole surgery in the emergency department, and decompressive craniectomy.ResultsAmong 60,390 head injury patients with head AIS score 3 or more, 284 (0.5%) patients had posttraumatic meningitis. Factors associated with posttraumatic meningitis were burr hole surgery in the emergency department (adjusted odds ratio [AOR] 2.158 [95% confidence interval (CI) 1.401–3.325]), decompressive craniectomy (AOR 2.123 [95% CI 1.506–2.993]), external ventricular drainage (AOR 1.843 [95% CI, 1.157–2.935]), CSF leakage (AOR 3.328 [95% CI 2.205–5.022]), and basilar skull fracture (AOR 1.651 [95% CI 1.178–2.314]).ConclusionsIn this population of trauma patients, burr hole surgery in the emergency department and decompressive craniectomy was associated with posttraumatic meningitis.

Tonic Upward Eyeball Deviation Mimicking Non-Convulsive Occipital Lobe Status Epilepticus That Was Induced by Hydrocephalus

Several seizure-like symptoms are difficult to differentiate from epileptic convulsion, and then if they were misdiagnosed, they could be led to grave prognosis. A 41-year-old man was referred to the emergency room due to unconsciousness. Brain computed tomography (CT) revealed acute subdural hemorrhage along the left frontal lobe, and intraparenchymal hemorrhage in the left temporo-occipital lobe. After emergent decompressive craniectomy, he recovered an alert mental state but became progressively drowsy. Four days later, virtually continuous tonic upward eyeball deviation was observed. He had been taking antiepileptic drugs following an occipital lobectomy 20 years prior due to intractable epilepsy, and we assumed these upward eyeball deviations were symptoms of non-convulsive occipital lobe status epilepticus. Hence, doses and classes of antiepileptic drugs were modified, but clinical manifestations did not improve. Follow-up brain CT revealed newly developed hydrocephalus and compression of the mesencephalon. His symptoms fully resolved after a ventriculo-peritoneal shunt operation. In this case report, we describe the case of a patient exhibiting tonic upward eyeball deviation induced by hydrocephalus that was not associated with a seizure.

Impact of Alcohol Screening for Traumatic Brain Injury Patients Being Admitted to Neurosurgical Intensive Care Unit

The aims of this study were to determine the prevalence and describe the importance of alcohol screening for all patients with traumatic brain injury (TBI) and examine the relationship between gender, age, Abbreviated Injury Scale (AIS), emergent decompressive craniectomy, Glasgow Coma Scale (GCS) from the emergency department (ED), and the length of stay with alcohol screening. This is a retrospective analysis of de-identified data from the 2012 TBI registry of a level 1 trauma center in the Pacific Northwest. Of 1591 patients with TBI, 1273 (80%) were screened for alcohol use and 318 (20%) were not screened. There was a significant association between alcohol screening and AIS (χ(5) = 15.46, P < .001), ED GCS (χ(12) = 22.13, P = .04), sex (χ(1) = 7.86, P ≤ .001), and age (r = 0.23, P < .001). Women and patients with high AIS (critical), low (mild) AIS, and midrange GCS scores were less likely to be screened, as were younger patients. Urgent decompressive craniectomy (χ(1) = 1.94, P = .16) and length of stay (r = -0.04, P = .14) did not display a significant association with alcohol screening. This study uncovered a systemic bias per sex and age for alcohol screening, as well as skewed AIS and GCS scores due to an unknown alcohol intoxication status. An updated ED's triage process and screening tool is recommended to achieve a targeted 100% alcohol screening rate for all head trauma patients in the ED before admission to the neurosurgical intensive care unit.

Case Report of Posttraumatic Middle Cerebral Artery Territory Infarct

A 27-year-old man had severe diffuse brain injury. The patient developed malignant right MCA territory infarction on second day. Emergency decompressive craniectomy was done. He was ventilated. He developed subdural hygroma on the opposite side that was drained. He improved slowly. He had hydrocephalus. VP shunt was done. He became conscious but dependent. PEG was done for feeding. Cranioplasty was done for syndrome of trephined. The patent improved to a state of good cognition with residual motor aphasia and left hemiplegia.Posttraumatic cerebral infarction is an indicator of poor prognosis. Vasospasm, intimal dissection, and thrombosis are the mechanisms. MCA territorial infarction is rare. Usual mechanism is impact of rotational forces on relatively fixed M1 segment on the posterior margin of lower wing of sphenoid, resulting in arterial dissection or intimal damage.

Preoperative serum lactate cannot predict in-hospital mortality after decompressive craniectomy in traumatic brain injury.

Despite the utility of serum lactate for predicting clinical courses, little information is available on the topic after decompressive craniectomy. This study was conducted to determine the ability of perioperative serum lactate levels to predict in-hospital mortality in traumatic brain-injury patients who received emergency or urgent decompressive craniectomy. The medical records of 586 consecutive patients who underwent emergency or urgent decompressive craniectomy due to traumatic brain injuries from January 2007 to December 2014 were retrospectively analyzed. Pre- and intraoperative serum lactate levels and base deficits were obtained from arterial blood gas analysis results. The overall mortality rate after decompressive craniectomy was 26.1%. Mean preoperative serum lactate was significantly higher in the non-survivors (P=0.034) than the survivors but had no significance for predicting in-hospital mortality in the multivariate regression analysis (P=0.386). Rather, preoperative Glasgow Coma Score was a significant predictor for in-hospital mortality (hazard ratio 0.796, 95% confidence interval 0.755-0.836, P<0.001). Preoperative lactate level is not an independent predictor of in-hospital mortality after decompressive craniectomy in traumatic brain-injury patients.

Predicting outcomes of decompressive craniectomy: use of Rotterdam Computed Tomography Classification and Marshall Classification

Background Data on the evaluation of the Rotterdam Computed Tomography Classification (RCTS) as a predictor of outcomes in patients undergoing decompressive craniectomy (DC) for trauma is limited and lacks clarity. Objective To explore the role of RCTS in predicting unfavourable outcomes, including mortality in patients undergoing DC for head trauma. Methods This was an observational cohort study conducted from 1 January 2009 to 31 March 2013. CT scans of adults with head trauma prior to emergency DC were scored according to RCTS. A receiver operating characteristic curve analysis was performed to identify the optimal cut-off RCTS for predicting unfavourable outcomes [Glasgow outcome scale (GOS) = 1–3]. Binary logistic regression analysis was performed to evaluate the relationship between RCTS and unfavourable outcomes including mortality. Results One hundred ninety-seven patients (mean age: 31.4 ± 18.7 years) were included in the study. Mean Glasgow coma score at presentation was 8.1 ± 3.6. RCTS was negatively correlated with GOS (r = −0.370; p < 0.001). The area under the curve was 0.687 (95% CI: 0.595–0.779; p < 0.001) and 0.666 (95% CI: 0.589–0.742; p < 0.001) for mortality and unfavourable outcomes, respectively. RCTS independently predicted both mortality (adjusted odds ratio for RCTS >3 compared with RCTS ≤3: 2.792, 95% CI: 1.235–6.311) and other unfavourable outcomes (adjusted odds ratio for RCTS >3 compared with RCTS ≤3: 2.063, 95% CI: 1.056–4.031). Conclusion RCTS is an independent predictor of unfavourable outcomes and mortality among patients undergoing emergency DC.

Emergency decompressive craniectomy after removal of convexity meningiomas.

Background:Convexity meningiomas are benign brain tumors that are amenable to complete surgical resection and are associated with a low complication rate. The aim of this study was to identify factors that result in acute postoperative neurological worsening after the removal of convexity meningiomas.Methods:Clinical evaluation and neuroradiological analysis of patients who underwent removal of a supratentorial convexity meningioma were reviewed. Patients were selected when their postoperative course was complicated by acute neurological deterioration requiring decompressive craniectomy.Results:Six patients (mean age: 43.3 years) underwent surgical removal of a supratentorial convexity meningioma. Brain shift (mean: 9.9 mm) was evident on preoperative imaging due to lesions of varying size and perilesional edema. At various times postoperatively, patient consciousness worsened (up to decerebrate posture) with contralateral paresis and pupillary anisocoria. Computed tomography revealed no postoperative hematoma, however, did indicate increased brain edema and ventricular shift (mean: 12 mm). Emergency decompressive craniectomy and brief ventilator assistance were performed in all patients. Ischemia of the ipsilateral posterior cerebral artery occurred in 3 patients and hydrocephalus occurred in 2 patients. Outcome was good in 2, fair in 2, 1 patient had severe disability, and 1 patient died after 8 months.Conclusions:Brain shift on preoperative imaging is a substantial risk factor for postoperative neurological worsening in young adult patients after the removal of convexity meningiomas. Emergency decompressive craniectomy must be considered because it is effective in most cases. Other than consciousness impairment, there is no reliable clinical landmark to guide the decision to perform decompressive craniectomy; however, brain ischemia may have already occurred.

The Effect of Preoperative Antiplatelet Therapy on Hemorrhagic Complications after Decompressive Craniectomy in Patients with Traumatic Brain Injury.

ObjectiveTraditionally, it is generally recommended that antiplatelet agent should be discontinued before surgery. However, decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) is performed emergently in most cases. Therefore, DC cannot be delayed to the time when the effect of antiplatelet agent on bleeding tendency dissipates. In this study, we evaluated the effect of preinjury antiplatelet therapy on hemorrhagic complications after emergent DC in patients with TBI.MethodsWe retrospectively investigated patients with TBI who underwent emergent DC between 2006 and 2015. The patients were separated into two groups according to the use of preinjury antiplatelet agent: group 1 (patients taking antiplatelet agent) and group 2 (patients not taking antiplatelet agent). The rate of hemorrhagic complications (postoperative epidural or subdural hemorrhage, newly developed, or progression of preexisting contusion or intracerebral hemorrhage within the field of DC) and the rate of reoperation within 7 days after DC were compared between two groups.ResultsDuring the study period, DC was performed in 90 patients. Of them, 19 patients were taking antiplatelet agent before TBI. The rate of hemorrhagic complications was 52.6% (10/19) in group 1 and 46.5% (33/71) in group 2 (p=0.633). The rate of reoperation was 36.8% (7/19) in group 1 and 36.6% (26/71) in group 2 (p=0.986). No statistical difference was found between two groups.ConclusionPreinjury antiplatelet therapy did not influence the rate of hemorrhagic complications and reoperation after DC. Emergent DC in patients with TBI should not be delayed because of preinjury antiplatelet therapy.

Malignant Cerebral Venous Sinus Thrombosis in Polycythemia.

Malignant Cerebral Venous Sinus Thrombosis in Polycythemia.

Severe Visual Loss and Cerebral Infarction After Injection of Hyaluronic Acid Gel

We report a case of a 23-year-old man with cerebral infarction and permanent visual loss after injection of a hyaluronic acid gel filler for augmentation rhinoplasty. The patient was admitted to the hospital with complaints of loss of vision in the right eye, facial paralysis on the right side, and paralysis of the left limbs with severe pain during augmentation rhinoplasty with filler injection. Brain magnetic resonance imaging and computed tomography showed ophthalmic artery obstruction and right middle cerebral artery infarction. Acute thrombolysis was performed to treat the infarction; however, the patient's condition did not improve. Intracerebral hemorrhage in the right temporal/frontal/occipital/parietal lobe, subarachnoid hemorrhage, and midline shifting were observed on brain computed tomography after 24 hours after thrombolysis. Emergency decompressive craniectomy was performed. After the surgery, the patient continued to experience drowsiness, with no improvement in visual loss and motor weakness. Three months later, he could walk with cane. This case indicates that surgeons who administer filler injections should be familiar with the possibility of accidental intravascular injection and should explain the adverse effects of fillers to patients before surgery.

Severe posterior reversible encephalopathy syndrome resolved with craniectomy

Posterior reversible encephalopathy syndrome (PRES) has been thought to be a benign disease, but recently severe cases have been reported with increasing recognition. A 3-year-old girl with congenital nephrotic syndrome had rapidly progressed to coma. Computed tomography (CT) of the head showed striking swelling of the brainstem and transtentorial herniation. Emergency decompressive craniectomy was performed. Consecutively, blood pressure was optimally controlled. The patient gradually recovered to the previous state before onset of PRES. Rapid improvement of clinical symptoms and rapid resolution of abnormal findings on serial CT led to diagnosis of PRES. In severe PRES with unstable vital signs, surgical intervention should be considered as well as appropriate blood pressure management.

A case of acute traumatic subdural hematoma in a child with previous bilateral encephaloduroarteriosynangiosis

The authors report the case of a 5-year-old female with right-sided hemiparesis and aphasia secondary to moyamoya disease, who had previously undergone staged bilateral encephaloduroarteriosynangiosis procedures. A subsequent ground-level fall caused an acute traumatic subdural hematoma with mass effect and neurological decline. She underwent emergency hematoma evacuation and decompressive craniectomy, which required interruption of the superficial temporal artery that had been used for indirect bypass, followed later by autologous cranioplasty. There were no acute or long-term ischemic events related to the occurrence or treatment of the traumatic hematoma. Follow-up angiography revealed extensive spontaneous vascular collateralization in the field of the decompressive craniectomy and cranioplasty. The patient returned to her pre-injury neurological baseline.

Eine Myokarditis mit gravierenden neurologischen Folgen

A 39-year-old woman developed severe dyspnea subsequent to a respiratory tract infection. Furthermore an acute loss of vision occurred two days prior to admission. DIAGNOSES AND TREATMENT: Left ventricular dilatation due to myocarditis had led to decompensated cardiac insufficiency. The loss of vision (cortical blindness) had been caused by multiple brain infarctions in the posterior cerebral circulation due to basilary artery occlusion subsequent to cardiogenic embolism. During anticoagulation with heparin and antiplatelet drugs a large, space-occupying intracranial hemorrhage occurred in a posterior cerebral artery infarction. Emergency decompressive craniectomy was necessary. Heart insufficiency and left ventricular dilatation resolved later on. Hydrocephalus became obvious after cranioplasty, thus leading to shunt procedure. After long-term neurorehabilitation, accompanied by several complications and two neurosurgical procedures, the patient gained more independence in her activities of daily living and quality of life. In the light of the initial burden of symptoms this course was rather favorable. Myocarditis as a cause for acute heart insufficiency has to be taken into account in young patients without any history of cardiac abnormalities and preceding infections. Cardioembolic stroke may be a consequence. Decisions in secondary stroke prevention should be made on an individual base with regard to medical guidelines as well as risk factors. Neurorehabilitation of sufficient length and quality can lead to functional recovery, improvement of independence in activities of daily living and quality of life, even if the initial situation seems worse and medical complications accompany the course.

Intracerebral bullet removal through an endoscopic transnasal craniectomy

Background:In the past decade, the endoscopic transnasal technique has been broadly applied as a feasible and less invasive approach to the skull base. The adaptability of the endoscopic technique allows a case-specific approach in order to minimize both endonasal and cranio-cerebral manipulation; therefore it can be also used in patients complaining exceptional skull base lesions and in weak patients. The objective of this paper is to present the first case of intracerebral bullet removal using a pure endoscopic transnasal route through a custom made unilateral craniectomy.Case Description:A 59-year-old patient was admitted to the emergency department after a gunshot injury to the head, thorax, abdomen, and pelvis. Admission Glasgow Coma Scale was 7. Brain computed tomography (CT) scan highlighted a right occipital hole defect due to perforative impact, intracerebral dislocations of bone fragments, right intracerebral and subdural hematoma, and midline shift to the left side; the bullet was localized in the right frontal lobe and its tip was in contact with the ethmoid roof.The patient underwent emergency decompressive craniectomy and evacuation of the subdural hematoma and abdominal explorative laparotomy, ileum resection, and gastrorrhaphy. After 1 month, the patient underwent endoscopic transnasal removal of the bullet and skull base reconstruction due to cerebrospinal fluid infection. The postoperative course was uneventful and he has done well in follow-up with no evidence of cerebrospinal fluid leak and preservation of olfaction.Conclusion:The adaptability of the endoscopic transnasal technique offers patients complaining exceptional skull base lesions a case-specific strategy minimizing morbidity and postoperative stay.