Large Craniectomies Research Articles

Modifying skin flaps for achieving very large decompressive craniectomies in malignant middle cerebral artery territory infarcts: A technical note.

Decompressive craniectomy is a well described treatment to salvage life in large middle cerebral artery (MCA) territory infarcts. The size of the craniectomy is limited by the size of the skin incision and very large craniectomies need large skin flaps that are prone to necrosis at the wound margins. We describe two modifications in the skin flap that we have used in 7 patients to achieve very large bony decompressions in malignant MCA infarctions without compromising on flap vascularity. One consists of a linear extension posteriorly from the question mark or reverse question mark incision while the other is an "n" shaped incision. With these modifications we achieved craniectomies of size 15.6-17.8 cm in the anteroposterior and 10.7-12 cm in vertical axis of the bone flap removed in our patients. There were no additional procedural or wound related complications in a 6-month follow up. Removal of a standard size bone flap may achieve suboptimal decompression in cases of large MCA territory infarctions. Imaginative tailoring of skin flaps helps to remove larger volumes of skull with no added procedural morbidity.

Craniectomy size for subdural haematomas and the impact on brain shift and outcomes.

Midline shift in trauma relates to the severity of head injury. Large craniectomies are thought to help resolve brain shift but can be associated with higher rates of morbidity. This study explores the relationship between craniectomy size and subtemporal decompression for acute subdural haematomas with the resolution of brain compression and outcomes. No systematic study correlating these measures has been reported. A retrospective study of all adult cases of acute subdural haematomas that presented to a Major Trauma Centre and underwent a primary decompressive craniectomy between June 2008 and August 2013. Data collection included patient demographics and presentation, imaging findings and outcomes. All imaging metrics were measured by two independent trained assessors. Compression was measured as midline shift, brainstem shift and cisternal effacement. Thirty-six patients with mean age of 36.1 ± 12.5 (range 16-62) were included, with a median follow-up of 23.5months (range 2.2-109.6). The median craniectomy size was 88.7cm2 and the median subtemporal decompression was 15.0mm. There was significant post-operative resolution of shift as measured by midline shift, brainstem shift and cisternal effacement score (all p < .00001). There was no mortality, and the majority of patients made a good recovery with 82.8% having a Modified Rankin Score of 2 or less. There was no association between craniectomy size or subtemporal decompression and any markers of brain shift or outcome (all R2 < 0.05). This study suggests that there is no clear relationship between craniectomy size or extent of subtemporal decompression and resolution of brain shift or outcome. Further studies are needed to assess the relative efficacy of large craniectomies and the role of subtemporal decompression.

Awake Cranioplasty: A Case Series

Background: Cranioplasty restores the normal cranial architecture and protective functions of the skull and may play a role in normalizing cerebrospinal fluid dynamics in patients undergoing large craniectomies. It has a definitive impact on restoration of normal intracranial physiology and improvement of patient neurological condition. Anesthesia for awake neurosurgery procedure poses a unique challenge to anesthesiologists. Objective: To present cases of awake cranioplasty and describe the principles of anesthetic management during this procedure. Case description: 3 patients who have skull defect underwent cranioplasty procedure. Patients were managed with dexmedetomidine load of 1 mcg/kg over 10-15 min followed by infusion at rates of 0.2 mcg/kg/hr to 0.7 mcg/kg/hr and a local infiltration without airway instrumentation. Discussion: Awake cranioplasty offers great advantages with respect to patient outcome. In this type of procedure, the anesthesiologist’s goal is to make the operation safe and effective and reduce the psychophysical distress of the patient. Personal experience, careful planning, and attention to detail are the basis for obtaining good awake cranioplasty results. Dexmedetomidine is a highly specific α2 adrenoceptor agonist with sedative, analgesic, anesthetic sparing effect, awake if neither stimulated brain protection with no addiction effect nor suppress ventilation. Patients treated with dexmedetomidine will be sedated, comfortably but is easily aroused. Conclusion: Awake cranioplasty procedures were successfully performed with stable hemodynamic intraoperative and no complications during procedure. Dexmedetomidine has been shown to provide sedation and analgesia without significant respiratory depression and has been used successfully in these settings.

ABSTRACT 337

Background and aims: The herniation paradoxal is consequence of the trephined syndrome that is a subacute complication of large craniectomies. Aims: We report a case of a 4-year-old male child who presented major trauma brain injury after motor vehicle accident versus pedestrian. Methods: He had a crushing lesion on the right side of the skull. Glasgow Coma Score (GCS) was 11T at the hospital admission. His initial CT scan showed frontal comminuted fracture of the right facial bones, frontal, temporal, parietal and nasal bones. Plus skull base fracture throught the temporal floor, soft tissue edema and large pneumocephalus. TBI guidelines was used and intracranial pressure monitoring. After 4 days he presented an uncontrollable intracranial hypertension and signs of severe infection of the brain. A new CT showed reducing size of the lateral ventricles, sulci and cisterns, mildline shift and transcalvarial herniation of the right temporal lobe. The decompressive craniectomy and dural repair was performed. His skul frontal, temporal and parietal right bones were necrotic and were removed. The ICP was controlled on post injury day 7. After 3 weeks his medical condition deteriorated with tachycardia, tachypnea, fever, worsening of nasal cerebrospinal fluid leak and decerebrate posture. CT scan showed paradoxal herniation with uncal herniation, brainstem compression and midline shift. Results: The medical management was to increase intracranial pressure by placing into Trendelenburg positioning and increasing hydratation. Conclusions: Our proposal was to bring attention to early diagnosis of paradoxal herniation whose outcome is severe acute neurological deterioration and death.

Minimally Invasive Strip Craniectomy for Sagittal Synostosis

The most common approaches used today for the correction of sagittal synostosis involve large craniectomies and extensive cranial vault remodeling. Although these techniques ultimately yield very good cosmetic results, they have significant drawbacks. They are lengthy, expensive, associated with significant blood loss, universally require transfusions, and often result in prolonged hospitalization.We present here our 5-year experience with correction of sagittal synostosis using the recently described minimally invasive strip craniectomy followed by postoperative cranial vault helmet molding. During this period, we treated a total of 97 children with nonsyndromic single-suture synostosis. The first 46 of 67 children treated for sagittal synostosis had at least 1 year of postoperative follow-up and were included in the analysis. There were 33 boys and 13 girls. Patients' mean age at surgery was 3.1 months, and the mean weight was 6.1 kg. The mean operative time was 75 minutes. The estimated blood loss during the procedure was 56 mL. Eight patients received blood transfusions during surgery (17.4%) and 3 patients received after surgery (6.5%). There were no significant postoperative complications. The mean hospitalization was 2.2 days. Excellent aesthetic outcomes were noted in all patients. The change in cranial index from a preoperative value of 0.7 to 0.8 postoperatively was virtually stabilized 3 months after the surgical intervention. Significantly better correction rates were observed in the youngest patients.Because of its excellent attributes, minimally invasive strip craniectomy followed by postoperative helmet molding is likely to become the preferred treatment modality for the correction of sagittal synostosis.

Spontaneous Resolution of Diabetes Insipidus After Cranioplasty and Cranial Defect Repair

We describe the resolution of persistent diabetes insipidus after cranioplasty with autogenous bone and bone morphogentic protein 2-infused collagen matrix in a patient who had large bilateral craniectomies for trauma. A potential pathogenic mechanism is presented.

Wartime decompressive craniectomy: technique and lessons learned

Decompressive craniectomy (DC) with dural expansion is a life-saving neurosurgical procedure performed for recalcitrant intracranial hypertension due to trauma, stroke, and a multitude of other etiologies. Illustratively, we describe technique and lessons learned using DC for battlefield trauma. Neurosurgical operative logs from service (October 2007 to September 2009) in Afghanistan that detail DC cases for trauma were analyzed. Illustrative examples of frontotemporoparietal and bifrontal DC that depict battlefield experience performing these procedures are presented with attention drawn to the L.G. Kempe hemispherectomy incision, brainstem decompression techniques, and dural onlay substitutes. Ninety craniotomies were performed for trauma over the time period analyzed. Of these, 28 (31%) were DCs. Of the 28 DCs, 24 (86%) were frontotemporoparietal DCs, 7 (25%) were bifrontal DCs, and 2 (7%) were suboccipital DCs. Decompressive craniectomies were performed for 19 penetrating head injuries (13 gunshot wounds and 6 explosions) and 9 severe closed head injuries (6 war-related explosions and 3 others). Thirty-one percent of craniotomies performed for trauma were DCs. Battlefield neurosurgeons use DC to allow for safe transfer of neurologically ill patients to tertiary military hospitals, which can be located 8-18 hours from a war zone. The authors recommend the L.G. Kempe incision for blood supply preservation, large craniectomies to prevent brain strangulation over bone edges, minimal brain debridement, adequate brainstem decompression, and dural onlay substitutes for dural closure.

Sinking Skin Flap Syndrome (SSFS) – Clinical Spectrum and Impact on Rehabilitation

"Sinking skin flap syndrome" (SSFS) is defined as a secondary neurological deterioration in the presence of a sinking skin flap in patients with large craniectomies. Although changes in cerebrospinal fluid (CSF) hydrodynamics, cerebral blood flow and brain metabolism have been described as partial aspects of the pathophysiology, a conclusive concept, integrating all contributing factors, is still lacking. Knowledge about the true incidence of this phenomenon is rare. This case series describes the clinical spectrum of SSFS. Since it is to be expected that decompressive craniectomies will be carried out more often in the future, SSFS will become increasingly important. Cranioplasty leads to clinical improvement in the majority of cases and should therefore be performed early in the course in order to avoid secondary neurological deterioration. Cranioplasty is thus a therapeutic and more than merely a cosmetic procedure.

Das Sinking-Skin-Flap-Syndrom (SSFS) – eine klinisch relevante Komplikation nach dekompressiver Kraniektomie

The sinking skin flap syndrome (SSFS) is defined as a secondary neurological deterioration which cannot be attributed to the primary illness and which occurs in the presence of a sinking skin flap in patients with large craniectomies. Although changes in cerebrospinal fluid (CSF) hydrodynamics, cerebral blood flow and brain metabolism have been described as partial aspects of the pathophysiology, a conclusive concept, integrating all contributing factors, is still lacking. Knowledge about the true incidence of this phenomenon is scarce. This case series describes the clinical spectrum of SSFS. Since it can be expected that decompressive craniectomies will be carried out more often in the future, SSFS will gain growing importance. Cranioplasty leads to a clinical improvement in the majority of cases and should therefore be performed early in the course in order to avoid secondary neurological deterioration. Cranioplasty is therefore a therapeutic and not merely a cosmetic procedure.

Selective image-guided venous sinus exposure for direct embolization of dural arteriovenous fistula: technical case report

Background Transcranial approaches for transsinusal endovascular therapy of DAVF have been sporadically reported by large craniectomies. Large craniectomies carry nevertheless a risk of postembolization extradural hematoma, reduced by delaying the endovascular procedure. We report a 1-session technique of SIGC for percutaneous transvenous DAVF embolization. Case Description This 58-year-old woman developed a right-sided cerebellar hematoma in relation with a high-grade left transverse and sigmoid sinus DAVF. The DAVF was fed by branches from the left vertebral artery, left internal, and left external carotid arteries, draining into the transverse sinus with retrograde flow in cortical veins. Transvenous retrograde embolization was not feasible either through the left internal jugular vein because of thrombosis, or through the right one because of torcular septa. During the same anaesthetic session, a 5-cm-length selective craniectomy was shaped under magnetic resonance image guidance navigation according to the left transverse sinus with high-speed drill. Thereafter, back in the angiography room, the transverse sinus was taped and coiled resulting in a complete exclusion of the DAVF. Conclusion Selective image-guided craniectomy is efficient and safe for direct percutaneous transvenous embolization of DAVF in a single anesthetic session. Leaving bone beside the sinus prevents a parenchymal traumatic puncture. This bone has nevertheless to be drilled to allow an adequate sharp puncture angle. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter and the possibility of direct compression.

Manual vs. robotic milling parameters for development of a new robotic system in cranial surgery

The milling of bone is a time-consuming and straining effort during surgery at the cranial vault. In order to determine possible advantages of a robotic system, the registration of different milling parameters during defined surgical procedures was the aim of this study. Eleven neurosurgeons were asked to mill a bovine scapula. The task consisted of geometric figures (one line and a circle) that had to be milled in a depth of 3 mm. Main focus was laid on the accuracy of the milling. In addition, the registered parameters such as forces, temperature and speed will be used as a reference for the design and validation of the robotic system. The same task was done by a robotic (hexapod) system, constructed at the Helmholtz-Institute Aachen (HIA). In comparison with the surgeon, the robotic system showed a higher accuracy at a greater velocity. The forces and temperatures showed minor differences. If further test results are consistent, it would be advantageous to use a robotic system to perform large craniectomies, especially in cosmetically relevant areas due to its advantage in accuracy and speed compared to a surgeon.

Continuous monitoring of cerebral tissue pressure in neurosurgical practice—experiences with 100 patients

The authors present their experience with the use of continuous monitoring of cerebral tissue pressure (CTP) in a neurosurgical intensive care unit. The CTP was monitored in 100 patients with a variety of neurosurgical diseases. In 13 patients simultaneous recording of the ventricular fluid pressure (VFP) was carried out for up to 134 h. In 21 patients intrahemispheric gradients of CTP were recorded and in 66 patients CTP alone was recorded (59 supratentorial, 7 infratentorial). In general CTP monitoring gave excellent results with no additional risk to the patient and low costs for the monitoring system. The behaviour of CTP in various clinical conditions and the indications and limitations of CTP monitoring compared with VFP or epidural pressure monitoring are outlined. The authors recommend monitoring of VFP as the method of choice in ICP supervision. Continuous monitoring of CTP is the preferred method in the posterior fossa, after large craniectomies, for postoperative supervision following open surgery and in cases of narrowed ventricles.