Large Decompressive Craniectomy Research Articles

Risk Factor Analysis of Cryopreserved Autologous Bone Flap Resorption in Adult Patients Undergoing Cranioplasty with Volumetry Measurement Using Conventional Statistics and Machine-Learning Technique.

Decompressive craniectomy (DC) with duroplasty is one of the common surgical treatments for life-threatening increased intracranial pressure (ICP). Once ICP is controlled, cranioplasty (CP) with reinsertion of the cryopreserved autologous bone flap or a synthetic implant is considered for protection and esthetics. Although with the risk of autologous bone flap resorption (BFR), cryopreserved autologous bone flap for CP is one of the important material due to its cost effectiveness. In this article, we performed conventional statistical analysis and the machine learning technique understand the risk factors for BFR. Patients aged >18 years who underwent autologous bone CP between January 2015 and December 2021 were reviewed. Demographic data, medical records, and volumetric measurements of the autologous bone flap volume from 94 patients were collected. BFR was defined with absolute quantitative method (BFR-A) and relative quantitative method (BFR%). Conventional statistical analysis and random forest with hyper-ensemble approach (RF with HEA) was performed. And overlapped partial dependence plots (PDP) were generated. Conventional statistical analysis showed that only the initial autologous bone flap volume was statistically significant on BFR-A. RF with HEA showed that the initial autologous bone flap volume, interval between DC and CP, and bone quality were the factors with most contribution to BFR-A, while, trauma, bone quality, and initial autologous bone flap volume were the factors with most contribution to BFR%. Overlapped PDPs of the initial autologous bone flap volume on the BRF-A crossed at approximately 60 mL, and a relatively clear separation was found between the non-BFR and BFR groups. Therefore, the initial autologous bone flap of over 60 mL could be a possible risk factor for BFR. From the present study, BFR in patients who underwent CP with autologous bone flap might be inevitable. However, the degree of BFR may differ from one to another. Therefore, considering artificial bone flaps as implants for patients with large DC could be reasonable. Still, the risk factors for BFR are not clearly understood. Therefore, chronological analysis and pathophysiologic studies are needed.

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.

Clinical Value of TCCD for Evaluating the Prognosis of Patients with Severe Traumatic Brain Injury After Large Decompressive Craniectomy: A Retrospective Study.

It is challenging to assess the prognosis of patients with severe traumatic brain injury (sTBI) after large decompressive craniectomy (DC). The aim of this study was to evaluate the clinical value of transcranial color-coded duplex sonography (TCCD) for assessing the prognosis of sTBI patients 6 months after large DC. This was a retrospective observational study that consecutively enrolled 84 patients with sTBI who were followed up for prognosis until 6 months after large DC. The primary endpoint was the Glasgow Outcome Score (GOS). According to the GOS, patients were divided into an unfavorable prognosis group (GOS 1-3, n = 47) and a favorable prognosis group (GOS 4-5, n = 37). Significant between-group differences were found in age and hemodynamic parameters (systolic peak blood flow velocity, end-diastolic blood flow velocity, mean blood flow velocity, pulsatility index and resistance index) of the middle cerebral artery detected by TCCD (P < 0.05 for all). Subsequently, ridge regression was used to build a prognostic model for patients with large DC. Based on the cerebral hemodynamic parameters measured by TCCD and age, the mean (± standard deviation) area under the curve of the prognostic model in patients with sTBI after large DC was 0.76 ± 0.22. The sensitivity and specificity were 82.08% and 74.17%, respectively. The cerebral hemodynamic parameters detected by TCCD, combined with age, may be used to predict the outcomes of patients with sTBI at 6 months after large DC. As a noninvasive method, TCCD has the potential to assess the prognosis of these patients. ChiCTR: ChiCTR1800019758. Registered 27 November 2018-retrospectively registered ( http://www.chictr.org.cn/index.aspx ).

Size does matter: The role of decompressive craniectomy extent for outcome after aneurysmal subarachnoid hemorrhage.

In previous studies in patients with traumatic brain injury and ischemic stroke, the size of decompressive craniectomy (DC) was reported to be paramount with regard to patient outcomes. We aimed to identify the impact of DC size on treatment results in individuals with aneurysmal subarachnoid hemorrhage (SAH). The extent of DC in 232 patients with SAH who underwent bifrontal or hemicraniectomy between January 2003 and December 2015 was analyzed using semi-automated surface measurements. The study endpoints were course of intracranial pressure (ICP) treatment after DC, occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6months (defined as modified Rankin scale score >3). The associations of DC size with the study endpoints were adjusted for DC timing, patient age, clinical and radiographic severity of SAH, aneurysm location, and treatment modality. The mean DC surface area was 100.9 (±45.8) cm2 . In multivariate analysis, a large DC (>105cm2 ) was independently associated with a lower risk of cerebral infarcts (adjusted odds ratio [aOR]0.30, 95% confidence interval [CI]0.16-0.56), in-hospital mortality (aOR 0.28, 95%CI0.14-0.56) and unfavorable outcome (aOR 0.51, 95% CI0.27-0.98). Moreover, SAH patients with a small DC size (<75cm2 ) were more likely to require prolonged (>3days, aOR 3.60, 95% CI1.37-9.42) and enhanced (aOR2.31, 95% CI1.12-4.74) postoperative ICP treatment. This is the first study showing the impact of DC size on postoperative ICP control and patient outcome in the context of SAH; specifically, a large craniectomy flap (>105cm2 ) might lead to better outcomes in SAH patients requiring decompressive surgery.

Outcomes after large decompressive craniectomy in patients with subarachnoid haemorrhages

Subarachnoid haemorrhage (SAH) accounts for 5% of all strokes. Estimations suggest fatality rates of ~30% and about 20% rates of functional dependency, with major impact on years of life lost1 . Intracranial hypertension (defined as an intracranial pressure >20 mm Hg) occurs in up to 50% of patients with SAH, during at acute (<24 hours), subacute (up to 7-10 days), and late (after 10 days) stages. This frequent complication contributes to secondary brain injury and independently predicts unfavorable outcome. Up to date, treating intracranial hypertension still represents a major therapeutic target for improving outcome in patients with SAH3 .

Abstract P197: Impact of Cranioplasty on Neurological Recovery in Syndrome of the Trephined: A Prospective Longitudinal Study

Introduction: Syndrome of the Trephined (SoT) is a common and underdiagnosed complication after decompressive craniectomy (DC). This study aimed to address the knowledge gap in SoT incidence, risk factors, and the impact of cranioplasty timing on neurological recovery. Methods: In a prospective single-center study we examined 40 consecutive patients that underwent a large DC and cranioplasty for diverse etiologies. The participants underwent a cognitive, motor, and radiological evaluation 1-4 days before and after cranioplasty. SoT was diagnosed when neurological symptoms worsened before cranioplasty (’a priori’) or a neurological improvement was observed after cranioplasty without previous overt symptoms (’a posteriori’). The primary outcome was the occurrence of SoT, and secondary outcome was improvement of disability after cranioplasty (mRS 0-3 as good outcome). We used logistic regression models to assess risk factors for SoT and the impact of cranioplasty timing on neurological recovery. Hemorrhagic lesions were defined as initial brain injury or DC-related intraparenchymal or subarachnoid hemorrhage. Radiologic signs were sinking skin flap, paradoxical midline shift, or slit-like ventricle. Results: Of 40 patients enrolled, 14 (35%) developed ’a priori’ and 12 (30%) ’a posteriori’ SoT. Cranioplasty resulted in mRS improvement in 7 (18%) patients 1-4 days after surgery. A shift towards good outcome was observed 1-4 days post-cranioplasty (62% vs. 42%, p=0.025) and at 90 days (73% vs. 42%, p=0.005) compared to 1-4 days pre-cranioplasty in the SoT group, but not in the non-SoT group. A composite score (0-3) of traumatic brain injury, hemorrhagic lesions, and radiologic markers had 92% sensitivity and 86% specificity to predict SoT. Increasing delay to cranioplasty was associated with decreased odds of disability improvement after cranioplasty, when adjusting for age and baseline disability (OR 0.96, p=0.03). Conclusions: In this prospective study, SoT occurred more frequently than previously reported after DC. Earlier cranioplasty was associated with neurological improvement. A proposed 3-variable score could help predict SoT and better allocate scarce rehabilitation resources by warranting an earlier cranioplasty.

Sinking Skin Flap Syndrome: Cause of Secondary Neurological Deterioration

Introduction: Sinking skin flap syndrome is a rare complication of craniectomy, which is performed as a treatment of severe intracranial hypertension. Cases Reports: The first case is a 55 year old man. Admitted with Glascow score of 13/15, rapid neurological deterioration was noted with a GCS of 9/15, and then anisocoria. CT scan had objectified hemorrhagic contusions, subdural hematoma measured 11 mm and deviation of the median line. The patient was operated with evacuation of the subdural hematoma through a large decompressive craniectomy. In the second month, he presented a cranial deformation with a deepening of the cutaneous plane, with deterioration of the neurological status and a generalized convulsive crisis. The second case is that of a 32 year old man, admitted to the emergency room with 8/15 of GCS with anisocoria. CT scan was showing an 11 mm right subdural hematoma with a hemorrhagic contusion opposite, a 12 mm midline deviation and diffuse cerebral edema. The patient was operated with evacuation of the subdural hematoma through a large craniectomy. The neurological examination after the extubation showed a GCS of 14. Two days later, the patient presented a depression of the right scalp with an aspect of skin flap syndrome on CT scan without significant neurological deterioration. Conclusion: The role of decompressive craniectomy in neurological improvement in still uncertain, and timing of cranioplasty is more debate: early with unclear neurologic status and preventing the skin flap syndrome or delete after final outcome.

Comparison of Clinical Outcome between Craniectomy and Craniotomy as Surgical Management of Traumatic Acute Subdural Hematoma: A Systematic Review and Meta-analysis

BACKGROUND: Acute subdural hematoma (ASDH) is a major problem in traumatic brain injury. Surgical techniques for treating ASDH are varied, including cranioplastic craniotomy and large decompressive craniectomy. The superiority of craniectomy and craniotomy for treating ASDH is still controversial.&#x0D; AIM: The aim of this study was to compare the clinical outcome between craniectomy and craniotomy for treating traumatic ASDH through systematic review and meta-analysis.&#x0D; METHODS: This study used electronic articles published in PubMed, EBSCO, Google Scholar, and Directory of Open Access Journal. Articles included were full-text observational studies in Indonesian or English. Clinical outcome using the Glasgow Outcome Scale was compared between craniectomy and craniotomy. Statistical analysis was done using Review Manager 5.3.&#x0D; RESULTS: Six articles met our inclusion and exclusion criteria. We performed random effect model analysis because of high heterogeneity between studies (I2 = 77%; X2 = 21.98). The pooled risk ratio between craniectomy and craniotomy on poor outcomes was 1.41 (p = 0.02; 95% CI: 1.06–1.88).&#x0D; CONCLUSION: Craniectomy increases the risk of poor clinical outcomes in treating a traumatic ASDH.

Syndrome of the Trephined: Quantitative Functional Improvement after Large Cranial Vault Reconstruction.

Large decompressive craniectomies may be life-saving; however, they may also result in syndrome of the trephined. This postrecovery sequela is characterized by dizziness, fatigue, depression, weakness, speech slowing, gait disturbance, and impaired mentation. Because this entity is poorly understood, the authors attempted to quantify the functional improvement in patients with syndrome of the trephined after cranial vault reconstruction. Patients with cranial vault defects (>50 cm) from trauma, meningioma, and hemorrhage were studied preoperatively and postoperatively (6 months) after cranial vault reconstruction using (1) the Cognistat Active Form and (2) the Functional Independence Measure instrument (n = 40). Cranial vault reconstructive techniques varied from split cranial bone to alloplastic implants (polyetheretherketone or titanium mesh). Of the 143 patients treated with decompressive craniectomies, 28 percent (n = 40) developed symptoms of syndrome of the trephined. A larger craniectomy defect size correlated with development of syndrome of the trephined. Time from craniectomy to presentation of symptoms was 4.5 months. Time from craniectomy to cranial vault reconstruction was 6.1 months. Time from cranial vault reconstruction to symptom improvement was 4.3 days. Complete functional recovery of syndrome of the trephined was seen in 70 percent. Type of cranial vault reconstruction included polyetheretherketone implant (57.5 percent), split calvarial graft (22.5 percent), and titanium mesh (20 percent), and was not a determinant of functional improvement. Cognistat assessment score noted improvement (from 38 to 69); likewise, the Functional Independence Measure measurement tool showed improvement (from 38 to 98). Syndrome of the trephined occurs more frequently than previously described in posttraumatic patients with large cranial vault defects. Cranial vault reconstruction leads to significant, quantifiable functional improvement in a large number of patients. Therapeutic, IV.

Epileptic Syndrome and Cranioplasty: Implication of Reconstructions in the Electroencephalogram

In the presence of a skull deformity after large decompressive craniectomy (DC), neurologic deterioration manifesting as epileptic syndrome (ES) may occur independently of the primary disease or spontaneous improvement may be unduly impaired, and these unfavorable outcomes have sometimes been reversed by cranioplasty. The objective of this study was to analyze the influence of cranioplasty on the presence of ES in patients who underwent DC. A prospective study was performed from October 2016 to October 2017 involving patients who underwent DC and subsequent cranioplasty. Electroencephalographic (EEG) status before and after cranioplasty was analyzed in the presence of seizures and was compared with results after DC. The sample included 52 patients. Male sex (78.8%) and traumatic brain injury (82.7%) were common indications for DC. ES after DC was verified in 26.9% of patients, and 50% of patients presented with abnormal EEG status. ES after cranioplasty was noted in 21.2% and 36.3% of patients followed by abnormal EEG status. All patients with precranioplasty epileptogenic paroxysms showed better EEG tracings after the procedure. In routine clinical practice, altered amplitudes were observed in the region of bone defects. Although cranioplasty reduced pathologic EEG status (epileptogenic paroxysms), it was not able to produce new EEG tracings that could predict changes in seizure discharge or reduce ES.

Optimal Bone Flap Size for Decompressive Craniectomy for Refractory Increased Intracranial Pressure in Traumatic Brain Injury: Taking the Patient's Head Size into Account

Decompressive craniectomy (DC) is a widely used treatment for refractory high intracranial pressure (ICP). While the Brain Trauma Foundation guidelines favor large DC, there remains a lack of consensus regarding the optimal size of DC in relationship to the patient's head size. The aim of this study is to determine the optimal size of DC to effectively control refractory ICP in traumatic brain injury and to measure that size with a method that takes into consideration the patient's head size. All cases of unilateral DC performed to control refractory increased ICP due to cerebral edema during a 7½-year period were included. Demographic and injury-related data were collected by retrospective chart review. The patients were categorized in 2 groups: 21 patients with a "small flaps" and 9 patients with a "large flap." Two groups had similar preoperative characteristics. The amount of cerebrospinal fluid drained and the doses of hyperosmolar therapy given were not different between the 2 groups. The postoperative ICP was significantly lower for the large craniectomy flap group: 13.3 mm Hg confidence interval 99% [12.7, 13.8] versus 16.9mm Hg confidence interval 99% [16.5, 17.2] (P= 0.01), and this difference was maintained for 96 hours postoperatively. Better ICP control was achieved in patients who underwent a large decompressive craniectomy (ratio >65%) when compared with smaller craniectomy sizes. The proposed method of measuring the craniectomy size, to our knowledge, is the first to take into account the patient's head size and can be easily measured intraoperatively.

Sinking flap syndrome revisited: the who, when and why.

The sinking flap syndrome (SFS) is one of the complications of decompressive craniectomy (DC). Although frequently presenting with aspecific symptoms, that may be underestimated, it can lead to severe and progressive neurological deterioration and, if left untreated, even to death. We report our experience in a consecutive series of 43 patients diagnosed with SFS and propose a classification based on the possible etiopathogenetic mechanisms. In 10years' time, 43 patients presenting with severely introflexed decompressive skin flaps plus radiological and clinical evidence of SFS were identified. We analysed potential factors involved in SFS development (demographics, time from decompression to deterioration, type, size and cause leading to DC, timing of cranioplasty, CSF dynamics disturbances, clinical presentation). Based on the collected data, we elaborated a classification system identifying 3 main SFS subtypes: (1) primary or atrophic, (2) secondary or hydrocephalic and (3) mixed. Very large DC, extensive brain damage, medial craniectomy border distance from the midline < 2cm, re-surgery for craniectomy widening and CSF circulation derangements were found to be statistically associated with SFS. Cranioplasty led to permanent neurological improvement in 37 cases. In our series, SFS incidence was 16%, significantly larger than what is reported in the literature. Its management was more complex in patients affected by CSF circulation disturbances (especially when needing the removal of a contralateral infected cranioplasty or a resorbed bone flap). Although cranioplasty was always the winning solution, its appropriate timing was strategical and, if needed, we performed it even in an emergency, to ensure patient's improvement.

Diagnosis and treatment of post-traumatic occlusion of internal carotid artery: A report of three cases

Objective To investigate the clinical characteristics, diagnosis and treatment strategies of post-traumatic occlusion of internal carotid artery. Methods The clinical data of 3 patients with post-traumatic occlusion of internal carotid artery were analyzed retrospectively who underwent treatment at neurological intensive care unit of Affiliated Hospital of Logistics University of Chinese People’s Armed Police Forces from April 2016 to March 2017. Results Among the 3 patients with massive cerebral infarction treated successfully, 1 underwent conservative treatment and the other 2 received decompressive craniectomy and internal decompression. Followed up for 5-12 months, the patients showed the GOS (Glasgow outcome scale) score of 4 in 1 case and 3 in 2 cases. Conclusions Post-traumatic occlusion of internal carotid artery is relatively rare and easy to be misdiagnosed, which often results in massive cerebral infarction and its prognosis seems to be very poor. Reasonable application of MRI, MRA, CTA and DSA could be helpful for early diagnosis. The major treatment includes early antiplatelet therapy, endovascular treatment and large decompressive craniectomy. Early diagnosis and treatment are important to its prognosis. Key words: Cerebrovascular trauma; Arterial occlusive diseases; Carotid artery, internal; Trauma; Therapy

Applied anatomy of large unilateral frontotemporoparietal decompressive craniectomy

Objective To study the anatomy of unilateral frontotemporoparietal structures of the Chinese people and to provide the anatomical basis for approach design in large craniectomy. Methods Large unilateral frontotemporoparietal decompressive craniectomy were performed on 15 corpse skulls. Through dissection layer by layer, anatomical landmarks were identified and relevant data were documented. Results The vertical distance between the distal point of posterior edge of parietal eminence and the external auditory canal was 79.90±4.06 mm. The distance from the midpoint between nasal root and external occipital protuberance to the midpoint of zygomatic arch was 144.60±4.73 mm. The distance between the eyebrow arch and the parietal eminence was 163.50±4.75 mm. Within the bone window, the longest distance between arachnoid granulation in the superior sagittal and midline was 19.62±3.98 mm. The vertical distance between the superior margin of zygomatic arch and the point where the Sylvian vein drains into sphenoparietal sinus was 25.26±3.77 mm. Conclusions In order to achieve adequate decompression, the vertical distance from the farthest point of skin incision around parietal eminence to the external auditory canal should not be less than 8 cm, the bone window could be 2 cm from the midline, and the lower margin of the bone could be located at the upper margin of zygomatic arch. Key words: Craniology; Anatomy; Decompressive hemicraniectomy

Abstract 20: Syndrome of the Trephined: Functional Improvement After Reconstruction of Large Cranial Vault Defects

PURPOSE: Large decompressive craniectomies performed after trauma may be life-saving; however, they may result in ‘Syndrome of the Trephined.’ This post-recovery sequella is characterized by dizziness, fatigue, depression, weakness, speech slowing, gait disturbance, and impaired mentation. This entity is poorly understood. Therefore, we attempted to quantify the functional disturbance in patients with large cranial vault defects and changes after cranial vault reconstruction using accepted functional analysis. METHODS: Patients with large cranial vault defects (>50cm2) were studied preoperatively and postoperatively (6 months) after cranial vault reconstruction using both: 1) Cognistat Active Form and 2) The FIM instrument (Functional Independence Measure) (n=35). Cranial vault reconstructive techniques varied from split cranial bone to alloplastic implants (PEEK) to titanium implants. Complications, reoperations, and patient scores on both outcome instruments were recorded. RESULTS: Of the 140 patients treated with decompressive craniectomies, 35 with large cranial defects were studied. Defects ranged from 55cm2 to 110cm2 with a mean of 65cm2. Reconstructions were: Split cranial bone (74%); alloplastic implants (PEEK) (15%); titanium implants (11%). Timing of postoperative symptom improvement varied with a range of 1 week to 3 months. Cognisant assessment showed functional improvement in 85% of patients undergoing cranial vault reconstruction; mean preop score 38 ± 9 and postop score of 69 ± 11. FIM also showed improvement (score=16 meant total dependence and score 126 meant complete independence): when comparing total preoperative 38 ± 7 to postoperative 98 ± 1 scores. Cognitive scores improved from 11 ± 4 to 26 ± 10 and Motor from 27 ± 10 to 71 ± 10. Type of reconstruction was not a determinant for functional improvement. Split calvarium was the longest procedure but had the least complications. In 2 patients, implants were removed due to infection and Syndrome of Trephined returned. Symptoms once again resolved after the patients underwent a second cranial vault reconstruction. CONCLUSIONS: Syndrome of the Trephined occurs more frequently then previously described in post-traumatic patients with large cranial vault defects; Cranial vault reconstruction leads to symptomatic improvement in large number of patients.

Large decompressive craniectomy combined with vascular reconstruction in patients with severe craniocerebral injury

Aim: This study aims to compare the effect of large decompressive craniectomy combined with vascular reconstruction and traditional decompressive craniectomy in the treatment of severe craniocerebral injury. Methods: Forty-eight cases of severe craniocerebral injury were collected from March 2012 to March 2015 in Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology. Patients undergoing large decompressive craniectomy combined with vascular reconstruction or traditional decompressive craniectomy were randomly divided into two groups: the experimental group and the control group. The hemodynamic changes were observed by computed tomography perfusion, and the postoperative Glasgow Outcome Score (GOS) was analyzed. Results: The cerebral blood flow (CBF) and cerebral blood volume (CBV) scores in experimental group were higher than that in the control group at 1 week and 1 month after the operation (P < 0.05). The mean transit time (MTT) and time to peak (TTP) scores in experimental group were lower than that in the control group at 1 week and 1 month after the operation (P < 0.05). The relative CBF and relative CBV values of the control group in 1 week were higher than that in 1 month, while the relative MTT and relative TTP values in 1 week were lower than that in 1 month. The rate of good recovery (including good and residual cases) in experimental group was higher than that in the control group whereas the rate of poor recovery (including severe disability, vegetative state, and death) in experimental group was lower than that in the control group (P < 0.05). Conclusion: The large decompressive craniectomy combined with vascular reconstruction can not only decrease intracranial pressure but also recover the blood supply of the brain. It deserves the clinical promotion.

Management of the Repeatedly Failed Cranioplasty Following Large Postdecompressive Craniectomy: Establishing the Efficacy of Staged Free Latissimus Dorsi Transfer/Tissue Expansion/Custom Polyetheretherketone Implant Reconstruction.

Postdecompressive craniotomy defect management following failed prior cranioplastyis challenging. The authors describe a staged technique utilizing free muscle transfer, tissue expansion, and custom polyetheretherketone (PEEK) implants for the management of previously failed cranioplasty sites in patients with complicating local factors. Consecutive patients with previously failed cranioplasties following large decompressive craniectomies underwent reconstruction of skull and soft tissue defects with staged free latissimus muscle transfer, tissue expansion, and placement of custom computer-aided design and modeling PEEK implants with a 'temporalis-plus' modification to minimize temporal hollowing. Implants were placed in a vascularized pocket at the third stage by elevating a plane between the previously transferred latissimus superficial fascia (left on the skin) and muscle (left on the dura/bone). Patients were evaluated postoperatively for cranioplasty durability, aesthetic outcome, and complications. Six patients with an average of 1.6 previously failed cranioplasties underwent this staged technique. Average age was 33 years. Average defect size was 139 cm. Average time to procedure series completion was 14.9 months. There were no flap failures. One patient had early postoperative incisional dehiscence following PEEK implant placement that was managed by immediate scalp flap readvancement. At 21.9 month average follow-up, there were no cranioplasty failures. Three patients (50%) underwent 4 subsequent refining outpatient procedures. All patients achieved complete coverage of their craniectomy defect site with hear-bearing skin, acceptable head shape, and normalized head contour. The described technique resulted in aesthetic, durable craniectomy defect reconstruction with retention of native hear-bearing scalp skin in a challenging patient population.

Decompressive craniectomy for arteriovenous malformation-related intracerebral hemorrhage

Arteriovenous malformation (AVM)-related intracerebral hemorrhage (ICH) is the cause of approximately 2–3% of ICH and is an important factor in the significant morbidity and mortality in patients with AVM. Decompressive craniectomy (DC) is a surgical procedure to relieve malignant elevation of intracranial pressure. The use of DC to treat patients with AVM-ICH has been much less common. The present study describes our experience with DC for AVM-ICH and discusses the safety of this procedure. The present retrospective analysis compared 12 consecutive patients treated with DC for AVM-ICH with 23 patients treated with DC for hypertensive ICH. Nine patients were male and three were female, aged from 11 to 53years (mean, 31.7years). Hematoma volumes ranged from 50 to 106ml (mean, 75.8ml). The outcomes were good recovery in one patient, moderate disability in three, severe disability in seven, and vegetative state in one. Complications after DC included subdural hygroma in four patients, hydrocephalus in one, intracranial infection in two, and intracranial hemorrhage in one. No significant difference was found in the incidence of complications between DC for large AVM-ICH and DC for hypertensive ICH. In conclusion, the present study found no significant difference in the incidence of complications between DC for large AVM-ICH and DC for hypertensive ICH. Further investigations including a prospective randomized trial are needed to confirm the safety and efficacy of DC for the treatment of large AVM-ICH.

Retrospective comparison of craniotomy and decompressive craniectomy for surgical evacuation of nontraumatic, supratentorial intracerebral hemorrhage

Surgical evacuation of nontraumatic, supratentorial intracerebral hemorrhage (SICH) is uncommonly performed, and outcomes are generally poor. On the basis of published experimental data and the authors' anecdotal observations, a retrospective chart review study was performed to test the hypothesis that large decompressive craniectomies (DCs), compared with craniotomies, would improve clinical outcomes after surgical evacuation of SICH. For patients with putaminal SICH, DC was associated with a statistically significant improvement in midline shift, compared with craniotomy. Decompressive craniectomies also resulted in a strong trend toward decreased likelihood of poor neurological outcome (modified Rankin Scale score > 3). For patients with lobar SICH, no associations were found between DC or craniotomy and clinical outcomes. For patients selected to undergo surgical evacuation of putaminal SICH, a DC in addition to surgical evacuation of the hematoma might improve outcome.

Incarcerated spinal cord: A preventable surgical debacle

Incarcerated spinal cord: A preventable surgical debacle