Postdecompressive Craniectomy Research Articles

A Systematic Review and Illustrative Case of Post- Decompressive Craniectomy Syndrome Following Traumatic Brain Injury

Post-decompressive craniectomy syndrome (PDCS) is a complication following decompressive craniectomy (DC). PDCS or also known as trephine or sunken skin flap syndrome has an indirect relationship with traumatic brain injury (TBI). The mechanism of PDCS is not yet fully understood and the clinical manifestations are diverse, causing PDCS to often be underdiagnosed. In this study, the authors aim to create a systematic review of PDCS following TBI including a discussion of incidence, clinical and radiological manifestations, management and outcome. This systematic review is conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline. The literature search included electronic databases PubMed, Cochrane, JNS and EMBASE. All studies included were available in English and full-text format. In this research, 42 case reports were obtained. The population was predominantly male (72%) with a mean population age of 44.7 ± 17.3 years. The mean interval for onset and cranioplasty procedure was 80.17 ± 77.34 days and 92.05 ± 77.06, respectively. The most common clinical manifestations were sunken skin flap in the defect area (74%) and decreased consciousness (64%). Paradoxical herniation (74%) was the most common radiological manifestation. There was no connection between the occurrence of PDCS and the size of the defect. Cranioplasty remains the mainstay of management with clinical improvement in 96% of cases. PDCS should be suspected in every patient with symptoms of new neurological deficits after DC. Early management must be carried out to prevent further deterioration.

Modified frontal horn index: a novel risk predictor for sunken flap syndrome in the patients undergoing shunt procedures for post-decompressive craniectomy hydrocephalus

BackgroundDecompressive craniectomy (DC) is a neurosurgical procedure, frequently used in lowering the refractory intracranial pressure (ICP) following traumatic brain injuries. Post-traumatic hydrocephalus (PTH), a debilitating complication in the patients with traumatic brain injuries, occurs in 11.9–36% patients undergoing DCs. Sunken flap syndrome (SFS) is a rare entity, following DCs or cerebrospinal fluid (CSF) diversion procedures for PTH after DCs and leads to neurological deterioration of the patients. Literature regarding risk factors associated with SFS in the patients undergoing ventriculoperitoneal shunt procedures for hydrocephalus following DCs is scarce. The aim of this study is to determine the incidence of SFS and to establish a relationship between several clinico-radiological features and SFS in patients undergoing shunt procedures for PTH.ResultsThis retrospective study was conducted in a tertiary care trauma centre upon 60 patients who underwent shunt procedures for PTH. Intraventricular haemorrhage (P < 0.0001), communicating-type hydrocephalus (P = 0.0006), and modified frontal horn index (P < 0.0001) were significantly associated with development of SFS. MFHI > 43 was a significant risk factor in development of SFS.ConclusionsSFS is the common complication following shunt procedures for PTH after DCs. MFHI is significant risk predictor for SFS. MFHI > 43 is associated with higher chances of developing SFS following shunt insertion in PTH. Early cranioplasty following DCs might prevent development of SFS.

Brain Stem Hemorrhage after Insertion of a Lumbar Drain: An Extremely Rare but Fatal Complication of a Routine Procedure

AbstractDecompressive craniectomy (DC) is a life-saving procedure to control refractory intracranial pressure after traumatic brain injury. Postdecompressive craniectomy hydrocephalus (PDCH) is debilitating complication following DCs. Lumbar drainage (LD) is a temporary measure that is helpful in the assessment of PDCH and its functioning can predict the risks and benefits of definitive cerebrospinal fluid (CSF) diversion procedures. LD is associated with multiple complications. Intracranial hemorrhage is a rare but devastating complication following LD. Here, the authors report a case in which LD was performed as a temporary measure to assess PDCH, resulting in brain stem hemorrhage (BSH). A 45-year-old male underwent DC for severe traumatic brain injury. Patient developed PDCH in postoperative period. LD was done as a bridging procedure for definitive CSF diversion procedure, which resulted in fatal BSH. Authors conclude that although a simple procedure, LD can be associated with fatal BSH. Since drainage of CSF after LD is unpredictable in patients of PDCH, a close monitoring of the functioning of the LD system is required to avoid overdrainage and brain herniations.

Correlation between Transcranial Ultrasound and CT Head to Detect Clinically Significant Conditions in Post-craniectomy Patients Performed by Emergency Physician: A Pilot Study.

The main objective is to detect clinically significant conditions by transcranial ultrasound (TCS) in post-decompressive craniectomy (DC) patients who come to the emergency department. This was a cross-sectional observational study. We studied 40 post-DC patients. After primary stabilization, TCS was done. Computer tomography of head was done within 2 hours of performing TCS. The correlation between both modalities were assessed by the measurement of lateral ventricle (LV) (Bland-Altman plot), Midline shift and mass lesion. Additionally, normal cerebral anatomy, 3rd and 4th ventricles and external ventricular drainage (EVD) catheter visualization were also done. About 14/40 patients came with non-neurosurgical complaints and 26/40 patients came with neurosurgical complaints. Patients with non-neurosurgical complaints (4/14) had mass lesions and 1/14 had MLS. Patients with neurosurgical complaints (11/26) had mass lesions and about 5 patients had MLS. A good correlation was found between TCS and CT of head in measuring LV right (CT head = 17.4 ± 13.8 mm and TCS = 17.1 ± 14.8 mm. The mean difference (95% CI) = [0.28 (-1.9 to 1.33), ICC 0.93 (0.88-0.96)], Left [CT head = 17.8 ± 14.4 mm and TCS = 17.1 ± 14.2 mm, the mean difference (95% CI) 0.63 (-1.8 to 0.61), ICC 0.96 (0.93-0.98)], MLS [CT head = 6.16 ± 3.59 (n = 7) and TCS = 7.883 ± 4.17 (n = 6)] and mass lesions (kappa 0.84 [0.72-0.89] [95% CI] p-value < 0.001). The agreement between both modalities for detecting mass lesions is 93.75%. Point of care ultrasound (POCUS) is a bedside, easily operable, non-radiation hazard and dynamic imaging tool that can be used for TCS as a supplement to CT head in post-DC patients in emergency as well as in ICU. However, assessment of the ventricular system (pre/post-EVD insertion), monitoring of regression/progression of mass lesion, etc. can be done with TCS. Repeated scans are possible in less time which can decrease the frequency of CT head. Chouhan R, Sinha TP, Bhoi S, Kumar A, Agrawal D, Nayer J, et al. Correlation between Transcranial Ultrasound and CT Head to Detect Clinically Significant Conditions in Post-craniectomy Patients Performed by Emergency Physician: A Pilot Study. Indian J Crit Care Med 2024;28(3):299-306.

Evolution of Severe Closed Head Injury: Assessing Ventricular Volume and Behavioral Measures at 30 and 90 Days Post-Injury

Background: Assessing functional outcomes in Severe Closed Head Injury (SCHI) is complex due to brain parenchymal changes. This study examines the Ventricles to Intracranial Volume Ratio (VBR) as a metric for these changes and its correlation with behavioral scales. Methods: Thirty-one SCHI patients were included. VBR was derived from CT scans at 3, 30, and 90 days post-injury and compared with Levels of Cognitive Functioning (LCF), Disability Rating Scale (DRS), and Early Rehabilitation Barthel Index (ERBI) assessments at 30 and 90 days. Results: Ten patients were excluded post-decompressive craniectomy or ventriculoperitoneal shunt. Findings indicated a VBR decrease at 3 days, suggesting acute phase compression, followed by an increase from 30 to 90 days, indicative of post-acute brain atrophy. VBR correlated positively with the Marshall score in the initial 72 h, positioning it as an early indicator of subsequent brain atrophy. Nevertheless, in contrast to the Marshall score, VBR had stronger associations with DRS and ERBI at 90 days. Conclusions: VBR, alongside behavioral assessments, presents a robust framework for evaluating SCHI progression. It supports early functional outcome correlations informing therapeutic approaches. VBR’s reliability underscores its utility in neurorehabilitation for ongoing SCHI assessment and aiding clinical decisions.

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

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

Assessment of Midline Shift in Postdecompressive Craniectomy Patients in Neurocritical Care: Comparison between Transcranial Ultrasonography and Computerized Tomography.

Monitoring and evaluation of intracranial structures remain a fundamental element in the neurointensive care unit. Most used technique to monitor progression is the use of computed tomography (CT) in intracranial hemorrhage (ICH) or stroke. Rapid assessment of brain pathology can be made using CT to analyze the midline shift (MLS), hematoma expansion, and ventricular size, but transferring a patient who is intubated is time and resource-consuming task. Ultrasonography is a noninvasive technique, portable, and has the possibility of fast interpretation. To measure the brain MLS in decompressive craniectomy patients using transcranial ultrasonography (TCS) and compare the correlation of these results with CT scan measurements of MLS in the same patient. Patients who have undergone decompressive craniectomy due to various reasons like ICH, traumatic brain injury, etc., and have a MLS. Trans cranial ultrasonography was assessed by a single consultant (Neuro Critical Care Intensivist) who was blinded for the CT scan measurement. CT scan measurement of MLS was assessed by a neuroradiologist using standard guidelines, who was blinded for the TCS results of MLS. The finding of a MLS >0.5 cm in the CT scan was considered a significant MLS. A total of 31 patients were recruited for the study. MLS measured using CT was 0.91 ± 0.67 cm. MLS via TCS was 0.91 ± 0.66 cm. A significant MLS via TCS was found in 77.4%. Intraclass correlation coefficient (ICC) was calculated between CT-MLS and TCS MLS and obtained the value of ICC as 0.996, indicating an almost perfect agreement. Patients after decompressive craniectomy may present as an ideal candidate to visualize intracerebral anatomy with a high resolution. TCS might be considered as an alternative to CT to measure MLS in decompressive craniectomy patients.

Contemporary Review on Craniectomy and Cranioplasty; Part 1: Decompressive Craniectomy.

This paper aims to review clinical benefits of decompressive craniectomy (DC) in both adult and paediatric populations; its indications and factors contributing to its postoperative success. The Glasgow Outcome Scale and the Modified Rankin Scale are the most commonly used scales to assess the long-term outcome in patients post DC. In adult traumatic brain injury patients, 2 randomized clinical trials were carried out; DECRA (Decompressive Craniectomy in Diffuse Traumatic Brain Injury) and RESCUEicp (Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of inter cranial pressure) employing collectively 555 patients. Despite the differences in these trials, their initial results affirm DC can lead to reduced mortality and more favorable outcomes. In ischemic stroke adult patients, different clinical trials of HAMLET (Dutch trial of Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema), DESTINY (German trial of Decompressive Surgery for the treatment of Malignant Infarct of the Middle Cerebral Artery), and DECIMAL (French trial of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarcts) suggested that DC improves survival compared with best medical management, but with an increased proportion of treated individuals surviving with moderate or severe disability. With regard to the size of bone to be removed, the larger the defect the better the results with a minimum diameter of 11 to 12 cm of bone flap. Cranioplasty timing varies and ranges from 6 weeks to more than 12 months post DC, depending on completion of medical treatment, clinical recovery, resolution of any infection, and an evaluation of soft tissues at the defect site.

Death, a Rare Complication of Cranioplasty in Emergency: A Case Report

Cranioplasty is a reconstructive procedure which is performed to restore the calvarial integrity with either a stored autologous bone flap or a custom synthetic prosthesis. It is performed to protect the brain and as a cosmetic procedure. It has been shown to improve patient’s functional outcome. This procedure has been performed as early as &lt;14 days postdecompressive craniectomy. Cranioplasty in emergency which is a variant of secondary cranioplasty is rarely indicated after decompressive craniectomy. Complication rate associated with cranioplasty is relatively high. Infection, convulsions, and epidural haematoma are frequent complications of cranioplasty which are not life threatening. Fatal complications associated with this procedure are not well documented and that could be among one of the reason that death, as a complication following cranioplasty is substantially low. Here, a case of unexpected death of a 37-year-old female postcranioplasty which was performed as an emergency procedure is reported. She was a previous case of right mid one-third parasagittal meningioma who developed severe sinking skin flap syndrome after three months of parasagittal craniectomy. The patient was operated under general anaesthesia for reconstruction of the residual calvarial defect. However, the patient developed bacterial meningitis and on the 16th day postcranioplasty procedure, she died of cardiac arrest. The procedure had otherwise been uneventful and it was speculated that infection and cerebral oedema postcranioplasty might have been the cause of death.

Patients with ventricular assist device and cerebral entrapment-Supporting skullcap reimplantation.

Effects of cranioplasty (CP) and skullcap reimplantation after decompressive craniectomy (DC) for cerebral hemorrhage or malignant brain infarction in patients with left ventricular assist device (LVAD) support as bridge to transplantation has not been surveyed yet. The aim of this study was to evaluate outcome and management after CP when aiming for transplantation. Data were collected from our prospective institutional database including all patients undergoing LVAD implantation between 2010 and 2019. Six patients needed CP procedures and were included. Our analysis focused on postoperative outcome, survival, and facilitation of heart transplantation. Study endpoints included also all-cause mortality. From a total of 1010 LVAD implantations during analysis period in our center, six bridge-to-transplantation LVAD patients [median age at LVAD implantation: 32.5years (IQR: 24.8-39.5years); four male, HVAD, n=3; HM II, n=1; HM 3, n=2] underwent CP with imminent entrapment secondary to cerebral hemorrhage or malignant infarction. Primary heart failure etiology was myocarditis (n=2), dilated (n=2), or ischemic (n=2). Median INTERMACS class was 1.5 (IQR; 1.0-2.8). Median time on LVAD support to DC procedure was 33months (IQR: 16-48months). The indication for DC was intraparenchymal hemorrhage (n=4), subdural hematoma (n=1), and malignant middle cerebral artery infarction (n=1). After a median time of 4months (IQR: 3.3-4.0months, range; 2.0-10months) post DC procedure, CP was subsequently performed without profound neurologic disabilities in all patients. After median time of 26months (IQR: 21-42months) follow-up, three patients successfully received heart transplantation, one patient could undergo LVAD explantation for myocardial recovery, and the remaining two patients are still on the list awaiting heart transplantation. CP procedure with skullcap reimplantation is feasible and can be safely performed in LVAD patients, which subsequently may even be eligible for heart transplantation with beneficial prognosis.

Relationship between early cranioplasty and outcomes of traumatic brain injury in adult patients

Objective To investigate the effects of early cranioplasty post decompressive craniectomy on the outcomes of traumatic brain injury in adult patients. Methods A retrospective analysis was conducted on the clinical data of 72 adult postoperative patients with traumatic brain injury who were admitted to Department of Neurosurgery, Zhongshan Hospital, Xiamen University from January 2015 to June 2017. According to the timing of cranioplasty, the patients were divided into early group (≤3 months after operation, 30 cases) and conventional group (>3 months after operation, 42 cases). The differences in the Glasgow outcome scale (GOS) score, Karnofsky performance scale(KPS) score and mini-mental state examination(MMSE) score between the two groups were compared at 6 months postoperatively, and the rates of postoperative complications were also compared. Results Compared with the conventional group, the GOS change values [the median(lower interquartile, upper interquartile): 1.0(1.0, 1.0)points vs. 1.0(0, 1.0)points], postoperative KPS (70.3±23.3 points vs. 58.8±17.3 points) and MMSE scores (21.0±7.7 points vs. 17.5±6.2 points) were significantly improved in the early group, and the differences were statistically significant (all P 0.05). Conclusion Compared with cranioplasty at 3 months post operation, early cranioplasty does not seem to increase the incidence of postoperative complications and has more significant improvement in the outcomes of patients. Key words: Craniocerebral trauma; Cranioplasty; Decompressive craniectomy; Early; Prognosis

Epidural multi-slitted microporous non-absorbable patch in decompressive craniectomy to facilitate cranioplasty: a preliminary study

Developing a surgical plane between the temporalis muscle and the dura is the most technically challenging step when performing cranioplasty for post-decompressive craniectomy defects. The authors report a simple technique to demarcate this surgical plane by laying a multi-slitted, microporous polyesterurethane (MPU) patch during decompressive craniectomy. Specifically, they tried to avoid creating potential spaces around the patch, which is the inherent drawback of published anti-adhesive techniques. In 21 patients undergoing decompressive craniectomy, and in 11 of them subsequently undergoing cranioplasty, there was no wound related complications. During cranioplasty, no epidural fluid collection was found; the patch could be separated from the temporalis muscle and the dura with blunt dissection leaving the muscle intact. They conclude that their epidural MPU patch technique is a safe technique, and appears useful to facilitate cranioplasty by helping the surgeon in developing the surgical plane between the temporalis muscle and the dura during cranioplasty.

Cerebral Microdialysis: Going Deep into Brain Biochemistry for a Better Understanding of Pathomechanisms of Acute Brain Injury

AbstractPatients with traumatic brain injury (TBI) have variable outcomes subject to intracranial hypertension, ischemia, hypotension, and various biochemical alterations. Multimodality neurointensive monitoring is standard of care for decision making in all severe TBI cases at present in most neurotrauma units. Neuromonitoring tools, such as cerebral microdialysis, may contribute to understanding the pathomechanisms of acute brain injury, provide an early warning of secondary cerebral deterioration (therapeutic window of opportunity), and help in selecting the patients most suitable to benefit from this very invasive surgical rescue therapy. Cerebral microdialysis can be used as a measure of the effect of decompressive craniectomy on neurochemistry derangement and brain energy crisis jeopardizing the injured brain. Present review discusses the cerebral microdialysis, its usefulness, and role in prognostication of severe TBIs, especially in patients post-decompressive craniectomy. The authors also discuss the current consensus guidelines on usage of cerebral microdialysis in TBI patients.

The clinical application of transcranial doppler ultrasonography in severe traumatic brain injury post decompressive craniectomy

Objective To explore the clinical application of transcranial doppler ultrasonography (TCD) in severe traumatic brain injury (sTBI)post decompressive craniectomy. Methods A retrospective study was conducted on 58 patients with sTBI who were admitted to Neurosurgical Intensive Care Unit of Tangdu Hospital, the Fourth Military Medical University From January 2015 to October 2016. All patients underwent hematoma evacuation, decompressive craniectomy and placement of intracerebral pressure (ICP) probe. The parameters of cerebral blood flow including mean velocity (Vmean), end of diastolic (Vedv) and pulsatility index (PI) in sTBI patients were measured by TCD post operation to assess the cerebral blood supply. Results The trend of Vmean and Vedv manifested U-shaped mode during the next 7 days, reaching the lowest levels [(72.5±22.6) cm/s and (43.6±19.8) cm/s, respectively] on day 3. There was significant difference in the value of Vmean between day 3 and day 1, 2, 5, 6, 7 (all P<0.05). There was significant difference in the value of Vedv between day 3 and day 1, 2, 6, 7 (all P<0.05). The trend of pulsatility index (PI) and intracranial pressure (ICP) showed parabolic shape during the next 7 days, reaching the highest level [(1.5±0.7) and (17.2±4.5)mmHg, respectively] on day 4. Significant difference was observed in ICP between day 4 and day 1, 2, 3, 6, 7 (P<0.05). The incidence of cerebral hyperemia showed the trend of declining during the next 7 days. There was significant difference in cerebral hyperemia between day 1 and day 5, 6, 7 (all P<0.05). The incidence of cerebral ischemia was up to 36.2% (12/58) on day 4, and it was significantly higher than that on day 1 (P<0.05). The incidence of cerebral vasospasm showed the rising trend and reached the highest level (15.5%) on day 6, which had significant difference compared with the incidences on day 1, 2 and 3 (all P<0.05). Conclusion TCD, as a noninvasive, portable, easy-to-use monitoring tool, could help effectively evaluate postoperative changes of cerebral hemodynamics in patients with sTBI. Key words: Craniocerebral trauma; Ultrasonography, doppler, transcranial; Decompressive craniectomy

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.

A trephined-szindróma - egy alulbecsült és kevéssé értett komplikáció dekompresszív craniectomia után

Decompressive craniectomy (DC) is still a matter of debate, with a numerous complications as expansion of haemorrhagic contusions, external cerebral herniation, subdural hygromas, post-traumatic hydrocephalus (HC). The often overlooked "syndrome of the trephined" (ST) as a delayed complication of DC also known as sinking skin flap sy initially described in 1939.ST is characterised by the neurological changes associated with alteration of the pressure/volume relationship between intracranial pressure (ICP), volume of cerebrospinal fluid (CSF), blood, and brain tissue in patients with large bone defects. This review aims at elucidating the mechanisms responsible for the development of ST, and providing useful tips and red-flag signs for healthcare professionals involved with care of post DC patients. Symptoms identified on time could help to develop appropriate treatment strategies for this suddenly deteriorating, but possible reversible condition. Although the treatment strategy is straightforward, calling for a prompt cranioplasty, the correction of HC through CSF diversion devices might require a lengthy optimisation period. Continuous changes in the setting of the shunting systems or spinal tap might lead to dangerous swinging of the midline structures causing further neurological deterioration. Thus, finding the right balance in terms of clinical management often represents a significant challenge.

Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications.

ObjectiveTo analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy.MethodsRetrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed.ResultsA total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome.ConclusionThis study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population.

Factors prognosticating the outcome of decompressive craniectomy in severe traumatic brain injury: A Malaysian experience.

Objective:The objective of this prospective cohort study was to analyse the characteristics of severe Traumatic Brain Injury (TBI) in a regional trauma centre Hospital Kuala Lumpur (HKL) along with its impact of various prognostic factors post Decompressive Craniectomy (DC).Materials and Methods:Duration of the study was of 13 months in HKL. 110 consecutive patients undergoing DC and remained in our centre were recruited. They were then analysed categorically with standard analytical software.Results:Age group have highest range between 12-30 category with male preponderance. Common mechanism of injury was motor vehicle accident involving motorcyclist. Univariate analysis showed statistically significant in referral area (P = 0.006). In clinical evaluation statistically significant was the motor score (P = 0.040), pupillary state (P = 0.010), blood pressure stability (P = 0.013) and evidence of Diabetes Insipidus (P < 0.001). In biochemical status the significant statistics included evidence of coagulopathy (P < 0.001), evidence of acidosis (P = 0.003) and evidence of hypoxia (P = 0.030). In Radiological sector, significant univariate analysis proved in location of the subdural clot (P < 0.010), location of the contusion (P = 0.045), site of existence of both type of clots (P = 0.031) and the evidence of edema (P = 0.041). The timing of injury was noted to be significant as well (P = 0.061). In the post operative care was, there were significance in the overall stability in intensive care (P < 0.001), the stability of blood pressure, cerebral perfusion pressure, pulse rates and oxygen saturation (all P < 0.001)seen individually, post operative ICP monitoring in the immediate (P = 0.002), within 24 hours (P < 0.001) and within 24-48 hours (P < 0.001) period, along with post operative pupillary size (P < 0.001) and motor score (P < 0.001). Post operatively, radiologically significant statistics included evidence of midline shift post operatively in the CT scan (P < 0.001). Multivariate logistic regression with stepwise likelihood ratio (LR) method concluded that hypoxia post operatively (P = 0.152), the unmaintained Cerebral Perfusion Pressure (CPP) (P = 0.007) and unstable blood pressure (BP) (P = <0.001). Poor outcome noted 10.2 times higher in post operative hypoxia [OR10.184; 95% CI: 0.424, 244.495]. Odds of having poor outcome if CPP unmaintained was 13.8 times higher [OR: 13.754; CI: 2.050, 92.301]. Highest predictor of poor outcome was the unstable BP, 32 times higher [OR 31.600; CI: 4.530, 220440].Conclusion:Our series represent both urban and rural population, noted to be the largest series in severe TBI in this region. Severe head injury accounts for significant proportion of neurosurgical admissions, resources with its impact on socio-economic concerns to a growing population like Malaysia. This study concludes that the predictors of outcome in severe TBI post DC were postoperative hypoxia, unmaintained cerebral perfusion pressure and unstable blood pressure as independent predictors of poor outcome. Key words: Decompressive craniectomy, prognostication of decompressive craniectomy, prognostication of severe head injury, prognostication of traumatic brain injury, severe head injury, severe traumatic brain injury, traumatic brain injury.

Paradoxical Herniation in Wartime Penetrating Brain Injury With Concomitant Skull-Base Trauma

A case of the syndrome of the trephined progressing to paradoxical herniation is presented in a patient with a penetrating brain injury, postdecompressive craniectomy, and a delayed cerebral spinal fluid leak from a skull base defect. The patient had a penetrating head trauma from a high-velocity ballistic projectile during military wartime operations. The patient's clinical course, which demonstrates a rare presentation of central sleep apnea syndrome or Ondine's curse, is reviewed. Radiographic imaging includes sequential computed tomography (CT) scans with and without intrathecal contrast. Medical management was directed at increasing the intracranial pressures (ICPs) by placing the patient into Trendelenburg position and increasing hydration. Surgical intervention involved correction of the skull base defect by intranasal endoscopic repair. A literature review of paradoxical herniation and delayed neurologic decline in postcraniectomy patients is conducted, and the surgical and neurocritical care management is discussed.

Cranioplasty After Postinjury Decompressive Craniectomy: Is Timing of the Essence?

The appropriate timing of cranioplasty after decompressive craniectomy for trauma is unknown. Potential benefits of delayed intervention (>6 weeks) for reducing the risk of infection must be balanced by persistent altered cerebrospinal fluid dynamics leading to hydrocephalus. We reviewed our recent 5-year experience in an effort to improve patient throughput and develop a rational decision making plan. A 5-year query (2003-2007) of our level I neurotrauma database. From 2,400 head injuries, we performed a total of 350 craniotomies. Of the 350 patients who underwent craniotomy for trauma, 70 patients (20%) underwent decompressive craniectomy requiring cranioplasty. Timing of cranioplasty, cranioplasty material, postoperative infections, and incidence of hydrocephalus were evaluated with logistic regression to study potential associations between complications and timing, adjusted for risk factors. No specific time frame was predictive of hydrocephalus or infection, and logistic regression failed to identify significant predictors among the collected variables. In our experience, the prior practice of delayed cranioplasty (3-6 months postdecompressive craniectomy), requiring repeat hospital admission, does not seem to lower postcranioplasty infection rates nor the need for cerebrospinal fluid diversion procedures. Our current practice emphasizes cranioplasty during the initial hospital admission, as soon as there is resolution on computed tomography scan of brain swelling outside of the cranial vault with concurrent clinical examination. This occurs as early as 2 weeks postcraniectomy and should lower the overall cost of care by eliminating the need for additional hospital admissions.