Simultaneous cranioplasty and subdural-peritoneal shunting for contralateral symptomatic subdural hygroma following decompressive craniectomy.
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ABSTRACT:
SUBMITTER: Lin MS
PROVIDER: S-EPMC4386681 | biostudies-other | 2015
REPOSITORIES: biostudies-other
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Project description:Cranioplasty (CP) after decompressive craniectomy (DC) for trauma is a neurosurgical procedure that aims to restore esthesis, improve cerebrospinal fluid (CSF) dynamics, and provide cerebral protection. In turn, this can facilitate neurological rehabilitation and potentially enhance neurological recovery. However, CP can be associated with significant morbidity. Multiple aspects of CP must be considered to optimize its outcomes. Those aspects range from the intricacies of the surgical dissection/reconstruction during the procedure of CP, the types of materials used for the reconstruction, as well as the timing of the CP in relation to the DC. This article is a narrative mini-review that discusses the current evidence base and suggests that no consensus has been reached about several issues, such as an agreement on the best material for use in CP, the appropriate timing of CP after DC, and the optimal management of hydrocephalus in patients who need cranial reconstruction. Moreover, the protocol-driven standards of care for traumatic brain injury (TBI) patients in high-resource settings are virtually out of reach for low-income countries, including those pertaining to CP. Thus, there is a need to design appropriate prospective studies to provide context-specific solid recommendations regarding this topic.
| S-EPMC7000464 | biostudies-literature
Project description:In the context of traumatic brain injury (TBI), decompressive craniectomy (DC) is used as part of tiered therapeutic protocols for patients with intracranial hypertension (secondary or protocol-driven DC). In addition, the bone flap can be left out when evacuating a mass lesion, usually an acute subdural haematoma (ASDH), in the acute phase (primary DC). Even though, the principle of "opening the skull" in order to control brain oedema and raised intracranial pressure has been practised since the beginning of the 20th century, the last 20 years have been marked by efforts to develop the evidence base with the conduct of randomised trials. This article discusses the merits and challenges of this approach and provides an overview of randomised trials of DC following TBI. An update on the RESCUEicp study, a randomised trial of DC versus advanced medical management (including barbiturates) for severe and refractory post-traumatic intracranial hypertension is provided. In addition, the rationale for the RESCUE-ASDH study, the first randomised trial of primary DC versus craniotomy for adult head-injured patients with an ASDH, is presented.
| S-EPMC4841020 | biostudies-literature
Project description:BACKGROUND AND PURPOSE:Posttraumatic hydrocephalus affects 11.9%-36% of patients undergoing decompressive craniectomy (DC) after traumatic brain injury and necessitates a ventriculo-peritoneal shunt placement. As bone and arachnoid trabeculae share the same collagen type, we investigated possible connections between the skull Hounsfield unit (HU) values and shunt-dependent hydrocephalus (SDHC) in patients that received cranioplasty after DC for traumatic acute subdural hematoma (SDH). METHODS:We measured HU values in the frontal bone and internal occipital protuberance from admission brain CT. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off skull HU values for predicting SDHC in patients receiving cranioplasty after DC due to traumatic acute SDH. We investigated independent predictive factors for SDHC occurrence using multivariable logistic regression analysis. RESULTS:A total of 162 patients (>15 years of age) were enrolled in the study over an 11-year period from two university hospitals. Multivariable logistic analysis revealed that the group with simultaneous frontal skull HU ?797.4 and internal occipital protuberance HU ?586.5 (odds ratio, 8.57; 95% CI, 3.05 to 24.10; P<0.001) was the only independent predictive factor for SDHC in patients who received cranioplasty after DC for traumatic acute SDH. CONCLUSIONS:Our study reveals a potential relationship between possible low bone mineral density and development of SDHC in traumatic acute SDH patients who had undergone DC. Our findings provide deeper insight into the association between low bone mineral density and hydrocephalus after DC for traumatic acute SDH.
| S-EPMC7192490 | biostudies-literature
Project description:IntroductionAcute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making.MethodsFollowing PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model.ResultsThe meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure.ConclusionThe meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.
| S-EPMC11017056 | biostudies-literature
Project description:BackgroundLimited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy.MethodsWe conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582).FindingsBetween December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]).InterpretationWe found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling.FundingHersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.
| S-EPMC10432786 | biostudies-literature
Project description:Malignant stroke occurs in a subgroup of patients suffering from ischemic cerebral infarction and is characterized by neurological deterioration due to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique aiming to open the "closed box" represented by the non-expandable skull in cases of refractory intracranial hypertension. It is a valuable modality in the armamentarium to treat patients with malignant stroke: the life-saving effect has been proven for both supratentorial and infratentorial DC in virtually all age groups. This leaves physicians with the difficult task to decide who will require early or preemptive surgery and who might benefit from postponing surgery until clear evidence of deterioration evolves. Together with the patient's relatives, physicians also have to ascertain whether the patient will have acceptable disability and quality of life in his or her presumed perception, based on preoperative predictions. This complex decision-making process can only be managed with interdisciplinary efforts and should be supported by continued research in the age of personalized medicine.
| S-EPMC6556035 | biostudies-literature
Project description:Decompressive craniectomy (DC) is often performed as an empirical lifesaving measure to protect the injured brain from the damaging effects of propagating oedema and intracranial hypertension. However, there are no clearly defined indications or specified guidelines for patient selection for the procedure.To evaluate outcome determinants and factors important in patient selection for the procedure.We reviewed the literature on DC, including single case reports and reported case series, to identify factors affecting outcome following the procedure, as well as its pitfalls and associated complications.Glasgow coma score of 8 and above, age less than 50 years and early intervention were found to be among the most significant determinants of prognosis.Improving patient selection for DC may be expected to further improve the outcome following the procedure in severely brain-injured patients.
| S-EPMC3066780 | biostudies-other
Project description:Hyperelastic finite element models, with either an idealized cylindrical geometry or with realistic craniectomy geometries, were used to explore clinical issues relating to decompressive craniectomy. The potential damage in the brain tissue was estimated by calculating the volume of material exceeding a critical shear strain. Results from the idealized model showed how the potentially damaged volume of brain tissue increased with an increasing volume of brain tissue herniating from the skull cavity and with a reduction in craniectomy area. For a given herniated volume, there was a critical craniectomy diameter where the volume exceeding a critical shear strain fell to zero. The effects of details at the craniectomy edge, specifically a fillet radius and a chamfer on the bone margin, were found to be relatively slight, assuming that the dura is retained to provide effective protection. The location in the brain associated with volume expansion and details of the material modeling were found to have a relatively modest effect on the predicted damage volume. The volume of highly sheared material in the realistic models of the craniectomy varied roughly in line with differences in the craniectomy area.
| S-EPMC5112297 | biostudies-literature
Project description:Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.
| S-EPMC4704457 | biostudies-literature
Project description:IntroductionThis study aims to assess the quality of life (QoL) in patients who have undergone decompressive craniectomy (DC) for any pathology that has caused life-threatening intracranial hypertension. Similarly, it aims to evaluate QoL perceived by caregivers or external informants. In addition to that, the last purpose is to determine which clinical or therapeutic factors could correlate with a better QoL.MethodsA single-center cross-sectional study was designed. All patients over 18 years old who underwent a supratentorial DC at our department due to intracranial hypertension of any etiology, from January 2015 to December 2021, were retrospectively selected. Patients with incomplete follow-up (under 1 year from the event or those who died) or who declined to participate in the study were excluded. QoL was assessed with SF-36 and CAVIDACE scales. The correlation between clinical and therapeutic variables and SF-36 subscales was studied with Spearman's correlation and the Mann-Whitney U-test.ResultsA total of 55 consecutive patients were recruited: 22 patients had died, three were missed for follow-up, and 15 declined to participate, thus 15 subjects were finally included. The mean follow-up was 47 months (IQR 21.5-67.5). A significant reduction in the "role physical" and "role emotional" subscales of SF-36 was observed compared with the general population. According to caregivers, a significant reduction was assigned to the "physical wellbeing" and "rights" domains. The "physical functioning" score was poorer in women, older patients, those with dominant hemisphere disease, those who required tracheostomy, and those with poor outcomes in the modified Rankin scale. A strong correlation was found between the QoL index at the CAVIDACE scale and the SF-36 subscales "physical functioning" and "role physical".ConclusionMost patients and caregivers reported acceptable QoL after DC due to a life-threatening disease. A significant reduction in SF- 36 subscales scores "role limitation due to physical problems" and "role limitation due to emotional problems" was referred by patients. According to caregivers' QoL perception, only 25% of the survey's participants showed low scores in the QoL index of the CAVIDACE scale. Only 26.7% of the patients showed mood disorders.
| S-EPMC10410286 | biostudies-literature