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Head Injury
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
Decompressive craniectomy is a neurosurgical procedure where a very large proportion of a patient’s skull (lateral or frontal) is removed to allow the brain to expand. This is a procedure with a high morbidity and is only used as a last result for life-threatening intracranial pressure rises when all medical therapies have failed. In a recent study, decompressive craniectomy was found to result in 22% more survivors (compared to thiopentone), but of those, six were left in a vegetative state with eight having lower severe disability. Only eight had upper severe disability or better.16 This raises considerable ethical problems and the need for good patient selection.
Clinical aspects of head injury
Published in Helen Whitwell, Christopher Milroy, Daniel du Plessis, Forensic Neuropathology, 2021
Decompressive craniectomy A particularly contentious issue is the role of surgery for generalised brain swelling in the absence of a focal mass lesion. Although the removal of a generous calvarial bone flap is commonly performed as an adjunct to evacuation of an acute subdural haematoma, the role of such external decompression alone, for progressive and diffuse brain swelling, remains a subject of debate. Two major studies have addressed this question and produced varying results (decompressive craniectomy in diffuse traumatic brain injury study – DECRA, and the Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure trial – RESCUE ICP). The number of good recoveries is, overall, the same with decompressive surgery and with best medical treatment alone (Hutchinson et al. 2016). Notwithstanding these study results, the younger patient, who displayed good motor responses before being ventilated, and who then develops progressively rising ICP, may well benefit from a craniectomy. In an older patient, in a person with significant co-morbidity and for the individual who was comatose from the outset, such surgical intervention may reasonably be deemed futile.
Understanding medications and medical investigations
Published in Ross Balchin, Rudi Coetzer, Christian Salas, Jan Webster, Addressing Brain Injury in Under-Resourced Settings, 2017
Ross Balchin, Rudi Coetzer, Christian Salas, Jan Webster
When there is raised (intracranial) pressure inside the skull, a decompressive craniectomy may be performed. This involves removing a piece of the skull for an extended period of time. Another procedure used for raised intracranial pressure (e.g. due to TBI or stroke) is intracranial pressure monitoring. Here, a device (there are various types) is placed inside the skull to check on pressure levels so that action can be taken if necessary.
Post-traumatic hydrocephalus may be associated with autologous cranioplasty failure, independent of ventriculoperitoneal shunt placement: a retrospective analysis
Published in British Journal of Neurosurgery, 2022
Carole S. L. Spake, Dardan Beqiri, Vinay Rao, Joseph W. Crozier, Konstantina A. Svokos, Albert S. Woo
The initial indications for decompressive craniectomy were as follows: cerebrovascular (88.9%), traumatic brain injury (4.7%), intractable intracranial pressure or herniation (3.9%), resection of neoplasm (1.6%), and gunshot wound (0.8%). Overall, the proportion of these indications were similar between the success and failure groups (p = 0.8) (Table 2). In our cohort, the average craniectomy defect circumference was 40.4 ± 5.6 cm, with a range of 23.4–59.2 cm. There was no difference in size of craniectomy defect between the two groups (p = 0.9). Similarly, the time interval between DC and CP was not significantly different between patients who experienced failure and those who did not (123 ± 78 days vs. 106 ± 82 days, respectively, p = 0.4). Of note, we identified a greater rate of intermediary surgical procedures at the site of DC prior to CP in the failure group (39% vs. 11%, p = 0.005) compared to the success group. Additional details regarding these procedures can be found in the ‘Predictors of Cranioplasty Failure’ results section below. Other characteristics related to DC and CP can be found in Table 2.
An economic evaluation for the use of decompressive craniectomy in the treatment of refractory traumatic intracranial hypertension
Published in Brain Injury, 2021
Ruqaiyah Behranwala, Nivaran Aojula, Arwa Hagana, Nour Houbby, Dr Laure de Preux
Management of elevated ICP following TBI is complex and often involves following a 3-step protocol. Step 1 involves maintaining an ICP below 25 mm HG, by head elevation, sedation, analgesia, temperature and fluid control. Cerebral perfusion pressure is also monitored and managed to ensure a level between 60 and 70 mm Hg (7). If ICP remains elevated, Step 2 is commenced requiring deeper sedation, moderate hypercapnia, repeat osmotherapy and extraventricular drainage if required. However, when conventional treatment using medical therapy fails to lower ICP, Step 3 may be required involving surgical management through decompressive craniectomy to prevent further deterioration (8). Decompressive craniectomy directly reduces ICP by removing a portion of the skull, increasing space and allowing the brain to swell without constraint (9). Previous studies have shown mixed results or no significant improvements for treating refractory intracranial hypertension with decompressive craniectomy compared to standard medical treatment alone, following TBI (10–13). However, several clinical trials have also reported promising evidence indicating improved prognosis and outcomes in those patients receiving a decompressive craniectomy (14,15), particularly within a recent trial reported in 2016 (16).
Retrospective analysis of nontraumatic subdural hematoma incidence and outcomes in Egyptian patients with end-stage renal disease on hemodialysis
Published in Renal Failure, 2021
Ahmed Fayed, Ayman Tarek, Mohamed I. Refaat, Sameh Abouzeid, Sohail Abdul Salim, Lajos Zsom, Tibor Fülöp, Karim M. Soliman, Mohamed A. Elmallawany
The burr hole should be wide enough (more than 2.5 cm in diameter) to allow continuous free drainage and prevent recurrence with careful dura coagulation to shrink its edges back to full width [22]. All of the above considerations help in successful drainage and the prevention of recurrence [22]. More commonly, acute subdural hematomas are associated with more impact damage and a rapid increase in intracranial pressure, leading to efficient drainage and preventing recurrence [22]. Attention is required for the increased risk (up to sevenfold in males and 26-fold in females) of acute subdural hematoma in patients receiving anticoagulants [23]. Timing is crucial, as previous studies have illustrated the ‘four-hour rules’ in which mortality rate is 30% for posttraumatic acute SDH in cases operated within four hours compared with 90% if surgery was postponed [24]. This explains that preoperative cases died (13 cases) largely from coagulopathy because they were not prepared for surgical intervention. In conjunction with duroplasty, a decompressive craniectomy flap was performed in our cohort with at least 12 cm in diameter. Both requirements are mandatory for achieving a decrease in intracranial pressure below 20 mmHg postoperatively. Kurland et al. demonstrated a survival outcome of 86.7% in SDH cases who underwent decompressive flap and duroplasty [25]. The authors concluded that decompressive craniectomy is an efficient lifesaving way to regulate elevated intracranial pressure, which accounts for the drastic increase in the use of this procedure.