Clinical aspects of head injury
Helen Whitwell, Christopher Milroy, Daniel du Plessis in Forensic Neuropathology, 2021
Reconstructive surgery may be indicated, to make good a skull vault defect created by earlier, emergency removal of a calvarial bone flap. Normally, an interval of 3 to 6 months is allowed to pass, during which time ICPs settle, inflammation subsides and a neo-dura forms between the brain and the overlying scalp. Thereafter, a cranioplasty can be performed, either by replacing the bone flap that was removed during the emergency decompression5 or by inserting a prosthetic substitute such as titanium. Smaller defects can be filled with acrylic cement. The commonest complication is that of chronic wound infection (Acciarri et al. 2016) but benefits include cosmesis and the provision of protection for the underlying brain. Another argument in favour of restoring the skull vault is that, by allowing the brainstem to adopt a less distorted position inside the head, the reticular activating system becomes more active. A dependent patient may then become more responsive and, at the very least, somewhat easier to nurse.
Cranioplasty
Barbara A. Wilson, Samira Kashinath Dhamapurkar, Anita Rose in Surviving Brain Damage After Assault, 2016
Overall, it has to be noted that cranioplasty is a relatively simple procedure. However, evidence indicates there is a high variability of complications following. It could be argued that to date there is an inaccurate estimation of complication rate and improvement rate. The majority of the existing studies are retrospective, and therefore findings are limited. When considering the issue of early cranioplasty and the optimal timing, there appears to be a lack of well-designed research studies: whilst there are a number of studies that highlight the need for early cranioplasty citing positive neurological, cognitive and motor changes, there are equal numbers of studies that cite that early cranioplasty is fraught with complications and that it is better to wait. However, there are significant findings across research which demonstrate that early cranioplasty mini-mises the risk of trephination syndrome (sinking flap syndrome), thus contributing to better outcome and overall prognosis in some individuals.
Overcoming the challenges of accurately assessing consciousness and communication in the context of pain assessment
Camille Chatelle, Steven Laureys in Assessing Pain and Communication in Disorders of Consciousness, 2015
Figure 4.2 shows command-following data over time to illustrate that the reliability of command-following changes gradually during recovery. The patient is a 32-year-old man who was injured in a fall of 20–30 feet. He suffered a seizure at the scene. On evaluation at the trauma center, he had a Glasgow Coma Score of five, and a CT scan revealed a right epidural hematoma with right to left shift, as well as multiple contusions. A craniectomy was performed, along with evacuation of the hematoma, but an early cranioplasty was performed six weeks post-injury and he was admitted to rehabilitation 10 weeks post-injury. On admission he was thought to occasionally touch his head or move his leg on command. Therefore, a dual-command protocol was begun in which he was randomly requested to “touch your head” or “move your leg.” Each trial was scored as “no response,” a head touch, or a leg movement. In general it was found that he made few errors but failed to respond at all on a substantial number of trials (see Figure 4.2 for a plot of his response rate [proportion of trials on which he responded]).
Malignant cerebral edema after cranioplasty: a case report and literature review
Published in Brain Injury, 2023
Shaoxiong Wang, Yongxin Luan, Tao Peng, Guangming Wang, Lixiang Zhou, Wei Wu
Cranioplasty is a common treatment for patients undergoing decompression craniectomy (DC) due to craniocerebral trauma, acute cerebral infarction, and cerebral hemorrhage, etc, and is generally regarded as a simple and conventional operation. It can get control of the patient’s appearance, protect the brain tissue, and improve the cognitive ability of patients with cognitive dysfunction caused by skull defects. It can improve patient’s cognitive ability, protect brain tissue, and restore the cranium appearance (1). Complications of cranioplasty may amount to 41% (2).Frequent complications after cranioplasty mainly include postoperative infection, wound healing the disorder, epidural hematoma, and implant displacement (3,4), malignant cerebral edema rarely occurs after cranioplasty but would lead to a high fatality rate if occurred. Previous studies are agreed that the size of the skull defect, the traumatic etiology, and bilateral repair are risk factors for complications after the surgery. The risk of complications would increase even 12 months after cranioplasty (5) .However, risk factors related to malignant cerebral edema remain unclear. This article reports a case of death from malignant cerebral after cranioplasty and reviews previous literature to explore the potential causes and clinical manifestations of this rare complication.
Subgaleal drains may be associated with decreased infection following autologous cranioplasty: a retrospective analysis
Published in British Journal of Neurosurgery, 2021
Carole S. L. Spake, Dardan Beqiri, Vinay Rao, Joseph W. Crozier, Konstantina A. Svokos, Albert S. Woo
Cranioplasty is a critical component for the definitive treatment of patients following decompressive craniectomy. A successful cranioplasty accomplishes multiple goals, which include restoration of the cosmetic appearance of the skull as well as the structural protection of the brain to optimize neurocognitive outcomes (Malcolm et al. 2018).38 Autologous cranioplasty has been well established in the literature as the first-choice technique for cranioplasty, taking advantage of the patient’s biology with adherence to the reconstructive principle of replacing ‘like with like’. The success rate of autologous cranioplasty in our cohort was 85.7%, comparing equivalently to a 90% success rate recently reported in a meta-analysis.5 However, it is important to note that autologous cranioplasty is not without its risks and complications. Namely, infection following reconstruction with autologous bone has been cited as the most common complication following this technique and often is the major contributing factor requiring subsequent explantation (Malcolm et al. 2018).38,5,6 We aim to contribute to the literature by describing our institutional experience with autologous cranioplasty reconstruction following decompressive craniectomy and identifying potential predictors of infection.
The utility of decompressive craniectomy in severe traumatic brain injury in Saudi Arabia trauma centers
Published in Brain Injury, 2021
Hosam Al-Jehani, Abdulaziz Al-Sharydah, Faisal Alabbas, Abdulrazag Ajlan, Wisam Al Issawi, Saleh Baeesa
Although DC is a life-saving procedure for medically intractable high ICP after TBI, a second procedure of cranioplasty is generally required to replace the bone. Repeated surgery has an inherently higher risk of morbidity and mortality. Furthermore, the appropriate time period for performing this staged procedure remains unknown. With regard to the appropriate timing for cranioplasty, the literature documents a predominant concern for various hazards, including residual brain swelling and the risk of infection and hydrocephalus (14,15). In the literature, some prognostic factors have been described to help in assessing the effect of initial head trauma, such as the GCS, the Marshall score for initial imaging, the size of the bone flap, the time to craniectomy, and relevant biomarkers. In particular, high levels of protein S100 during initial management have shown an association with poor prognosis. Notwithstanding, the value of this biomarker of long-term outcomes requires further evaluation in prospective studies (16,17).