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Background: This observational study was performed to show the impact of complications and interventions during neurocritical care on the outcome after aneurysmal subarachnoid hemorrhage (SAH)., Methods: We analyzed 203 cases treated for ruptured intracranial aneurysms, which were classified regarding clinical outcome after one year according to the modified Rankin Scale (mRS). We reviewed the data with reference to the occurrence of typical complications and interventions in neurocritical care units., Results: Decompressive craniectomy (odds ratio 21.77 / 6.17 ; p < 0.0001 / p = 0.013), sepsis (odds ratio 14.67 / 6.08 ; p = 0.037 / 0.033) and hydrocephalus (odds ratio 3.71 / 6.46 ; p = 0.010 / 0.00095) were significant predictors for poor outcome and death after one year beside "World Federation of Neurosurgical Societies" (WFNS) grade (odds ratio 3.86 / 4.67 ; p < 0.0001 / p < 0.0001) and age (odds ratio 1.06 / 1.10 ; p = 0.0030 / p < 0.0001) in our multivariate analysis (binary logistic regression model)., Conclusions: In summary, decompressive craniectomy, sepsis and hydrocephalus significantly influence the outcome and occurrence of death after aneurysmal SAH.

Background: The mortality rate of patients with brain oedema after malignant middle cerebral artery (MCA) infarction approaches 80 % without surgical intervention. Surgical treatment with ipsilateral decompressive hemicraniectomy (DHC) has been shown to dramatically improve survival rates. DHC currently lacks established inclusion criteria and additional research is needed to assess the impact of prognostic factors on functional outcome. The aim of this study was to assess the impact of prognostic factors on functional outcome., Method: A retrospective cohort study was carried out including 46 patients who underwent DHC at the Karolinska University Hospital between 2004 and 2014. The maximum time to surgery was 5 days after symptom debut. The primary endpoint was a dichotomised score on the modified Rankin Scale (mRS) 3 months after surgery, with favourable outcome defined as mRS ≤ 4., Results: When the study population was dichotomised according to the primary endpoint, a significant difference between the groups was seen in preoperative Glasgow Coma Score (GCS), blood glucose levels and the infarction's involvement of the basal ganglia (p < 0.05). In a logistic regression model, preoperative GCS contributed significantly with a 59.6 % increase in the probability of favourable outcome for each point gained in preoperative GCS (p = 0.035)., Conclusions: The results indicate that preoperative GCS, blood glucose and the infarction's involvement of the basal ganglia are strong predictors of clinical outcome. These factors should be considered when assessing the probable outcome of DHC, and additional research based on these factors may contribute to improved inclusion criteria for DHC.

Objectives: Most knowledge related to the pathophysiology of microcirculation in ischemic stroke comes from experimental research. Unfortunately, data on microcirculation in the human brain are limited, partially as a result of the lack of appropriate investigational techniques. The objective of our study was to test the hypothesis that cortical microcirculatory alterations in the brain, in terms of blood flow and vessel density, occur in patients with stroke who require surgical decompression compared with a control group., Design: Prospective and observational study., Setting: Third-level university hospital., Patients: Six patients who had undergone decompressive surgery as a result of a space-occupying hemispheric infarction. These patients were compared with five patients who had undergone craniotomy for a disease not affecting the cortex., Interventions: Cortical microcirculation in the brain was directly observed using sidestream dark-field imaging. All images were analyzed offline., Measurements and Main Results: In patients with stroke with a space-occupying hemispheric infarction, 18 good-quality movie images were compared with 25 control group images. In the control group, cortical vessels showed a continuous flow in small, medium, and large vessels compared with patients with stroke who presented intermittent or no flow in all vessels. The proportion of perfused vessels was near 100% in control subjects and 63.44% in patients with stroke. The perfused vessel density index was also higher in control subjects (6.16 1/mm; interquartile range, 5.65-7.56) than in patients with stroke (2.77 1/mm; interquartile range, 1.75-3.86)., Conclusion: Sidestream dark-field imaging allowed direct visualization of cerebral microcirculatory alterations in the operating room. This technique allowed the documentation of a significant blood flow reduction in the cortical microvascular and a decreased vascular density in patients with stroke compared with control subjects.

Object: Decompressive surgery can be life saving after malignant cerebral infarction. However, severe residual disability occurs in a significant number of surviving patients. Most discussion about the benefits of surgery is based on studies performed in patients who are < or = 60 years of age. Less is known about the benefits of the procedure in the elderly population. The authors undertook a review of the literature on decompressive craniectomy for malignant cerebral infarction and compared the mortality and outcome data published in patients older and younger than 60 years of age. The authors discuss their analysis, with specific reference to the limitations of the studies analyzed, the outcome measures used, and the special considerations required when discussing stroke recovery in the elderly., Methods: Studies on decompressive craniectomy for malignant middle cerebral artery infarction reported in the English literature were analyzed. A cutoff point for age of > 60 or < or = 60 years was set, and the study population was segregated. No studies specifically analyzed patients > 60 years old. A total of 19 studies was identified, 10 of which included patients who were > 60 years of age. A comparison between the 2 age groups was made within the 10 studies and also among all the patients in the 19 studies. Mortality rates and outcome scores were assessed for each study, and a Barthel Index (BI) score of < 60 or a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome. Rates were compared using the Fisher exact test, and p values < 0.05 were considered statistically significant., Results: Nineteen studies were found, which included 273 patients undergoing decompressive craniectomy for malignant cerebral infarcts. Ten of these studies included 73 patients (26.7%) who were > 60 years of age. The mean follow-up times ranged from 5.75 to 12.3 months in the > 60-years group and 4.2 to 28 months in the < or = 60-years group. The mortality rate was significantly higher, at 51.3% in the > 60-years group (37 of 72 patients) compared with 20.8% (41 of 197 patients) in the < or = 60-years group (p < 0.0001). Similarly, patients who survived in the > 60-years group had significantly higher rates of poor outcomes, at 81.8% (27 of 33), compared with 33.1% (47 of 142) in the < or = 60-year-old group (p < 0.0001). The BI was the most commonly used primary outcome measure (15 out of 19 studies), followed by the mRS score, which was used in 4 studies., Conclusions: The mortality rate and functional outcome, as measured by the BI and mRS, were significantly worse in patients > 60 years of age following decompressive craniectomy for malignant infarction. Age is an important factor to consider in patient selection for surgery. However, cautious interpretation of the results is required because the outcome scores that were used only measure physical disability, whereas other factors, including psychosocial, financial, and caregiver burden, should be considered in addition to age alone.

Decompressive craniectomy procedures are used for malignant hemispheric infarctions. However, the temporal muscle and fascia are significant limiting factors for external herniation of an edematous brain. Therefore, the authors performed a decompressive craniectomy and expansive duraplasty combined with resection of the temporal muscle and fascia for 15 patients with a malignant hemispheric infarction. The volume of the maximum external herniation that was measured on the basis of a CT volumetry study ranged from 130 to 300 ml (mean +/- standard deviation, 200 +/- 64 ml) on postoperative Day 3.2 +/- 1.5 (range 2-5 days postoperatively). The mean value represented a 2-fold volume expansion in comparison with the conventional decompressive craniectomy, and the greater the external herniation obtained by external decompression, the smaller the midline brain shift after surgery. The mortality rate, favorable outcomes (modified Rankin Scale Scores 1-3), and unfavorable outcomes were 20, 60, and 20%, respectively, and the masticatory function was only minimally affected. Furthermore, a cranioplasty involving reconstruction of the temporal muscle defect performed using a MEDPOR implant resulted in good cosmetic outcomes with no temporal hollow. Resection of the temporal muscle in a decompressive craniectomy was shown to provide greater decompression and better clinical outcomes for malignant hemispheric infarctions at an acceptable cost of minimal masticatory dysfunction and cosmetic disfigurement.

Background: Many previous studies have reported that decompressive craniectomy has improved clinical outcomes in patients with intractable increased intracranial pressure (ICP) caused by various neurosurgical diseases. However there is no report that compares the effectiveness of the procedure in the different conditions. The authors performed decompressive craniectomy following a constant surgical indication and compared the clinical outcomes in different neurosurgical diseases., Materials and Methods: Seventy five patients who underwent decompressive craniectomy were analysed retrospectively. There were 28 with severe traumatic brain injury (TBI), 24 cases with massive intracerebral haemorrhage (ICH), and 23 cases with major infarction (MI). The surgical indications were GCS score less than 8 and/or a midline shift more than 6 mm on CT. The clinical outcomes were assessed on the basis of mortality and Glasgow Outcome Scale (GOS) scores. The changes of ventricular pressure related to the surgical intervention were also compared between the different disease groups., Findings: Clinical outcomes were evaluated 6 months after decompressive craniectomy. The mortality was 21.4% in patients with TBI, 25% in those with ICH and 60.9% in MI. A favourable outcome, i.e. GOS 4-5 (moderate disability or better) was observed in 16 (57.1%) patients with TBI, 12 (50%) with ICH and 7 (30.4%) with MI. The change of ventricular pressure after craniectomy and was 53.2 (reductions of 17.4%) and further reduced by 14.9% (with dural opening) and (24.8%) after returning to its recovery room, regardless of the diseases group., Conclusions: According to the mortality and GOS scores, decompressive craniectomy with dural expansion was found to be more effective in patients with ICH or TBI than in the MI group. However, the ventricular pressure change during the decompressive craniectomy was similar in the different disease groups. The authors thought that decompressive craniectomy should be performed earlier for the major infarction patients.

Background: Decompressive craniectomy is an important method for managing refractory intracranial hypertension in patients with head injury. We reviewed a large series of patients who underwent this surgical procedure to establish the incidence and type of postoperative complications., Methods: From 1998 to 2005, decompressive craniectomy was performed in 108 patients who suffered from a closed head injury. The incidence rates of complications secondary to decompressive craniectomy and risk factors for developing these complications were analysed. In addition, the relationship between outcome and clinical factors was analysed., Findings: Twenty-five of the 108 patients died within the first month after surgical decompression. A lower GCS at admission seemed to be associated with a poorer outcome. Complications related to surgical decompression occurred in 54 of the 108 (50%) patients; of these, 28 (25.9%) patients developed more than one type of complication. Herniation through the cranial defect was the most frequent complication within 1 week and 1 month, and subdural effusion was another frequent complication during this period. After 1 month, the "syndrome of the trephined" and hydrocephalus were the most frequent complications. Older patients and/or those with more severe head trauma had a higher occurrence rate of complications., Conclusions: The potential benefits of decompressive craniectomy can be adversely affected by the occurrence of complications. Each complication secondary to surgical decompression had its own typical time window for occurrence. In addition, the severity of head injury was related to the development of a complication.

Object: Severe traumatic brain injury (TBI) is often accompanied by early death due to transtentorial herniation. Decompressive craniectomy, performed alone or in conjunction with evacuation of the mass lesion, can reduce the incidence of raised intracranial pressure (ICP). In this paper the authors evaluate mortality and morbidity and long-term outcomes in children who underwent decompressive craniectomy for severe TBI at a single institution., Methods: Children with severe TBI who underwent decompressive craniectomy at the Primary Children's Medical Center between 1996 and 2005 were identified retrospectively. Descriptive statistics were used to report postoperative mortality and morbidity rates. Long-term recovery in patients who survived was reported using the King's Outcome Scale for Closed Head Injury (KOSCHI). Fifty-one children with a mean follow-up period of 18.6 months were identified. Nonaccidental trauma accounted for 23.5% of cases. The mean preoperative Glasgow Coma Scale (GCS) score was 4.6. Six patients underwent decompressive craniectomy for elevated ICP only; all other patients underwent decompressive craniectomy in conjunction with removal of the mass lesion. The mean postoperative GCS score was 9.7, and 69.4% of patients had normal ICP levels immediately after surgery. Sixteen children (31.4%) died, including five of six children who underwent decompressive craniectomy for raised ICP alone. Among surviving patients, 2.9% required a tracheostomy, 11.4% required a gastrostomy, 40% experienced posttraumatic shunt-dependent hydrocephalus, and 20% suffered posttraumatic epilepsy requiring antiepileptic agents. The mean KOSCHI score at the last follow-up examination was 4.5 and the mean time to cranioplasty was 2.3 months., Conclusions: Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high.

Decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial. We conducted a retrospective review of prospectively collected data on all patients requiring surgery for TBI from 1995 through 2001 at Cedars-Sinai Medical Center. Patients were separated into two groups: Group A, craniectomy, and Group B, craniotomy. We had 120 patients; 24 (20%) had craniectomy and 96 (80%) had craniotomy. There were no significant differences in demographics or Injury Severity Scores. The craniectomy group had significantly more TBI as evidenced by more frequently collapsed basilar cisterns on CT scan (P = 0.0001). There was no significant difference in actuarial survival between the groups: 52.8 per cent in the craniectomy group and 79.2 per cent in the craniotomy group (P = 0.08). Calculated mortality for craniectomy was 37.5 per cent versus 18.8 per cent for craniotomy (P = NS). We found four preoperative findings to be significant predictors of mortality: 1) Glasgow Coma Scale score, 2) Injury Severity Score, 3) Simplified Acute Physiology Score, and 4) Acute Physiology and Chronic Health Evaluation II. The type of surgery was not found to be a significant predictor of death even when adjusted for severity of injury. Craniectomy may be helpful for patients with TBI associated with preoperative CT scan evidence of basilar cistern collapse. This is evidenced by similar survival rates between the two groups despite clinical evidence of greater TBI among craniectomy patients.