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Purpose: For malignant middle cerebral artery (MCA) infarctions, the mortality rate is very high. Although decompressive craniotomy (DC) appears to reduce mortality, the quality of life remains a current topic of debate. We aimed to present the outcomes of patients with malignant MCA infarctions treated medically or surgically at our high-volume tertiary care hospital. Materials and Methods: The study was designed as a prospective cohort. Decompressive craniotomy (DC) was offered to all patients meeting the criteria, while those who declined were included in the control group receiving medical treatment. Patients were evaluated preoperatively and early postoperatively and also in the follow-ups at 1, 3, 6, and 12 months. Result: Forty-two patients were included in the study (17/surgery, 25/medical). Survival rates of those who received DC in each follow-up period were higher than those who received only medical treatment. This difference was also significant at the postoperative 1st, 3rd, and 6th months. In addition, the modified Rankin-Scale examination showed that DC was superior in each control period. Conclusion: In our study, the higher mortality among patients who underwent DC, albeit lower than those treated with medical therapy alone, could be attributed to poorer neurological status at the time of surgery compared to other series. The indication for surgery should not wait until the patient's condition deteriorates significantly. Therefore, it is crucial to promptly report any neurological deterioration observed during early period to the neurosurgeon. Referring patients who are at risk of neurological decline to a neurosurgery clinic could serve as an alternative solution.

Subdural hygromas occur after various brain interventions, are often asymptomatic but sometimes may require surgical treatment. They can develop in the immediate postoperative period, but they are more common a few weeks or even months after surgery. Subdural hygromas are particularly common after decompressive craniotomy in patients with traumatic brain injury or massive stroke. The pathogenesis is explained by the fact that a large bone defect causes a pressure difference in the skull, and a concomitant displacement of the ventricular system disrupts the normal cerebrospinal fluid circulation, contributing to the redistribution of cerebrospinal fluid flow into the subdural space.We review data from contemporary studies on subdural hygromas after decompressive craniotomy, their risk factors, and management strategies. We also present our case of recurrent subdural hygroma in a patient operated on for a ruptured aneurysm of the middle cerebral artery.

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Abstract Introduction As a disorder of the brain in adults and children, traumatic brain injury (TBI) is considered the major cause of mortality and morbidity. As a serious complication of TBI, post-traumatic hydrocephalus (PTH) is commonly identified and significantly associated with neurocognitive impairment, motor dysfunction, and growth impairment. The long-term functional outcomes after shunt dependence are totally not clear. Methods This study included 6279 patients between 2012 and 2022. To identify the unfavorable functional outcomes and the PTH-related factors, we carried out univariable logistic regression analyses. To identify the occurrence time of PTH, we conducted the log-rank test and Kaplan–Meier analysis. Results Mean patient age was 51.03 ± 22.09 years. Of the 6279 patients with TBI, 327 developed PTH (5.2%). Several PTH development-associated factors, such as intracerebral hematoma, diabetes, longer initial hospital stay, craniotomy, low GCS (Glasgow Coma Scale), EVD (external ventricular drain), and DC (decompressive craniectomy) (p 80 years, repeated operations, hypertension, EVD, tracheotomy, and epilepsy (p

Background Basal ganglia hemorrhage (BGH) is a severe neurologic condition associated with significant morbidity and mortality, and its optimal management remains a topic of debate. Our study assessed the surgical outcomes of BGH patients at the 3-month mark using the modified Rankin Scale (mRS). Methods This retrospective observational study was conducted over 10 years at an advanced neuro-specialty hospital in Eastern India, including patients who underwent decompressive craniotomy and hematoma evacuation. Variables were systematically coded and analyzed to evaluate the postoperative outcome with age (in years), preoperative motor (M) status, and hematoma volume. Results This study enrolled 2,989 patients with a mean age of 59.62 (standard deviation: 9.64) years, predominantly males (n = 2,427; 81.2%). Hypertension (1,612 cases) and diabetes mellitus (1,202 cases) were the most common comorbidities. Common clinical presentations included ipsilateral weakness (1,920 cases) and/or altered mental status (1,670 cases). At the 3-month mark postsurgery, 2,129 cases (71.2%) had a favorable outcome based on mRS, while 389 cases (13.0%) had an unfavorable outcome. The regression equation showed that age was inversely related to the percentage of individuals achieving a favorable outcome. It also revealed that the preoperative motor score was positively correlated with favorable outcomes. Hematomas smaller than 60 mL had better outcomes, with 1,311 cases (69.1%) classified as good outcomes and 337 cases (17.8%) as bad outcomes. Fatal outcomes related to the illness were observed in 471 patients (15.8%) within the study population. Conclusion Surgery for BGH showed a substantial improvement in outcomes, particularly in patients with M5/M4 motor status. The preoperative motor score (M status) emerged as a crucial predictor of favorable neurological outcomes. Age and hematoma volume, however, were found to be nondefinitive factors in determining good outcomes. [ABSTRACT FROM AUTHOR]

Introduction: As a disorder of the brain in adults and children, traumatic brain injury (TBI) is considered the major cause of mortality and morbidity. As a serious complication of TBI, post-traumatic hydrocephalus (PTH) is commonly identified and significantly associated with neurocognitive impairment, motor dysfunction, and growth impairment. The long-term functional outcomes after shunt dependence are totally not clear. Methods: This study included 6279 patients between 2012 and 2022. To identify the unfavorable functional outcomes and the PTH-related factors, we carried out univariable logistic regression analyses. To identify the occurrence time of PTH, we conducted the log-rank test and Kaplan–Meier analysis. Results: Mean patient age was 51.03 ± 22.09 years. Of the 6279 patients with TBI, 327 developed PTH (5.2%). Several PTH development-associated factors, such as intracerebral hematoma, diabetes, longer initial hospital stay, craniotomy, low GCS (Glasgow Coma Scale), EVD (external ventricular drain), and DC (decompressive craniectomy) (p < 0.01), were identified. We also analyzed the factors of unfavorable outcomes after TBI including > 80 years, repeated operations, hypertension, EVD, tracheotomy, and epilepsy (p < 0.01). Ventriculoperitoneal shunt (VPS) itself is not an independent factor of the unfavorable outcome but shunt complication is a strong independent factor of unfavorable outcome (p < 0.05). Conclusion: We should emphasize the practices that can minimize the risks of shunt complications. Additionally, the rigorous radiographic and clinical surveillance will benefit those patients at high risk of developing PTH. Trial registration: ClinicalTrials.gov identifier, ChiCTR2300070016. [ABSTRACT FROM AUTHOR]

The second part of this paper analyses the role of scientific factor in emergence of neurosurgery. It includes special diagnostic methods, surgical instruments and new operative approaches. Aseptics, antiseptics and anesthesia as well as topical diagnosis of neurological disorders are rooted in the progress of natural sciences. Such diagnostic methods as pneumovetriculography, pneumoencephalography, myelography, cerebral angiography and EEG were invented in 1910–1920-s. Cranioplastic craniotomy enabled to enlarge trepanation window. New surgical instruments (such as Gigli saw, de Martel electric trepan, electric suction, hemostatic clips, electrocoagulation etc.) and new surgical approaches to brain structures (transnasal, suboccipital, perforation of third ventrical floor etc.) reduced postoperative mortality and facilitated neurosurgery interventions.

Background Cranioplasty following decompressive craniotomy is considered to be a "routine procedure" but several large series have documented a significant amount of both delayed and immediate complications and also a mortality rate of up to 3.6%. Materials and Methods We went through some of the salient complications (excluding seizures) needing resurgery following interval cranioplasty over the past 18 years at our institution in over 300 cases and analyzed the literature that mention these complications and their treatment. Results In addition to the commonly mentioned complications, we found some that had been rarely described or not mentioned hitherto in the literature which we have presented as a pictorial narrative. Based on our experience, we recommend some measures that may decrease the incidence or prevent the occurrence of the same. Conclusions Attention to small but basic surgical techniques will go a long way in preventing unwanted postoperative events. [ABSTRACT FROM AUTHOR]

Decompressive craniotomy is a neurosurgical emergency procedure in which a large skull bone is removed and the dura matter is extensively opened. Duraplasty is required to avoid cerebrospinal fluid (CSF) leakage during the decompressive craniotomy. DuraGen® is a safe and effective type I collagen matrix graft, which is frequently used in decompressive craniotomy procedures. Since DuraGen® does not require labor-intensive suturing, the operative time is shortened by DuraGen® closure with sufficient tightness preventing CSF leakage. Recently, early cranioplasty is preferred to achieve efficient rehabilitation after decompressive craniotomy. Although evidence of efficacy and safety of DuraGen® has been increasing in the management of duraplasty, no reports have previously discussed the condition of DuraGen® during the second surgery (cranioplasty) at this early timing. DuraGen®-derived neodura develops a mature dura 1 year post its placement, and the neodura remain fragile at this early time point. A deconstructed fragile neodura may result in postoperative CSF leakage. Here, we illustrated a multilayered dural repair technique with DuraGen® to avoid disruption of the fragile neodura during early cranioplasty.

Background: Common complications following cranioplasty (CP) include infections, seizures, bone flap resorption, and intra-cranial hemorrhages. Epidural fluid collections (EFCs), often seen in the immediate post-operative scan as hypo-dense accumulations below the bone flap, have been very infrequently discussed in the literature as in the majority of the cases, they are small, get resorbed spontaneously, and usually do not cause neurological deficits.Objective: To document our experience with EFCs that needed re-operation and analyze their clinical and radiological findings.Materials and Methods: We describe a series of six cases of symptomatic EFCs following CP that necessitated re-operation in a series of 89 cases over 7 years.Conclusions: EFCs following CP have a different pathogenetic mechanism compared to post-operative epidural hemorrhages. Meticulous surgical techniques can reduce their incidence. Symptomatic EFCs can be evacuated by either re-opening the flap or placing burr holes in the replaced bone. EFCs may become symptomatic even a few days after CP. [ABSTRACT FROM AUTHOR]

Background: Subdural hematoma in infants is a challenging condition. Acute subdural hematomas can cause intracranial hypertension and a midline shift, but decompressive craniotomies in young patients have shown promising results with specific complications in this age group. Hinge craniotomy is an old technique used in many neurosurgical procedures associated with elevated intracranial pressure. The objective of this study is to report the usage of flail bone flap in the management of acute subdural hematoma in infants, its outcome, advantages, disadvantages and related complications. Methods: This is a review of the medical records of 5 infants younger than one-yearold who underwent decompressive craniotomy as management of acute subdural hematoma at Mansoura university hospital. Results: In this series, five babies were included. Operative time for decompressive craniotomy (DC) ranged from 1 h and 40 min to 3 h. Four infants survived. Three infants recovered with good outcomes and one infant developed hemiparesis. Conclusion: The use of flail bone flap technique in decompressive craniotomy is associated with a high success rate and low incidence of complications. Large-based studies are still required for a better assessment of the results. [ABSTRACT FROM AUTHOR]

Background: Subdural hematoma in infants is a challenging condition. Acute subdural hematomas can cause intracranial hypertension and a midline shift, but decompressive craniotomies in young patients have shown promising results with specific complications in this age group. Hinge craniotomy is an old technique used in many neurosurgical procedures associated with elevated intracranial pressure. The objective of this study is to report the usage of flail bone flap in the management of acute subdural hematoma in infants, its outcome, advantages, disadvantages and related complications. Methods: This is a review of the medical records of 5 infants younger than one-year-old who underwent decompressive craniotomy as management of acute subdural hematoma at Mansoura university hospital. Results: In this series, five babies were included. Operative time for decompressive craniotomy (DC) ranged from 1 h and 40 min to 3 h. Four infants survived. Three infants recovered with good outcomes and one infant developed hemiparesis. Conclusion: The use of flail bone flap technique in decompressive craniotomy is associated with a high success rate and low incidence of complications. Large-based studies are still required for a better assessment of the results.

Influenza has a common occurrence during its peak seasons. It usually causes disease of the respiratory tract including severe acute respiratory distress syndrome. However, it may also cause disease and complication of other organ systems. We present a rare complication of influenza in which a patient secondary to influenza developed massive middle cerebral artery ischemic stroke. The patient however survived following recovery of both severe acute respiratory distress syndrome and ischemic stroke after decompressive craniectomy and a prolonged intensive care unit stay. This case report is to highlight the importance of influenza related complications besides the pulmonary infliction which can lead to morbidity and even mortality if not managed on time.

Salvage decompressive craniotomies performed following complications after initial planned craniotomies may be inadequate if they are only restricted to removal of the small previously replaced bone flap with some additional nibbling of bone from the surrounding craniotomy margins by retracting the skin. To achieve the aim of adequately decreasing intracranial pressure without affecting wound healing, fresh incisions need to be placed to expand the craniotomy adequately while not compromising vascularity of the scalp. The rationale and safety of the simple posteriorly placed release incision to expand frontotemporal flaps is described. [ABSTRACT FROM AUTHOR]

Background: Although associated with controversy, decompressive craniotomy (DC) for malignant middle cerebral artery infarction (MMCAI) is an unequivocally lifesaving intervention. DC for MMCAI is rarely performed in lower- to middle-income countries. Methods: A systemic review was performed in attempt to determine the rates of utilization and outcomes of DC on the African continent. Results: Only two African studies describing DC for MMCAI were found. Conclusion: DC for MMCAI is rarely performed and/or reported on the African continent. The African perspective for this needs to be urgently broadened. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide. Method: A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019. Results: We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC. Conclusion: Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial. [ABSTRACT FROM AUTHOR]

Cranioplasty complications after decompressive craniectomy (DC) in infants are not fully recognized. We aimed to devise and assess the efficacy of a hinge and floating DC (HFDC) technique for treating infantile acute subdural hematoma. Five infants, aged 2–20 months, were included. Intracranial pressure was controlled below 20 mmHg, no additional surgery was required, and there was no incidence of surgical site infection or bone graft resorption. [ABSTRACT FROM AUTHOR]

Severe traumatic brain injuries (TBIs) are a principal cause of neurologic dysfunction and death in the pediatric population. After medical management, the second-tier treatment is decompressive craniectomy in cases of intractable intracranial pressure (ICP) elevation. This literature review offers evidence of early (within 24 hours) and ultraearly (6–12 hours) decompressive craniectomy as an effective form of management for severe TBI in the pediatric population. We conducted a literature review of articles published from 1996 to 2019 to elucidate neurologic outcomes after early decompressive craniectomy in pediatric patients who suffered a severe TBI. Time to decompressive craniectomy and neurologic outcomes were recorded and reported descriptively. Qualitative data describe clinically important correlations between pre- and postoperative ICP levels and improved postoperative neurologic outcomes. Seventy-eight patients were included in this study. The median age of patients at diagnosis was 10 years of age (range, 1 months to 19 years). Median admission Glasgow Coma Scale score was 5 (range, 3–8). Time to decompressive craniectomy ranged from 1 to 24 hours. Median peak preoperative ICP was 40 (range, 3–90; n = 49). Median postoperative ICP was 20 (range, 0–80; n = 33). Median Glasgow Outcome Scale (GOS) score at discharge was 2 (range, 1–5; n = 11). Median GOS score at 3- and 6-month follow-up was 3 (range, 1–5; n = 11). Median GOS score at 7- to 23-month follow-up was 4 (range, 1–5; n = 29). Median GOS score at 24- to 83-month follow-up was 4 (range, 1–5; n = 31). Median modified Rankin Scale score at discharge was 3 (range, 2–4; n = 6). Median modified Rankin Scale score at 6- to 48-month follow-up was 2 (range, 0–3; n = 6). Median Rancho Los Amigos Scale (RLAS) score at discharge was 6 (range, 4–8; n = 5). Median RLAS score at 6-month follow-up was 10 (range, 8–10; n = 5). Early (within 24 hours), with consideration of ultraearly (within 6–12 hours), decompressive craniectomy for severe TBI should be offered to pediatric patients in settings with refractory ICP elevation. Reduction of ICP allows for prompt disruption of pathophysiologic cascades and improved neurologic outcomes. [ABSTRACT FROM AUTHOR]

Background Numerous investigators have shown that early postinjury Glasgow Coma Scale (GCS) values are associated with later clinical outcomes in patients with traumatic brain injury (TBI), in-hospital mortality, and post-hospital discharge Glasgow Outcome Scale (GOS) results. Following TBI, early GCS, and brain computed tomography (CT) scores have been associated with clinical outcomes. However, only one previous study combined GCS scores with CT scan results and demonstrated an interaction with in-hospital mortality and GOS results. We aimed to determine if interactive GCS and CT findings would be associated with outcomes better than GCS and CT findings alone. Methodology Our study included TBI patients who had GCS scores of 3-12 and required mechanical ventilation for ≥five days. The GCS deficit was determined as 15 minus the GCS score. The mass effect CT score was calculated as lateral ventricular compression plus basal cistern compression plus midline shift. Each value was 1 for present. A prognostic CT score was the mass effect score plus subarachnoid hemorrhage (2 if present).The CT-GCS deficit score was the sum of the GCS deficit and the prognostic CT score. Results One hundred and twelve consecutive TBI patients met the inclusion criteria. Patients with surgical decompression had a lower GCS score (6.0±3.0) than those without (7.7±3.3; Cohen d=0.54). Patients with surgical decompression had a higher mass effect CT score (2.8±0.5) than those without (1.7±1.0; Cohen d=1.4). The GCS deficit was greater in patients not following commands at hospital discharge (9.6±2.6) than in those following commands (6.8±3.2; Cohen d=0.96). The prognostic CT score was greater in patients not following commands at hospital discharge (3.7±1.2) than in those following commands (3.1±1.1; Cohen d=0.52). The CT-GCS deficit score was greater in patients not following commands at hospital discharge (13.3±3.2) than in those following commands (9.9±3.2; Cohen d=1.06). Logistic regression stepwise analysis showed that the failure to follow commands at hospital discharge was associated with the CT-GCS deficit score but not with the GCS deficit. The GCS deficit was greater in patients not following commands at three months (9.7±2.8) than in those following commands (7.4±3.2; Cohen d=0.78). The CT-GCS deficit score was greater in patients not following commands at three months (13.6±3.1) than in those following commands (10.5±3.4; Cohen d=0.94). Logistic regression stepwise analysis showed that failure to follow commands at three months was associated with the CT-GCS deficit score but not with the GCS deficit. The proportion not following commands at three months was greater with a GCS deficit of 9-12 (50.9%) than with a GCS deficit of 3-8 (21.1%; odds ratio=3.9; risk ratio=2.1). The proportion of not following commands at three months was greater with a CT-GCS deficit score of 13-17 (56.0%) than with a CT-GCS deficit score of 4-12 (18.3%; OR=5.7; RR=3.1). Conclusion The mass effect CT score had a substantially better association with the need for surgical decompression than did the GCS score. The degree of association for not following commands at hospital discharge and three months was greater with the CT-GCS deficit score than with the GCS deficit. These observations support the notion that a mass effect and subarachnoid hemorrhage composite CT score can interact with the GCS score to better prognosticate TBI outcomes than the GCS score alone., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Dunham et al.)

Purpose: We present the potential usefulness of a greenstick fracture-hinge decompressive craniotomy, a variant of a hinge-craniotomy, as an alternative technique for use with a decompressive craniectomy (DC) in infants. A literature review of hinge-craniotomy procedures and technical variants is also provided, with a focus on complications associated with a DC peculiar to infants and children. Methods: Illustrative case presentation along with literature review. Result: Significant rates of complications associated with a DC and subsequent cranioplasty have been reported, such as bone flap resorption, hydrocephalus, cerebrospinal fluid collection, and infection, especially in infants. A hinge-craniotomy is an older technique reported to have potential usefulness with some modifications, though concerns have been raised about adequate decompression and definitive indications. Conclusion: A DC procedure performed in children, especially infants, includes a significantly high risk of various complications; thus, a hinge-craniotomy technique is worthwhile for consideration to avoid such complications. Additional studies are required to clarify whether this technique may contribute to reduce complications related to a DC in infants and children. [ABSTRACT FROM AUTHOR]

A 20-year-old male patient presented with a recent history of two episodes of seizures and Glasgow Coma Scale of E3V3M6. He was drowsy at presentation with bradycardia. On further examination, he was found to be having a 10 × 6cm well-circumscribed mass in the right medial thigh whose fine needle aspiration cytology was suggestive of soft tissue sarcoma. Contrast-enhanced magnetic resonance imaging brain showed enhancing lobulated lesions in bilateral hemispheres with significant edema. A decision to decompress the intracranial space occupying lesion was taken. Left-sided larger brain lesions underwent total gross excision followed by excision of the thigh mass. Histopathology of brain lesion was suggestive of metastatic deposits of alveolar soft part sarcoma, whereas the thigh mass was suggestive of alveolar soft part sarcoma grade 2 according to Fédération Nationale des Centres de Lutte Contre Le Cancer grading system. Postoperative course of the patient was unremarkable and his general condition improved remarkably (Functional Assessment of Cancer Therapy–Brain version 4 score improvement >50% at 1 month). He is in follow-up for the last 12 months and currently has completed chemoradiotherapy and is living a self-sufficient life. Though patients with aforementioned rare diagnosis have overall poor prognosis, decompressive craniotomy with metastasectomy may improve the overall quality of life of such young patients, and further chemoradiotherapy may help in prolonging life with acceptable level of comorbidity. This case is being discussed here in terms of the rarity of the final diagnosis, the management strategy used, and the quality of life improvement. [ABSTRACT FROM AUTHOR]

Objective: Surgical treatment options are limited for medically and endovascular refractory cerebral venous sinus thrombosis (CVT). We describe the technical feasibility of open, direct sinus thrombectomy in a pediatric patient with medically and endovascular refractory CVT. Methods: A 15-year-old patient with superior sagittal sinus (SSS) thrombosis refractory to medical and endovascular treatment experienced clinical deterioration with the progression of bifrontal hematomas and cerebral edema. The patient was treated surgically with a decompressive hemicraniectomy and burr hole SSS thrombectomy with a Fogarty balloon and direct sinus injection of tissue plasminogen activator. Results: Surgical treatment with decompressive craniotomy and direct sinus thrombectomy was technically feasible with excellent intracranial pressure control, and radiological recanalization of the superior sagittal sinus with a good clinical outcome. Conclusion: Direct surgical sinus thrombectomy is a potential concomitant treatment strategy with decompressive craniectomy for medically refractory CVT in a pediatric setting. [ABSTRACT FROM AUTHOR]

Decompressive craniotomy is a commonly performed surgery to relieve raised intracranial pressure. At the end of the procedure, it is the convention to cover the exposed brain by performing a lax duraplasty which allows for both brain expansion and provides protection to the underlying parenchyma. Various commercially available dural substitutes are used for this purpose. These have the drawback of being both expensive and nonvascularized. We propose a technique of using pericranium along with everted temporalis fascia (both being locally harvested vascularized pedicle flaps) that can suffice in a vast majority of cases for covering the brain. [ABSTRACT FROM AUTHOR]

Background: Postoperative hydrocephalus and subdural fluid collection (SFC) have been reported as the rare complications following foramen magnum decompression in patients with Chiari malformation. Case Description: The paper reports the case of a 63-year-old female patient who underwent foramen magnum decompression for basilar invagination. The patient developed a shifting, bilateral SFC and subsequent acute hydrocephalus. A ventriculoperitoneal shunting was performed and the clinical symptom resolved. The dramatic change in CSF distribution supported the diagnosis of external hydrocephalus, which was associated with a postoperative cervical pseudomeningocele. Conclusions: Postoperative SFC in patients underwent foramen magnum decompression may harbor different mechanisms. Subdural drainage for patients having external hydrocephalus may have a higher recurrence rate. [ABSTRACT FROM AUTHOR]

Abstract Background A novel technique of step ladder expansive cranioplasty was suggested, in a recent study, as a credible alternative to decompressive hemicraniectomy and found feasible on evaluation on a mathematical model, where human cranium was represented by a hemisphere of 9 cm radius. The findings on the mathematical model required to be validated in clinical setting before planning any clinical trial. Methods A retrospective analysis of cases of decompressive craniectomy performed at a single neurosurgery center over past 18 months was done. Cases in which an NCCT head was repeated on the first postoperative day, due to evidence of intractable raised ICP postoperatively, were included in the study. The pre- and postoperative films were evaluated to determine various parameters, namely the thickness of skull bone at the craniectomy margins, projection of dural outpouching beyond the craniectomy defect, and the height required to be gained by an expansive cranioplasty to accommodate the augmented volume of the dural sac. Results Six cases that satisfied all criteria were included. The mean surface area of craniectomy defects were 66.89 cm2 in size. The maximum projection of the dural outpouching, as measured from the craniectomy margin, was 2.7 cm, necessitating construction of an expansive cranioplasty achieving 1.6 cm of gain in height in the cranium with minimum calvarial convexity. Conclusion The results of this study indicate that a two-step expansive cranioplasty can accommodate adequate volume expansion in individuals whose average calvarial thickness at the craniectomy defect is 0.8 cm.

Abstract Background Role of decompressive craniectomy in reducing intracranial pressure is well established. However, it comes with a cost of requiring a second surgery in the form of cranioplasty without which unacceptable hemodynamic consequences occur. It is generally felt that a credible alternative is required. Objective The aim of the study is to devise a mathematical model, which closely represents the cranium and intracranial contents, on which various alternatives can be evaluated with reproducible results, and to work out the effects of a novel technique of expansive cranioplasty on that model. Methods A mathematical model was designed based on the presumption that dura forms a watertight bag-containing brain, floating in cerebrospinal fluid (CSF). A model for an expansive cranioplasty was designed, and its ability to provide the space required to allow volume expansion and to achieve adequate reduction in intracranial pressure (ICP) was evaluated on this model. Results The mathematical model could closely reproduce the surface area–volume relationships in the published literature. Based on the calculations on the model, it was found that a projection of dural outpouching of 0.83 cm beyond the craniectomy margin on either side of a bilateral 12 × 15 cm elliptical craniectomy defect is required to achieve and accommodate a volume expansion of 157 cm3, which was recorded to be the maximum volume expansion in the reviewed literature. A two-step step-ladder cranioplasty can be constructed to achieve an increase in cranial width by 1.1 to 1.3 cm on each side. Conclusion Calculations based on the present model indicate that a two-step expansive cranioplasty can accommodate adequate volume expansion while alleviating the ill effects of a craniectomy and necessity of a second surgery. However, these are discussions on mathematical model, based on multitude of assumptions and approximations, and hence these discussions require clinical trials to validate the findings.

Increased intracranial pressure and decreased cerebral perfusion in patients with severe traumatic brain injury are associated with cerebral ischemia and poor outcome. Lowering intracranial pressure is one of the goals of treatment. We analyzed the effects of decompressive craniotomy on intracranial pressure levels and outcome. In addition, we compared the results of decompressive craniotomy performed with our original technique (modified “in-window” technique, with no need for cranioplasty) with results of classic techniques. We formed two groups: 52 patients with TBI (GCS≤8), with monitored intracranial pressure, and the control: 45 patients without intracranial pressure monitoring. In the first group, malignant intracranial hypertension was treated by decompressive craniotomy, using a modified "in-window" technique. Results were analyzed using standard statistical methods. In the first group, with intracranial pressure monitoring, 17/52 had decompressive craniotomy, and significant reduction of intracranial pressure appeared in the early postoperative period (38.82 to 22.76 mmHg, mean), with significant decrease of intracranial pressure at the end of treatment, compared to the control group (mean=25.00, and 45.30 mmHg, respectively). Late complications were similar to results of other studies. Our results were 20% of epileptic seizures, 8% of hydrocephalus, 12% contusion/hematoma progression and 12% subdural hygroma. Outcome (measured with Glasgow Outcome Score-GOS) in the first group, at the time of discharge, was better with decompressive craniotomy than without decompressive craniotomy (GOS=2.47, and GOS=1.00, respectively). Modified "in-window" technique for decompressive craniotomy in severe traumatic brain injury is safe, promising and according to our experience offers a lower rate of complications with no need for additional cranioplastic surgery.

The prognosis for patients with traumatic brain injury (TBI) with subdural hematoma (SDH) remains poor. In accordance with an increasing elderly population, the incidence of geriatric TBI with SDH is rising. An important contributor to the neurological injury associated with SDH is the ischemic damage which is caused by raised intracranial pressure (ICP) producing impaired cerebral perfusion. To control intracranial hypertension, the current management consists of hematoma evacuation with or without decompressive craniotomy. This removal of the SDH results in the immediate reversal of global ischemia accompanied by an abrupt reduction of mass lesion and an ensuing reperfusion injury. Experimental models can play a critical role in improving our understanding of the underlying pathophysiology and in exploring potential treatments for patients with SDH. In this review, we describe the epidemiology, pathophysiology and clinical background of SDH. [ABSTRACT FROM AUTHOR]

Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: To assess the feasibility of a dynamic craniotomy procedure with the use of a novel reversibly expandable cranial bone flap fixation plate. The expandable plate allows outward bone flap migration with an increase in intracranial volume or intracranial pressure (ICP). Methods: Dynamic craniotomy intracranial hypertension compliance was evaluated in a skull model with progressive increase in intracranial volume and compared with the standard craniotomy with fixed plates. Results: Dynamic craniotomy provided significant control of ICP with increasing intracranial volume compared with the standard craniotomy. With an incremental increase in intracranial volume from 360 mL to 600 mL, the ICP increased from 2.6 to 91.9 mm Hg with the standard craniotomy, whereas with the dynamic craniotomy the ICP for similar intracranial volume increased from 2.5 to 25 mm Hg (p < 0.00001). Conclusions: The dynamic craniotomy procedure provides superior control of ICP with an abrupt intracranial volume increase when compared with the standard craniotomy. [ABSTRACT FROM AUTHOR]