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Decompressive craniectomies are a neurosurgical operation aimed at normalizing intracranial pressure (ICP). Occasionally, there is delayed replacement of the skull resulting in an acquired skull defect. When managing laboring patients with an acquired skull defect there is often fear associated with traditional labor involving the Valsalva maneuver and with neuraxial anesthesia. These fears typically stem from potential ICP changes and risk of herniation. In reviewing the literature, only 15 cases are described detailing labor management after decompressive craniectomy (DC), mostly with incomplete labor histories. We aim to expand that literature by reporting two cases of safe labor with epidural anesthesia in patients with large skull defects. The first described patient underwent a cranioplasty during pregnancy because of trauma. Later, because of concerns for pre‐eclampsia, induction of labor was initiated and she received neuraxial anesthesia via epidural. The patient ultimately underwent cesarean delivery 48 h after induction began due to nonreassuring fetal heart tones. The second patient underwent a cranioplasty because of infection prior to pregnancy. Once in labor, she was cleared by neurosurgery and the anesthesia team placed her epidural. She later underwent an uncomplicated standard vaginal delivery. The existing literature on labor following DC is sparse. Retrospective review of case reports can advance discussion and standardization regarding care for laboring women with a history of DC. We advocate that the Valsalva maneuver and epidural anesthesia is safe for pregnant women who are neurologically asymptomatic. [ABSTRACT FROM AUTHOR]

Decompressive craniectomy substantially reduces mortality and disability rates following a malignant stroke. This procedure remains a life-saving option, especially in contexts with little access to mechanical thrombectomy despite downward trends in the performance of decompressive craniectomy due to discussions on the acceptance of living with severe disabilities. However, the outcomes of the surgery in cases involving concomitant occlusion of anterior or posterior cerebral arteries have not been extensively studied. In this retrospective cohort study, spanning January 2010 to December 2022 and including patients who underwent decompressive craniectomy, we compared outcomes between patients with and without additional vascular territory involvement. Independent variables included age, sex, comorbidities, admission National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, time elapsed between stroke and surgery, laterality of the stroke, midline shift, and postoperative infarction volume. Outcomes included mortality and modified Rankin Score at the 3-month follow-up. Of the 86 patients analyzed, 61 (70.9%) and 25 (29.1%) demonstrated no territory and additional territory involvement, respectively. Patients with involvement of additional territories exhibited lower admission Glasgow Coma Scale scores, higher National Institutes of Health Stroke Scale scores, and larger postoperative infarction volumes. However, these variables were not associated with poor outcomes. Univariate analyses revealed no differences in mortality or severe disability. Even after adjustment, the differences remained insignificant for mortality and severe disability. Age emerged as the sole variable linked to increased mortality. Our data suggest that, for patients with malignant stroke undergoing decompressive craniectomy, the outcomes for patients with and without involvement of additional vascular territory are similar. [ABSTRACT FROM AUTHOR]

Acute rupture and hemorrhage of pediatric brain arteriovenous malformations (AVMs) may lead to cerebral herniation or intractable intracranial hypertension, necessitating emerging surgical interventions to alleviate intracranial pressure. However, there is still controversy regarding the timing of treatment for ruptured AVMs. This study aimed to assess the feasibility of utilizing three-pillar expansive craniotomy (3PEC) at different times during the treatment of pediatric ruptured supratentorial AVMs. A retrospective analysis was conducted on all consecutive cases of acute rupture in supratentorial AVM children who underwent 3PEC at a single institution from 2020 to 2022. General information, clinical characteristics, radiological data, and prognosis were reviewed and analyzed. Thirteen children were included in the analysis. The intracranial pressure of all patients decreased to below 15 mmHg within 10 days. The expansion volume of the cranial cavity of the patients increased by 18.3 cm3 (95% confidence interval, 10.2–26.3; P < 0.001) compared to the hematoma volume. None of the patients required decompressive craniectomy due to intractable intracranial hypertension caused by cerebral swelling. The median waiting period for patients with delayed AVMs treatment was 8 days, during which no rebleeding occurred. Emergency intervention with 3PEC in children experiencing acutely ruptured supratentorial AVMs appears to be feasible. For children requiring delayed management of the AVMs, 3PEC may diminish the risk of rebleeding during the waiting period and shorten the waiting period. [ABSTRACT FROM AUTHOR]

Background The COVID-19 pandemic has significantly affected acute ischemic stroke (AIS) care. In this study, we examined the effects of the pandemic on neurosurgical AIS care by means of decompressive surgery (DS). Methods In this retrospective observational study, we compared the characteristics, in-hospital processes, and in-hospital mortality rates among patients hospitalized for AIS during the first four waves of the pandemic (between January 1, 2020 and October 26, 2021) versus the corresponding periods in 2019 (prepandemic). We used administrative data from a nationwide hospital network in Germany. Results Of the 177 included AIS cases with DS, 60 were from 2019 and 117 from the first four pandemic waves. Compared with the prepandemic levels, there were no changes in weekly admissions for DS during the pandemic. The same was true for patient age (range: 51.7–60.4 years), the number of female patients (range: 33.3–57.1%), and the prevalence of comorbidity, as measured by the Elixhauser Comorbidity Index (range: 13.2–20.0 points). Also, no alterations were observed in transfer to the intensive care unit (range: 87.0–100%), duration of in-hospital stay (range: 14.6–22.7 days), and in-hospital mortality rates (range: 11.8–55.6%). Conclusion In Germany, compared with the prepandemic levels, AIS patients undergoing DS during the first four waves of the pandemic showed no changes in demographics, rates of comorbidity, and in-hospital mortality rates. This is in contrast to previous evidence on patients with less critical types of AIS not requiring DS and underlines the uniqueness of the subgroup of AIS patients requiring DS. Our findings suggests that these patients, in contrast to AIS patients in general, were unable to forgo hospitalization during the COVID-19 pandemic. Maintaining the delivery of DS is an essential aspect of AIS care during a pandemic. [ABSTRACT FROM AUTHOR]

Introduction The main goal of this study was to assess the feasibility of a head-mounted display (HMD) providing telemedicine neurosurgical support during a decompressive craniectomy by a military surgeon who is isolated from readily available neurosurgical care. The secondary aim was to assess the usability perceived by the military surgeon and to evaluate technical aspects of the head-mounted display. Materials and Methods After a standard concise lecture, 10 military surgeons performed a decompressive craniectomy on a AnubiFiX-embalmed post-mortem human head. Seven military surgeons used a HMD to receive telemedicine neurosurgical support. In the control group, three military surgeons performed a decompressive craniectomy without guidance. The performance of the decompressive craniectomy was evaluated qualitatively by the supervising neurosurgeon and quantified with the surgeons' operative performance tool. The military surgeons rated the usability of the HMD with the telehealth usability questionnaire. Results All military surgeons performed a decompressive craniectomy adequately directly after a standard concise lecture. The HMD was used to discuss potential errors and reconfirmed essential steps. The military surgeons were very satisfied with the HMD providing telemedicine neurosurgical support. Military surgeons in the control group were faster. The HMD showed no hard technical errors. Conclusions It is feasible to provide telemedicine neurosurgical support with a HMD during a decompressive craniectomy performed by a non-neurosurgically trained military surgeon. All military surgeons showed competence in performing a decompressive craniectomy after receiving a standardized concise lecture. The use of a HMD clearly demonstrated the potential to improve the quality of these neurosurgical procedures performed by military surgeons. [ABSTRACT FROM AUTHOR]

Introduction: Decompressive craniectomy (DC) is rarely required in infants. These youngest patients are vulnerable to blood loss, and cranial reconstruction can be challenging due to skull growth and bone flap resorption. On the other hand, infants have thin and flexible bone and osteogenic potential. Material and methods: We propose a new technique called DCST, which makes use of these unique aspects by achieving decompression using the circumstance of the thin and flexible bone. We describe the surgical technique and the follow-up course over a period of 13 months. Results and conclusion: In our study, DCST achieved adequate decompression and no further repeated surgeries in accordance with decompressive craniectomy were needed afterwards. [ABSTRACT FROM AUTHOR]

Post-decompressive craniectomy syndrome (PDCS) is a complication following decompressive craniectomy (DC). PDCS or also known as trephine or sunken skin flap syndrome has an indirect relationship with traumatic brain injury (TBI). The mechanism of PDCS is not yet fully understood and the clinical manifestations are diverse, causing PDCS to often be underdiagnosed. In this study, the authors aim to create a systematic review of PDCS following TBI including a discussion of incidence, clinical and radiological manifestations, management and outcome. This systematic review is conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline. The literature search included electronic databases PubMed, Cochrane, JNS and EMBASE. All studies included were available in English and full-text format. In this research, 42 case reports were obtained. The population was predominantly male (72%) with a mean population age of 44.7 ± 17.3 years. The mean interval for onset and cranioplasty procedure was 80.17 ± 77.34 days and 92.05 ± 77.06, respectively. The most common clinical manifestations were sunken skin flap in the defect area (74%) and decreased consciousness (64%). Paradoxical herniation (74%) was the most common radiological manifestation. There was no connection between the occurrence of PDCS and the size of the defect. Cranioplasty remains the mainstay of management with clinical improvement in 96% of cases. PDCS should be suspected in every patient with symptoms of new neurological deficits after DC. Early management must be carried out to prevent further deterioration. [ABSTRACT FROM AUTHOR]

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The COVID-19 (coronavirus disease) pandemic had a severe impact on public health worldwide. A rare but serious complication after administration of adenoviral vaccines against SARS-CoV-2 (AstraZeneca–Oxford and Johnson & Johnson) is vaccine-induced immune thrombotic thrombocytopenia and thrombosis (VITT), which can lead to serious complications such as cerebral venous sinus thrombosis (CVST). CVST itself can cause subarachnoid hemorrhage (SAH) and/or intracerebral hemorrhage (ICH), leading to high mortality due to herniation of brain parenchyma. In those patients, an emergent decompressive hemicraniectomy (DC) is regularly performed. Herein, the authors want to focus on the patients who survive DC following VITT-associated CVST and shed light on the neurosurgical considerations in those patients. We herein propose a treatment algorithm regarding the timing and the perioperative management of cranioplasty. We describe an exemplary case highlighting that special circumstances may result in a more urgent need for autologous cranioplasty than usual, based on individual risk assessment. [ABSTRACT FROM AUTHOR]

Background: Decompressive craniectomy (DC) can alleviate increased intracranial pressure in aneurysmal subarachnoid hemorrhage patients with concomitant space-occupying intracerebral hemorrhage, but also carries a high risk for complications. We studied outcomes and complications of DC at time of ruptured aneurysm repair. Methods: Of 47 patients treated between 2010 and 2020, 30 underwent DC during aneurysm repair and hematoma evacuation and 17 did not. We calculated odds ratios (OR) for delayed cerebral ischemia (DCI), angiographic vasospasm, DCI-related infarction, and unfavorable functional outcome (extended Glasgow Outcome Scale 1–5) at three months. Complication rates after DC and cranioplasty in the aneurysmal subarachnoid hemorrhage patients were compared to those of all 107 patients undergoing DC for malignant cerebral infarction during the same period. Results: In DC versus no DC patients, proportions were for clinical DCI 37% versus 53% (OR = 0.5;95%CI:0.2–1.8), angiographic vasospasm 37% versus 47% (OR = 0.7;95%CI:0.2–2.2), DCI-related infarctions 17% versus 47% (OR = 0.2;95%CI:0.1–0.7) and unfavorable outcome 80% versus 88% (OR = 0.5;95%CI:0.1–3.0). ORs were similar after adjustment for baseline predictors for outcome. Complications related to DC and cranioplasty occurred in 18 (51%) of subarachnoid hemorrhage patients and 41 (38%) of cerebral infarction patients (OR = 1.7;95%CI:0.8–3.7). Conclusions: In patients with aneurysmal subarachnoid hemorrhage and concomitant space-occupying intracerebral hemorrhage, early DC was not associated with improved functional outcomes, but with a reduced rate of DCI-related infarctions. This potential benefit has to be weighed against high complication rates of DC in subarachnoid hemorrhage patients. [ABSTRACT FROM AUTHOR]

(1) Background: Most intracranial aneurysms (IAs) can be treated either with microsurgical clipping or endovascular techniques. In a few cases, simultaneous treatment utilizing both modalities in a hybrid operation room may be favorable. This study analyzes the indication and benefits of a true hybrid approach (tHA) that combines simultaneous endovascular and microsurgical procedures for treatment of IAs in one session. (2) Methods: All patients receiving a true hybrid procedure between 2010 and 2022 in our institution were included. Demographic characteristics, neurological symptoms, pre-interventional treatments, angiographic findings, and postoperative clinical and radiological outcomes were analyzed. Results are discussed in the light of a systematic literature review on reported true hybrid procedures for IA treatment. (3) Results: In total, 10 tHAs were performed. Of these, coiling and concomitant decompressive craniectomy or hematoma evacuation was performed on six occasions. In two patients, multiple IAs were treated with different modalities during the same procedure. In two patients, intraoperative conditions did not allow for complete IA clipping, and the remnant was coiled in the same session. The review of the literature revealed nine papers comprising 58 IAs treated with a tHA. (4) Conclusions: The need for a tHA for IA treatment is rare and limited to highly selective cases. In our experience, tHAs have been most valuable in an emergency setting concerning ruptured IAs. Furthermore, tHAs may also be considered in patients with multiple aneurysms in different vascular territories. [ABSTRACT FROM AUTHOR]

Acute subdural hematoma (ASDH) is a common critical neurosurgical condition, often requiring immediate surgical intervention. Craniotomy and decompressive craniectomy are the 2 mainstay surgical approaches. This comprehensive review and meta-analysis aims to summarize the existing evidence and compare the outcomes of these 2 procedures. PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL electronic databases were searched for relevant studies, published between inception of databases till June 2023. Eligible studies reported data of patients diagnosed with ASDH who underwent craniotomy or decompressive craniectomy for ASDH. Outcome measures included the Glasgow Coma Scale score, residual subdural hematoma, requirement of revision surgery, poorer outcomes, and mortality. Data were presented as pooled odds ratios with 95% confidence intervals. Quality assessment and risk of bias were performed for each study. Fourteen studies with a total of 3095 patients were included. The results showed that patients who underwent craniotomy had significantly lower mortality, lower odds of poorer outcomes, and a higher rate of residual subdural hematoma, compared to patients who underwent decompressive craniectomy. There was no significant difference in the requirement of revision surgery between the 2 groups. Heterogeneity was high for most outcomes, and the quality of evidence ranged from moderate to low. Our findings suggest that craniotomy is associated with better clinical outcomes and lower mortality compared to decompressive craniectomy for ASDH, but a higher rate of residual subdural hematoma. Further high-quality randomized controlled trials are needed to validate our findings. [ABSTRACT FROM AUTHOR]

Autologous bone is often the first choice in cranioplasty following a decompressive craniectomy. However, infection is a common complication, with reported rates up to 25%. While the incidence and management of infection are well documented, the risk factors associated with infection remain less clear. The current study aims to identify predictors of infection risk following autologous cranioplasty. A retrospective analysis was conducted on patients who underwent decompressive craniectomy and cranioplasty using cryopreserved autologous bone flaps between 2010 and 2020. Patient demographics and factors related to both surgeries and infection rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in the development of infection. In our cohort, 126 patients underwent autologous cranioplasty. A total of 10 patients (7.9%) developed an infection following reconstruction, with half resulting in implant failure. We did not identify any significant risk factors for infection. Regression analysis identified placement of subgaleal drain following cranioplasty as a protective factor against the development of infection (OR: 0.16, p = 0.007). On average, drains remained in for 3 days, with no difference between the length of drains for those with infection vs. those without (p = 0.757). The current study demonstrates an infection rate of 7.9% in patients who receive an autologous cranioplasty following decompressive craniectomy, which is consistent with previous data. Half (4%) of patients who experienced an infection ultimately required removal of the implant. While it is common practice for neurosurgeons to use drains to prevent hematomas and fluid collections, we found that subgaleal drain placement following cranioplasty was associated with decreased infection, thus demonstrating another benefit of a commonly used tool. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to investigate the prevalence and time of occurrence of complications in patients with seamless duraplasty after reverse question mark incision, and the morbidity and mortality rates after surgery. Material and Methods: Twenty-four patients admitted with different supratentorial indications and underwent decompressive craniectomy and seamless duraplasty between 2019 and 2023, were retrospectively included in this study. The patient's age, gender, etiological reason at admission, and Glasgow coma score before surgery were recorded. The types of complications, their time of occurrence, their relationships with each other, and the procedures performed were recorded. Results: The median time for complications during one-month follow-up was 7 (range, 1-28) days. A total of 18 complications were observed in 15 (62.5%) patients. While 7 (46.7%) of 15 patients with complications died within one month of follow-up, 7 (77.8%) of 9 patients without complications died. Although the mortality rate was higher in patients without complications, there was no statistically significant difference between patients with and without complications (p=0.210). The survival rate in the first month was 53.3% in patients with complications and 22.2% in patients without, and the median survival time was 5 days in patients with complications and 8 days in patients without complications (p=0.214). Conclusion: The onset time and management of the complications is crucial during the first month after decompressive craniectomy which has high mortality and morbidity rates, since the complications can lead to each other, and also these complications can cause serious economic and labor loss. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) remains a significant global problem with an increasing socioeconomic impact. Increasing knowledge of the pathophysiology of TBI has led to a systematic multidisciplinary approach towards management aiming to protect the brain from secondary injury. Early management starting from the scene of injury, to intensive care and surgical settings is paramount to achieve this purpose. TBI includes a large spectrum of diseases, therefore identifying the correct pathology on imaging is fundamental to define the appropriate next steps of management. Computed tomography (CT) imaging to date remains the gold standard for initial radiological assessment. Intracranial and cerebral perfusion pressure targeted therapies are still the minimum requirement in most of modern intensive care units worldwide. Decompressive craniectomy is a fundamental technique to control medically refractory intracranial hypertension and reduce mortality; however, its burden in terms of outcomes remains a controversial topic requiring further debate. There is emerging evidence that TBI is a chronic illness, with increased incidence of cognitive and behavioural deficits, neurodegenerative disease such as seizures and epilepsy, and an increased mortality that extends well beyond the initial TBI stage. Ongoing research into novel biomarkers, the application of artificial intelligence (AI) and an increasing global effort may yield future therapeutic strategies to improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Intracerebral hemorrhages (ICHs) are prevalent, with high morbidity and mortality. We analyzed whether decompressive craniectomy (DC) without evacuation of the acute intraparenchymal hematoma could produce better functional outcomes than treatment with evacuation. Methods: Patients with acute ICH treated with DC without clot evacuation, or evacuation with or without associated craniectomy were included. Matched univariate analyses were performed, and a binary logistic regression model was constructed using the Glasgow Outcome Scale (GOS) and modified Rankin scale (mRS) as dependent variables. Results: 27 patients treated with DC without clot evacuation were compared to 36 patients with clot evacuation; eleven of the first group were matched with 18 patients with evacuation. A significantly better functional prognosis in the group treated with DC without clot evacuation was found. Patients aged < 55 years and treated with DC without clot evacuation had a significantly better functional prognosis (p = 0.008 and p = 0.039, respectively). In multivariate analysis, the intervention performed was the greatest predictor of functional status at the end of follow-up. Conclusions: DC without clot evacuation improves the functional prognosis of patients with acute intraparenchymal hematomas. Larger multicenter studies are warranted to determine whether a change in the management of acute ICH should be recommended. [ABSTRACT FROM AUTHOR]

Craniotomy or decompressive craniectomy are among the therapeutic options to prevent or treat secondary damage after severe brain injury. The choice of procedure depends, among other things, on the type and severity of the initial injury. It remains controversial whether both procedures influence the neurological outcome differently. Thus, estimating the risk of brain herniation and death and consequently potential organ donation remains difficult. All patients at the University Hospital Münster for whom an isolated craniotomy or decompressive craniectomy was performed as a treatment after severe brain injury between 2013 and 2022 were retrospectively included. Proportion of survivors and deceased were evaluated. Deceased were further analyzed regarding anticoagulants, comorbidities, type of brain injury, potential and utilized donation after brain death. 595 patients were identified, 296 patients survived, and 299 deceased. Proportion of decompressive craniectomy was higher than craniotomy in survivors (89% vs. 11%, p < 0.001). Brain death was diagnosed in 12 deceased and 10 donations were utilized. Utilized donations were comparable after both procedures (5% vs. 2%, p = 0.194). Preserved brain stem reflexes as a reason against donation did not differ between decompressive craniectomy or craniotomy (32% vs. 29%, p = 0.470). Patients with severe brain injury were more likely to survive after decompressive craniectomy than craniotomy. Among the deceased, potential and utilized donations did not differ between both procedures. This suggests that brain death can occur independent of the previous neurosurgical procedure and that organ donation should always be considered in end-of-life decisions for patients with a fatal prognosis. [ABSTRACT FROM AUTHOR]

Traumatic Brain Injury (TBI) is a significant global health concern, particularly in low- and middle-income countries (LMICs) where access to medical resources is limited. Decompressive craniectomy (DHC) is a common procedure to alleviate elevated intracranial pressure (ICP) following TBI, but the cost of subsequent cranioplasty can be prohibitive, especially in resource-constrained settings. We describe challenges encountered during the beta-testing phase of CranialRebuild 1.0, an automated software program tasked with creating patient-specific cranial implants (PSCIs) from CT images. Two pilot clinical teams in the Philippines and Ukraine tested the software, providing feedback on its functionality and challenges encountered. The constructive feedback from the Philippine and Ukrainian teams highlighted challenges related to CT scan parameters, DICOM file arrays, software limitations, and the need for further software improvements. CranialRebuild 1.0 shows promise in addressing the need for affordable PSCIs in LMICs. Challenges and improvement suggestions identified throughout the beta-testing phase will shape the development of CranialRebuild 2.0, with the aim of enhancing its functionality and usability. Further research is needed to validate the software's efficacy in a clinical setting and assess its cost-effectiveness. [ABSTRACT FROM AUTHOR]

Cranioplasty is a common neurosurgical procedure that follows hemicraniectomy in the setting of neoplasm resection or increased intracranial pressure. Although standardized practices aim at minimizing infection risk, infection of the surgical site has been reported in 6.6%–8.4% of patients. In this work, we document the novel use of synthetic dissolvable antibiotic-impregnated calcium sulfate beads (STIMULANⓇ Rapid Cure, Biocomposites Ltd, Wilmington, NC, USA) in five cases of cranioplasty at our institution. Four patients experienced wound healing as expected with no complications related to the use of Stimulan beads. One patient's clinical course was complicated by pseudomeningocele with superficial wound infection occurring 74 days following cranioplasty. Of note, this patient had suffered an avulsion injury and subgaleal hematoma of the scalp ipsilateral to the cranial incision, predisposing to infection due to incompetent scalp vasculature. No complications could be directly attributed to the use of STIMULANⓇ beads. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Accurately identifying fulminant demyelinating diseases is important for sudden onset of asymmetric cerebral white matter lesions with mass effect. Initially, immunotherapy should be administered; however, surgical intervention should be performed with poor response to medical management and evident signs of cerebral herniation. A case of fulminant demyelinating disease of the central nervous system that required decompressive craniectomy 8 days after symptom onset is presented. The patient recovered without sequelae after a combination of neurosurgery and immunotherapy with steroids and has remained relapse‐free for 4 years. [ABSTRACT FROM AUTHOR]

Abstract Introduction Decompressive craniectomy [DC] is one of the leading armaments to lower refractory intracranial pressure. Post-DC hydrocephalus [PDCH] occurs in 11.9–36% of patients undergoing DCs for TBIs. Various theories have been given regarding pathophysiological mechanism of PDCH but remain dubious. Risk factors predicting PDCH still under research. Exact timeline regarding developmental process of PDCH remains undefined. Method This retrospective study was conducted on 422 patients who underwent DCs in our tertiary care trauma center over the period of one year. 60 patients out of 422 who developed PDCH were analyzed with respect to demographic variables and preoperative and postoperative risk factors. A total of 20 randomly selected patients, who underwent DCs but did not develop hydrocephalus, were selected and compared with patients who developed PDCH. Outcome analysis was done by dichotomizing the groups into independent and dependent groups. Results Among 422 patients undergoing DC, 14.21%[n = 60] developed PDCH. Younger [34.2 y vs 43.3 y, p = 0.0004] male age group was predominant in our study. Age [p = 0.021, multivariate analysis] and midline shift [p = 0.008, multivariate analysis] were significant preoperative predicting risk factors for PDCH. Interhemispheric hygroma [p = 0.031], brain bulge [ p = 0.008], and blood in postoperative scan [p = 0.029] were significant postoperative risk factors. Lower GCS score at admission [p = 0.0003], postoperative day 10 and at the time of establishment of PDCH were significantly predicted surgery to hydrocephalus time. Midline shift [p = 0.007] and thickness of interhemispheric hygroma [p = 0.021] were associated with poor outcome in patients with PDCH. Conclusion Younger age group and presence of midline shift are significant preoperative predictors of PDCH. Blood in postoperative scan, interhemispheric hygroma and brain bulge in postoperative period are significant predictors for PDCH. Deterioration in GCS score in postoperative period following DC should be taken as high index of suspicion for developing PDCH.

Abstract Craniotomy or decompressive craniectomy are among the therapeutic options to prevent or treat secondary damage after severe brain injury. The choice of procedure depends, among other things, on the type and severity of the initial injury. It remains controversial whether both procedures influence the neurological outcome differently. Thus, estimating the risk of brain herniation and death and consequently potential organ donation remains difficult. All patients at the University Hospital Münster for whom an isolated craniotomy or decompressive craniectomy was performed as a treatment after severe brain injury between 2013 and 2022 were retrospectively included. Proportion of survivors and deceased were evaluated. Deceased were further analyzed regarding anticoagulants, comorbidities, type of brain injury, potential and utilized donation after brain death. 595 patients were identified, 296 patients survived, and 299 deceased. Proportion of decompressive craniectomy was higher than craniotomy in survivors (89% vs. 11%, p

BACKGROUND: Limited 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. METHODS: We 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). FINDINGS: Between 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

Objective To investigate the effect of bone window closure on moderate to severe traumatic brain injury (TBI) in mice by controlled cortical impact (CCI). Methods A total of 200 healthy male mice were divided into 2 groups for moderate and severe TBI. Fifty were randomly selected from each group for bone window closed, and the remaining 50 were not closed. The intracranial pressure (ICP) was monitored, the water content of brain tissue and the volume of cerebral edema were measured, the degree of neurological impairment was assessed by modified Neurological Severity Score (mNSS), and the spatial learning ability and memory were evaluated by Morris water maze test. Nissl staining assessed the degree of neuronal damage in the cerebral cortex and CA1 region of the hippocampus. Results For ICP, there were differences in ICP between the bone window closed group and the unclosed group in both the moderate and severe TBI (P = 0.007, 0.000). There were also significant differences in ICP at different observation time points after modeling (P = 0.000, 0.000). The ICP on 1 d of the moderate bone window closed group was higher than that in the moderate bone window unclosed group (P = 0.009), 1 d (P = 0.000) and 3 d (P = 0.038) of the severe bone window closed group was higher than that of the severe bone window unclosed group. On 7 d, the ICP in the moderate bone window closed group (P = 0.000, 0.000) and the severe bone window closed group (P = 0.000, 0.008) was lower than that on 1 and 3 d, and the ICP on 3 d was also lower than that on 1 d (P = 0.000, 0.000). The ICP in the moderate bone window unclosed group on 7 d was lower than that on 1 d (P = 0.031). The water content of brain tissue was lower on 1 d (P = 0.028), 3 d (P = 0.023) and 7 d (P = 0.023) in severe bone window closed group than that of severe bone window unclosed group. The volume of brain edema in the bone window closed group was smaller than that in the bone window unclosed group (P = 0.021, 0.037). In the evaluation of the degree of neurological impairment, there were differences in mNSS scores at different observation time points between the bone window closed group and the bone window unclosed group (P = 0.000, 0.001). On 7 d, the mNSS scores of the moderate bone window closed group (P = 0.002), the moderate bone window unclosed group (P = 0.013) and the severe bone window closed group (P = 0.009) were all lower than those on 1 d. The mNSS scores of the severe bone window closed group (P = 0.006) and the severe bone window unclosed group (P = 0.002) were all lower than those of 3 d. Morris water maze test showed that the platform latency of mice in the severe bone window closed group was longer than that in the severe bone window unclosed group (P = 0.045), and the target quadrant residence time was shorter than that in the severe bone window unclosed group (P = 0.025). Nissl staining showed compared with the moderate bone window unclosed group, the density of Nissl bodies in cerebral cortex neurons was decreased, the staining was lighter, and the density of Nissl bodies in cerebral cortex neurons of CA1 region of hippocampus was decreased, the Nissl staining was lighter and the shape was blurred in the moderate bone window closed group. In severe TBI model mice, compared with the bone window unclosed group, the density of Nissl bodies in cerebral cortex and hippocampal CA1 region of the bone window closed group was decreased, the staining was blurred, and more metachromic particles appeared, hippocampal CA1 region body edema, the Nissl staining blurred. Conclusions In moderate TBI model mice, bone window closure increases ICP in the acute stage, but has no significant effect on the degree of cerebral edema, neurological function and cognitive function. In severe TBI model mice, bone window closure can lead to increased ICP and decreased spatial learning ability and memory, but it can reduce the degree of brain edema and improve neurological function. It is suggested that bone window closure should be selected according to the purpose of the study.

Objective To screen the risk factors of hydrocephalus after decompressive craniectomy in patients with cerebral hernia after traumatic brain injury (TBI), and construct a Bayesian network model based on the risk factors. Methods A total of 77 patients with cerebral hernia after TBI who underwent decompressive craniotomy in Nanjing Tongren Hospital Affiliated to Southeast University from March 2020 to January 2022 were included. They were divided into hydrocephalus group (n = 25) and non - hydrocephalus group (n = 52) according to whether hydrocephalus was complicated after surgery. The risk factors of hydrocephalus after decompressive craniectomy in patients with cerebral hernia after TBI were analyzed by univariate and multivariate Logistic regression analyses. The Bayesian network model was constructed based on the risk factors, and the receiver operating characteristic (ROC) curve and calibration curve were drawn and Hosmer-Lemeshow goodness-of-fit test was conducted. Results In hydrocephalus group, the Glasgow Coma Scale (GCS) score at admission (t = 2.178, P = 0.032), the ratio of cerebrospinal fluid replacement after lumbar puncture (χ2 = 8.675, P = 0.003), and the level of β2 -microglobulin after operation (t = 11.146, P = 0.000) were lower than those in non-hydrocephalus group, while subarachnoid hemorrhage (χ2 = 5.901, P = 0.015), bilateral operation (χ2 = 6.441, P = 0.011), the ratio of dural unstitched during operation (χ2 = 9.759, P = 0.002), postoperative intraventricular hemorrhage (χ2 = 8.938, P = 0.003), postoperative midline displacement > 10 mm (χ2 = 7.589, P = 0.006), and intracranial infection (χ2 = 4.519, P = 0.034), as well as postoperative coma time (t = 2.709, P = 0.008) were higher than those in non - hydrocephalus group. Logistic regression analysis showed that subarachnoid hemorrhage (OR = 1.885, 95%CI: 1.432-2.240; P = 0.012), dural unstitched during operation (OR = 1.468, 95%CI: 1.215-1.930; P = 0.006), long postoperative coma time (OR = 1.574, 95%CI: 1.358-1.926; P = 0.007), postoperative intraventricular hemorrhage (OR = 1.550, 95%CI: 1.254-1.768; P = 0.010), the level of β2- microglobulin increased after operation (OR = 1.622, 95%CI: 1.165-1.840; P = 0.004) were risk factors for hydrocephalus after decompressive craniectomy in patients with cerebral hernia after TBI. Based on these 5 factors, the Bayesian network model was constructed, and the area under ROC curve was 0.886 (95%CI: 0.823-0.925, P = 0.000). The calibration curve showed that there was a good consistency between the predicted probability and the actual probability, while the Hosmer-Lemeshow goodness-of-fit test showed no significant difference (χ2 = 8.760, P = 0.232), which indicated that the model had good discrimination, calibration and accuracy. Conclusions Subarachnoid hemorrhage, dural unstitched during operation, long postoperative coma time, postoperative intra ventricular hemorrhage, and elevated β2 - microglobulin level are the risk factors for hydrocephalus after decompressive craniectomy in patients with cerebral hernia after TBI.

Abstract The rapid perfusion of cerebral arteries leads to a significant increase in intracranial blood volume, exposing patients with traumatic brain injury to the risk of diffuse brain swelling or malignant brain herniation during decompressive craniectomy. The microcirculation and venous system are also involved in this process, but the precise mechanisms remain unclear. A physiological model of extremely high intracranial pressure was created in rats. This development triggered the TNF-α/NF-κB/iNOS axis in microglia, and released many inflammatory factors and reactive oxygen species/reactive nitrogen species, generating an excessive amount of peroxynitrite. Subsequently, the capillary wall cells especially pericytes exhibited severe degeneration and injury, the blood–brain barrier was disrupted, and a large number of blood cells were deposited within the microcirculation, resulting in a significant delay in the recovery of the microcirculation and venous blood flow compared to arterial flow, and this still persisted after decompressive craniectomy. Infliximab is a monoclonal antibody bound to TNF-α that effectively reduces the activity of TNF-α/NF-κB/iNOS axis. Treatment with Infliximab resulted in downregulation of inflammatory and oxidative–nitrative stress related factors, attenuation of capillary wall cells injury, and relative reduction of capillary hemostasis. These improved the delay in recovery of microcirculation and venous blood flow.

Abstract Background Decompressive craniectomy (DC) is a neurosurgical procedure, frequently used in lowering the refractory intracranial pressure (ICP) following traumatic brain injuries. Post-traumatic hydrocephalus (PTH), a debilitating complication in the patients with traumatic brain injuries, occurs in 11.9–36% patients undergoing DCs. Sunken flap syndrome (SFS) is a rare entity, following DCs or cerebrospinal fluid (CSF) diversion procedures for PTH after DCs and leads to neurological deterioration of the patients. Literature regarding risk factors associated with SFS in the patients undergoing ventriculoperitoneal shunt procedures for hydrocephalus following DCs is scarce. The aim of this study is to determine the incidence of SFS and to establish a relationship between several clinico-radiological features and SFS in patients undergoing shunt procedures for PTH. Results This retrospective study was conducted in a tertiary care trauma centre upon 60 patients who underwent shunt procedures for PTH. Intraventricular haemorrhage (P 43 was a significant risk factor in development of SFS. Conclusions SFS is the common complication following shunt procedures for PTH after DCs. MFHI is significant risk predictor for SFS. MFHI > 43 is associated with higher chances of developing SFS following shunt insertion in PTH. Early cranioplasty following DCs might prevent development of SFS.

Abstract Background This study aims to investigate the benefits of employing a Physical Lifelike Brain (PLB) simulator for training medical students in performing craniotomy for glioblastoma removal and decompressive craniectomy. Methods This prospective study included 30 medical clerks (fifth and sixth years in medical school) at a medical university. Before participating in the innovative lesson, all students had completed a standard gross anatomy course as part of their curriculum. The innovative lesson involved PLB Simulator training, after which participants completed the Learning Satisfaction/Confidence Perception Questionnaire and some received qualitative interviews. Results The average score of students’ overall satisfaction with the innovative lesson was 4.71 out of a maximum of 5 (SD = 0.34). After the lesson, students’ confidence perception level improved significantly (t = 9.38, p

Background: Decompressive craniectomy (DC) is a neurosurgical procedure, frequently used in lowering the refractory intracranial pressure (ICP) following traumatic brain injuries. Post-traumatic hydrocephalus (PTH), a debilitating complication in the patients with traumatic brain injuries, occurs in 11.9–36% patients undergoing DCs. Sunken flap syndrome (SFS) is a rare entity, following DCs or cerebrospinal fluid (CSF) diversion procedures for PTH after DCs and leads to neurological deterioration of the patients. Literature regarding risk factors associated with SFS in the patients undergoing ventriculoperitoneal shunt procedures for hydrocephalus following DCs is scarce. The aim of this study is to determine the incidence of SFS and to establish a relationship between several clinico-radiological features and SFS in patients undergoing shunt procedures for PTH. Results: This retrospective study was conducted in a tertiary care trauma centre upon 60 patients who underwent shunt procedures for PTH. Intraventricular haemorrhage (P < 0.0001), communicating-type hydrocephalus (P = 0.0006), and modified frontal horn index (P < 0.0001) were significantly associated with development of SFS. MFHI > 43 was a significant risk factor in development of SFS. Conclusions: SFS is the common complication following shunt procedures for PTH after DCs. MFHI is significant risk predictor for SFS. MFHI > 43 is associated with higher chances of developing SFS following shunt insertion in PTH. Early cranioplasty following DCs might prevent development of SFS. [ABSTRACT FROM AUTHOR]

Background: Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. Methods: From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. Results: Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. Conclusions: The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case. [ABSTRACT FROM AUTHOR]

Objective: The timing of cranioplasty (CP) has become a widely debated topic in research, there is currently no unified standard. To this end, we established a outcome prediction model to explore the factors influencing the outcome of early CP. Our aim is to provide theoretical and practical basis for whether patients with skull defects after decompressive craniectomy (DC) are suitable for early CP. Methods: A total of 90 patients with early CP after DC from January 2020 to December 2021 were retrospectively collected as the training group, and another 52 patients with early CP after DC from January 2022 to March 2023 were collected as the validation group. The Nomogram was established to explore the predictive factors that affect the outcome of early CP by Least absolute shrinkage analysis and selection operator (LASSO) regression and Logistic regression analysis. Receiver operating characteristic (ROC) curve was used to evaluate the discrimination of the prediction model. Calibration curve was used to evaluate the accuracy of data fitting, and decision curve analysis (DCA) diagram was used to evaluate the benefit of using the model. Results: Age, preoperative GCS, preoperative NIHSS, defect area, and interval time from DC to CP were the predictors of the risk prediction model of early CP in patients with skull defects. The area under ROC curve (AUC) of the training group was 0.924 (95%CI: 0.867-0.980), and the AUC of the validation group was 0.918 (95%CI, 0.842-0.993). Hosmer-Lemeshow fit test showed that the mean absolute error was small, and the fit degree was good. The probability threshold of decision risk curve was wide and had practical value. Conclusion: The prediction model that considers the age, preoperative GCS, preoperative NIHSS, defect area, and interval time from DC has good predictive ability. [ABSTRACT FROM AUTHOR]

Background: Falcotentorial meningiomas (FM) are surgical challenges for protecting sinus, and the technique notes on the management of superior sagittal or transverse sinus are required for good results. Methods: We improved the technique notes on the management of superior sagittal or transverse sinus in three FMpatients with signs of increased intracranial pressure or chronic headache. Results: All patients underwent surgeries in the prone position, and occipital/sup-occipital/sub-occipital craniotomy was performed. In one patient, the skull was removed traditionally with exposure of the confluence of sinuses, superior sagittal, and transverse sinus, while the longitudinal skull bridge was left to suspend the dura for protecting the superior sagittal sinus in one patient, and the transverse skull bridge was left to suspend the dura for protecting the transverse sinus in one patient. The dura was opened infratentorially or supratentorially to spare the sinus and then the "skull bridge" was suspended. The tumor was then removed completely without brain swelling or significant venous bleeding. Complete tumor resection was confirmed by early postoperative imaging, and all patients recovered well without postoperative morbidity. Conclusion: The authors recommend the "skull bridge" to suspend the dura for optimal control of the venous sinuses during FM surgery (less venous bleeding). [ABSTRACT FROM AUTHOR]

raumatic brain injury (TBI) is a significant global health concern, particularly affecting young individuals, and is a leading cause of mortality and morbidity worldwide. Despite improvements in treatment infrastructure, many TBI patients choose discharge against medical advice (DAMA), often declining necessary surgical interventions. We aimed to investigate the factors that can be associated with DAMA in TBI patients that were recommended to have surgical treatment. This study was conducted at single tertiary university center (2008–2018), by retrospectively reviewing 1510 TBI patients whom visited the emergency room. We analyzed 219 TBI surgical candidates, including 50 declining surgery (refused group) and the others whom agreed and underwent decompressive surgery. Retrospective analysis covered demographic characteristics, medical history, insurance types, laboratory results, CT scan findings, and GCS scores. Statistical analyses identified factors influencing DAMA. Among surgical candidates, 169 underwent surgery, while 50 declined. Age (60.8 ± 17.5 vs. 70.5 ± 13.8 years; p < 0.001), use of anticoagulating medication (p = 0.015), and initial GCS scores (9.0 ± 4.3 vs. 5.3 ± 3.2; p < 0.001) appeared to be associated with refusal of decompressive surgery. Based on our analysis, factors influencing DAMA for decompressive surgery included age, anticoagulant use, and initial GCS scores. Contrary to general expectations and some previous studies, our analysis revealed that the patients' medical conditions had a larger impact than socioeconomic status under the Korean insurance system, which fully covers treatment for TBI. This finding provides new insights into the factors affecting DAMA and could be valuable for future administrative plans involving national insurance. [ABSTRACT FROM AUTHOR]

Background and objective: Current data on the optimal treatment modality for ruptured anterior communicating artery (AComA) aneurysms are limited. We conducted this multicenter retrospective study to evaluate the safety and clinical outcomes of endovascular treatment (EVT) and microsurgical clipping (MC) for the treatment of ruptured AComA patients. Methods: Patients with ruptured AComA aneurysms were screened from the Chinese Multicenter Cerebral Aneurysm Database. Propensity score matching (PSM) was used to adjust for baseline characteristic imbalances between the EVT and MC groups. The safety outcomes included total procedural complications, procedure-related morbidity/death and remedial procedure for complication. The primary clinical outcome was 2-year functional independence measured by the modified Rankin scale (mRS) score. Results: The analysis included 893 patients with ruptured AComA aneurysms (EVT: 549; MC: 346). PSM yielded 275 pairs of patients in the EVT and MC cohorts for comparison. Decompressive craniectomy being more prevalent in the MC group (19.3% vs. 1.5%, p< 0.001). Safety data revealed a lower rate of total procedural complications (odds ratio [OR] = 0.62, 95% CI 0.39-0.99; p= 0.044) in the EVT group and similar rates of procedure-related morbidity/ death (OR = 0.91, 95% CI 0.48-1.73; p= 0.880) and remedial procedure for complication (OR = 1.35, 95% CI 0.51-3.69, p= 0.657) between the groups. Compared with that of MC patients, EVT patients had a greater likelihood of functional independence (mRS score 0-2) at discharge (OR = 1.68, 95% CI 1.142.50; p = 0.008) and at 2years (OR = 1.89, 95% CI 1.20-3.00; p = 0.005), a lower incidence of 2-year all-cause mortality (OR = 0.54, 95% CI 0.31-0.93; p = 0.023) and a similar rate of retreatment (OR = 1.00, 95% CI 0.23-4.40; p = 1.000). Conclusion: Clinical outcomes after treatment for ruptured AComA aneurysms appear to be superior to those after treatment with MC, with fewer overall procedure-related complications and no increase in the retreatment rate. Additional studies in other countries are needed to verify these findings. [ABSTRACT FROM AUTHOR]

To analyze the factors related to the efficacy of consciousness-regaining therapy (CRT) for prolonged disorder of consciousness. A retrospective analysis was conducted on the case data of 114 patients with prolonged disorder of consciousness (pDOC) admitted to the Department of Functional Neurosurgery of Tianjin Huanhu Hospital from January 2019 to January 2022 to explore the relevant factors that affect the efficacy of CRT for pDOC. Next, basic information on the cases, data on pDOC disease assessment, CRT methods, and efficacy evaluation were collected. These 114 patients were grouped, and a comparative analysis was done based on the efficacy at the end of treatment. Of these, 61 cases were allotted to the ineffective group and 53 cases to the effective group. There was a lack of statistical difference (P > 0.05) between the 2 groups based on gender, age, etiology, acute cerebral herniation, emergency craniotomy surgery, emergency decompressive craniectomy, time from onset to start of CRT, and CRT duration (P > 0.05). However, secondary hydrocephalus, CRT methods, JFK Coma Recovery Scale-Revised grading before treatment, and extended Glasgow Outcome Scale score at six months after treatment were found to be statistically different. The results of binary logistic regression analysis showed that the type of therapy (OR = 0.169, 95% CI: 0.057–0.508) affected the efficacy of CRT (P < 0.05). Personalized awakening therapy using various invasive CRT methods could improve the efficacy of therapy for pDOC compared with noninvasive therapy. [ABSTRACT FROM AUTHOR]

Background: There are pathological conditions in which intracranial hypertension and patent basal cisterns in computed tomography coexist. These situations are not well recognized, which could lead to diagnostic errors and improper management. Methods: We present a retrospective case series of patients with traumatic brain injury, subarachnoid hemorrhage, and cryptococcal meningitis who were treated at our intensive care unit. Criteria for deciding placement of an external lumbar drain were (1) intracranial hypertension refractory to osmotherapy, hyperventilation, neuromuscular blockade, intravenous anesthesia, and, in some cases, decompressive craniectomy and (2) a computed tomography scan that showed open basal cisterns and no mass lesion. Results: Eleven patients were studied. Six of the eleven patients treated with controlled lumbar drainage are discussed as illustrative cases. All patients developed intracranial hypertension refractory to maximum medical treatment, including decompressive craniectomy in Four of the eleven cases. Controlled external lumbar drainage led to immediate and sustained control of elevated intracranial pressure in all patients, with good neurological outcomes. No brain herniation, intracranial bleeding, or meningitis was detected during this procedure. Conclusions: Our study provides preliminary evidence that in selected patients who develop refractory intracranial hypertension with patent basal cisterns and no focal mass effect on computed tomography, controlled lumbar drainage appears to be a therapeutic option. In our study there were no deaths or complications. Prospective and larger studies are needed to confirm our results. [ABSTRACT FROM AUTHOR]

Background: Cerebral autoregulation is impaired early on after aneurysmal subarachnoid hemorrhage (aSAH). The study objective was to explore the pressure reactivity index (PRx) and cerebral perfusion pressure (CPP) in the earliest phase after aneurysm rupture and to address the question of whether an optimal CPP (CPPopt)–targeted management is associated with less severe early brain injury (EBI). Methods: Patients with aSAH admitted between 2012 and 2020 were retrospectively included in this observational cohort study. The PRx was calculated as a correlation coefficient between intracranial pressure and mean arterial pressure. By plotting the PRx versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. EBI was assessed by applying the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) on day 3 after ictus. An SEBES ≥ 3 was considered severe EBI. Results: In 90 of 324 consecutive patients with aSAH, intracranial pressure monitoring was performed ≥ 7 days, allowing for PRx calculation and CPPopt determination. Severe EBI was associated with larger mean deviation of CPP from CPPopt 72 h after ictus (r = 0.22, p = 0.03). Progressive edema requiring decompressive hemicraniectomy was associated with larger deviation of CPP from CPPopt on day 2 (r = 0.23, p = 0.02). The higher the difference of CPP from CPPopt on day 3 the higher the mortality rate (r = 0.31, p = 0.04). Conclusions: Patients with CPP near to the calculated CPPopt in the early phase after aSAH experienced less severe EBI, less frequently received decompressive hemicraniectomy, and exhibited a lower mortality rate. A prospective evaluation of CPPopt-guided management starting in the first days after ictus is needed to confirm the clinical validity of this concept. [ABSTRACT FROM AUTHOR]

Objective: There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age). Methods: Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV–V) and unfavourable outcome (GOS I to III). Results: 56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years). Conclusion: Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities. [ABSTRACT FROM AUTHOR]

This article examines the research trends in optic nerve sheath diameter (ONSD) monitoring through a bibliometric study. The study reveals a consistent increase in the number of articles on ONSD, with the highest number of publications in 2023. The analysis of keywords indicates that ONSD monitoring is widely used for predicting neurological outcomes and has gained significance in non-neurological intensive care settings. The article also highlights the potential of ONSD monitoring for non-invasive intracranial pressure measurement in neurosurgery. However, the study's inclusion of all PubMed titles may have led to the repetition of keywords, limiting its findings. Nonetheless, the article offers valuable insights into the current state of research in ONSD monitoring. [Extracted from the article]

It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone. In this multicentre, randomised, open-label, assessor-blinded trial conducted in 42 stroke centres in Austria, Belgium, Finland, France, Germany, the Netherlands, Spain, Sweden, and Switzerland, adults (18–75 years) with a severe intracerebral haemorrhage involving the basal ganglia or thalamus were randomly assigned to receive either decompressive craniectomy plus best medical treatment or best medical treatment alone. The primary outcome was a score of 5–6 on the modified Rankin Scale (mRS) at 180 days, analysed in the intention-to-treat population. This trial is registered with ClincalTrials.gov , NCT02258919 , and is completed. SWITCH had to be stopped early due to lack of funding. Between Oct 6, 2014, and April 4, 2023, 201 individuals were randomly assigned and 197 gave delayed informed consent (96 decompressive craniectomy plus best medical treatment, 101 best medical treatment). 63 (32%) were women and 134 (68%) men, the median age was 61 years (IQR 51–68), and the median haematoma volume 57 mL (IQR 44–74). 42 (44%) of 95 participants assigned to decompressive craniectomy plus best medical treatment and 55 (58%) assigned to best medical treatment alone had an mRS of 5–6 at 180 days (adjusted risk ratio [aRR] 0·77, 95% CI 0·59 to 1·01, adjusted risk difference [aRD] −13%, 95% CI −26 to 0, p=0·057). In the per-protocol analysis, 36 (47%) of 77 participants in the decompressive craniectomy plus best medical treatment group and 44 (60%) of 73 in the best medical treatment alone group had an mRS of 5–6 (aRR 0·76, 95% CI 0·58 to 1·00, aRD −15%, 95% CI −28 to 0). Severe adverse events occurred in 42 (41%) of 103 participants receiving decompressive craniectomy plus best medical treatment and 41 (44%) of 94 receiving best medical treatment. SWITCH provides weak evidence that decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep intracerebral haemorrhage. The results do not apply to intracerebral haemorrhage in other locations, and survival is associated with severe disability in both groups. Swiss National Science Foundation, Swiss Heart Foundation, Inselspital Stiftung, and Boehringer Ingelheim. [ABSTRACT FROM AUTHOR]

Background: Agitation is frequently encountered in patients recovering from traumatic brain injury (TBI) in the intensive care unit (ICU). The etiopathology for agitation is multifactorial. Melatonin has been widely used to study the effects of delirium in ICU, however, its effect on agitation is not well studied. Aims and Objectives: The aim of this study was to assess the effect of melatonin administration on the prevalence of agitation and length of stay in patients with severe TBI, managed conservatively, or undergoing decompressive craniectomy. Materials and Methods: A retrospective observational study with 70 patients undergoing various decompressive craniotomy or managed conservatively, and admitted to neurosurgical ICU was included in the study. Thirty-six patients were recruited from the control group and 34 patients received melatonin during their stay in the ICU. In this study, records of 70 patients who had suffered isolated TBI with no associated injuries were analyzed. The patients had a Glasgow coma score of 3–14 on admission to ICU. The patients were managed as per the standard protocols, as per the existing guidelines, and based on TBI guidelines. Results: A non-significant decreasing trend of agitation and reduced duration of ICU stay was noted in patients who received melatonin compared with the control group. The prevalence of agitation observed on modified Ramsay scale (Mean±SD) in patients who received melatonin on Day 3, Day 4, Day 5, Day 6, Day 7, Day 8, and Day 9 were -1.67±3.01; -1.61±2.82; -1.2±2.55; -1.23±2.51; -1.23±2.11; -1.05±2.09; and 0.76±2.03, respectively. These scores were slightly lower than observed in the control group on Day 3, Day 4, Day 5, Day 6, Day 7, Day 8, and Day 9 as -1.58±3.16; -1.33±2.72; -1.08±2.46; -1.13±2.25; -0.94±1.87; -0.52±1.7; and 0.52±1.36, respectively. The mean±SD duration of stay in ICU of patients receiving melatonin (13.14±3.37) and not receiving melatonin (14.52±3.73) was comparable (P=0.1). Conclusion: Although there was a decreased prevalence of agitation and a decrease in the mean duration of the ICU stay in patients who received oral melatonin, these beneficial effects did not show any statistical significance once compared with the control group. [ABSTRACT FROM AUTHOR]

Purpose of Review: To care for patients with cerebrovascular disease (CVD), neurointerventionalists, intensivists, and other healthcare providers must be equipped to address associated ethical challenges. This review aims to delineate the applicability of fundamental bioethical approaches to CVD, highlight key ethical issues in CVD care, and delineate an ethical framework to streamline ethical decision-making for people with CVD. Recent Findings: Three introductory cases are presented. The four key principles of principalism and the approach of narrative ethics are described with reference to CVD. Key ethical considerations include decision-making capacity and informed consent, uncertainty, and resource allocation. A categorization of CVD as emergent/nonemergent and the recommended management as intervention/no intervention helps frame the spectrum of CVD. A different six-pathway may then be taken based on which category the patient case corresponds to. Summary: Physicians involved in the care of people with cerebrovascular disease must understand how the ethical issues manifest in individual patient cases to ensure appropriate care. The aforementioned ethical framework may aid physicians in providing ethically sound care. All decisions must involve a balance between clinical expertise and patient values and preferences or those articulated by a surrogate to properly respect the wishes of patients with CVD. [ABSTRACT FROM AUTHOR]

Background: Computed tomography (CT) can be a substantial source of guiding lights during the early postoperative hours in traumatic brain injury (TBI) patients. However, controversy still exists regarding: What is the appropriate time for the first postoperative CT? And what are the guiding lights that can be gained from an early follow-up CT? Therefore, our objective was to reach more clear answers for these questions and to design a simple algorithm for the follow-up of TBI patients during the first 24 h after cranial surgery. Methods: This is a retrospective study included 164 TBI patients who were surgically treated for various traumatic cranial and/or intracranial lesions in our neurosurgery department from January 2022 to April 2023. Pre- and postoperative clinical and radiological data of these patients were collected and analyzed. Results: The mean age was (23.46 ± 15.126) years. The mean glasgow coma scale (GCS) on presentation was (11.62 ± 3.004). 51.2% of patients had their first follow-up CT done within the first postoperative hour (0–1 h). Postoperative remarkable CT findings were detected in 39 patients (23.8%), with 13 cases (33.3%) of them required re-surgery. 69.2% of the postoperative remarkable findings were recognized in the first hour CT (P = 0.025). Acute subdural hematoma was the only significant primary lesion associated with the need for re-surgery (P = 0.015). Postoperative development of remarkable CT findings was significantly (P < 0.001) associated with increased possibility of re-surgery, high mortality rate, prolonged hospital stay and poor outcome. Conclusions: Immediate (0–1 h) follow-up CT brain can be more lucrative in the early postoperative assessment for TBI patients. The first hour CT can provide distinct guiding lights of significant value for the subsequent postoperative management and prediction of patients' clinical course and discharge outcome. [ABSTRACT FROM AUTHOR]

Introduction: Decompressive craniectomy [DC] is one of the leading armaments to lower refractory intracranial pressure. Post-DC hydrocephalus [PDCH] occurs in 11.9–36% of patients undergoing DCs for TBIs. Various theories have been given regarding pathophysiological mechanism of PDCH but remain dubious. Risk factors predicting PDCH still under research. Exact timeline regarding developmental process of PDCH remains undefined. Method: This retrospective study was conducted on 422 patients who underwent DCs in our tertiary care trauma center over the period of one year. 60 patients out of 422 who developed PDCH were analyzed with respect to demographic variables and preoperative and postoperative risk factors. A total of 20 randomly selected patients, who underwent DCs but did not develop hydrocephalus, were selected and compared with patients who developed PDCH. Outcome analysis was done by dichotomizing the groups into independent and dependent groups. Results: Among 422 patients undergoing DC, 14.21%[n = 60] developed PDCH. Younger [34.2 y vs 43.3 y, p = 0.0004] male age group was predominant in our study. Age [p = 0.021, multivariate analysis] and midline shift [p = 0.008, multivariate analysis] were significant preoperative predicting risk factors for PDCH. Interhemispheric hygroma [p = 0.031], brain bulge [ p = 0.008], and blood in postoperative scan [p = 0.029] were significant postoperative risk factors. Lower GCS score at admission [p = 0.0003], postoperative day 10 and at the time of establishment of PDCH were significantly predicted surgery to hydrocephalus time. Midline shift [p = 0.007] and thickness of interhemispheric hygroma [p = 0.021] were associated with poor outcome in patients with PDCH. Conclusion: Younger age group and presence of midline shift are significant preoperative predictors of PDCH. Blood in postoperative scan, interhemispheric hygroma and brain bulge in postoperative period are significant predictors for PDCH. Deterioration in GCS score in postoperative period following DC should be taken as high index of suspicion for developing PDCH. [ABSTRACT FROM AUTHOR]

AbstractPurposeCase PresentationConclusionTension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH).An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day.TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patient's age is considered to be one of the most relevant factors in selecting surgical candidates for decompressive hemicraniectomy after malignant hemispheric infarction. However, questions about surgical indication in older patients, patients with consciousness disorder or patients with large infarctions remain unanswered. OBJECTIVE: Our aim was to design a multifactorial scoring scale based on a combination of patient-specific factors in order to optimize the assessment of prognosis in patients after hemicraniectomy malignant strokes. METHODS: In this prospective observational study with a one-year follow-up, we assessed clinical and imaging data of patients who underwent decompressive hemicraniectomy due to malignant brain infarction. Barthel index was used as a single outcome measure to distinguish favorable vs. unfavorable outcomes. Associations between multiple variables and clinical outcome were assessed. Subsequently, a design of a predictive scoring system was proposed. RESULTS: Age of the patient, preoperative level of consciousness, midline shift, and volume of infarction showed a significant association with postoperative Barthel index. According to the identified factors, a multifactorial prognostic scoring system was introduced, aimed to distinguish between favorable and unfavorable outcomes. Using ROC analysis, it has achieved an AUC of 0.74 (95%CI 0.58-0.89, p=0.01) CONCLUSIONS: Prediction of postoperative outcome should be based on multiple variables. Our scale, based on the clinical and imaging data, can be used during decision-making to estimate potential benefit of decompressive craniectomy in patients after malignant brain infarction [ABSTRACT FROM AUTHOR]

In recent years, the endoscopic transorbital (TO) approach has gained increasing interest for the treatment of middle cranial fossa lesions. We propose a technical refinement to the conventional superior eyelid TO approach, which improves the surgical exposure and augments the working angles when targeting the opticocarotid region. Four embalmed adult cadaveric specimens (8 sides) were dissected at the Laboratory of Surgical Neuroanatomy of our institution. A TO approach was performed, with removal of the anterior clinoid process and the lateral orbital rim. Subsequently, the MacCarty keyhole was drilled in the superolateral orbital wall. Given that the lesser sphenoid wing was already drilled in the conventional TO craniectomy, the opening of the keyhole was essentially a lateral extension of the craniectomy. The procedure was successfully conducted in all 4 orbits. Clinoidectomy was performed either before or after extending the craniectomy to the MacCarty point. Extending the craniectomy made anterior clinoidectomy easier, by increasing the surgical exposure, and allowing a more lateral entrance for the endoscope. The extension also facilitated frontal lobe retraction, and it facilitated the optic nerve and carotid artery manipulation. Postoperative computed tomography scans showed a minimal 10-mm craniectomy extension, which remained covered by the temporal muscle after reconstruction. The modified endoscopic TO approach with the extension of the craniectomy to MacCarty point improves surgical access and visualization of the opticocarotid region. This facilitates anterior clinoidectomy and optic nerve decompression. Although it implies judicious instrument manipulation and a larger incision size, further studies can define its potential benefits. [ABSTRACT FROM AUTHOR]

Describe a new, safe, technique that uses titanium mesh to partially cover skull defects immediately after decompressive craniectomy (DC). This study is a retrospective review of 8 patients who underwent DC and placement of a titanium mesh. The mesh partially covered the defect and was placed between the temporalis muscle and the dura graft. The muscle was sutured to the mesh. All patients underwent cranioplasty at a later time. The study recorded and analyzed demographic information, time between surgeries, extra-axial fluid collections, postoperative infections, need for reoperation, cortical hemorrhages, and functional and aesthetic outcomes. After craniectomy, all patients underwent cranioplasty within an average of 112.5 days (30–240 days). One patient reported temporalis muscle atrophy, which was the only complication observed. During the cranioplasties, no adhesions were found between temporalis muscle, titanium mesh, and underlying dura. None of the patients showed complications in the follow-up computerized tomography scans. All patients had favorable aesthetic and functional results. Placing a titanium mesh as an extra step during DC could have antiadhesive and protective properties, facilitating subsequent cranioplasty by preventing adhesions and providing a clear surgical plane between the temporalis muscle and intracranial tissues. This technique also helps preserve the temporalis muscle and enhances functional and aesthetic outcomes postcranioplasty. Therefore, it represents a safe alternative to other synthetic anti-adhesive materials. Further studies are necessary to draw definitive conclusions and elucidate long-term outcomes, however, the results obtained hold great promise for the safety and efficacy of this technique. [ABSTRACT FROM AUTHOR]