No abstract available.
Brain Edema* ; Brain* ; Decompressive Craniectomy*

The importance of treating traumatic brain injury (TBI) is well known worldwide. Although many studies have been conducted in this topic, there is still much uncertainty about the effectiveness of surgical treatment in TBI. Recently, good randomized controlled trial (RCT) papers about the effectiveness of decompressive craniectomy (DC) in TBI has been published. In this article, we will review the overall contents of the DC (historical base, surgical technic, rationale, complications) and the results of the recently published RCT paper.
Brain Injuries* ; Decompressive Craniectomy* ; Neurosurgery ; Uncertainty

OBJECTIVE: Measurement of intracranial pressure(ICP) is important in patients at risk of raised ICP. To evaluate the usefulness of measuring epidural pressure measurements for the estimation of intracranial pressure, we studied the relationship between epidural pressure and ventricular pressure. PATIENTS AND METHODS: From Nov. '97 to Jul. '98, 10 patients of extraventricular drainage(Group A) and 12 patients of decompressive craniectomy(Group B) are included in this study. Simultaneous recording of intracranial pressure (ICP) from an air-pouch epidural pressure monitoring system and a ventricular catheter was compared. RESULTS: The epidural pressure group(Group A) showed marked high epidural pressure(32.6+/-13.4mmHg) compared with those of intraventricular pressure, but in decompressive craniectomy group(Group B) shows nearly the same values(2.1+/-6.9mmHg). CONCLUSIONS: On the basis of the available comparison between these two methods of measuring intracranial pressure, in the light of the data we had established and the importance of ICP monitoring in neurosurgical critical care, intradural monitoring technique appears to be our measuring method of choice.
Catheters ; Critical Care ; Decompressive Craniectomy ; Humans ; Intracranial Pressure ; Ventricular Pressure*

Hypothermia is considered a useful intervention for limiting pathophysiological changes after brain injury. Local hypothermia is a relatively safe and convenient intervention that circumvents many of the complications associated with systemic hypothermia. However, successful hypothermia treatment requires careful consideration of several factors including its practicality, feasibility, and associated risks. Here, we review the protective effects-and the cellular mechanisms that underlie them-of delayed and prolonged local hypothermia in rodent and canine brain injury models. The data show that the protective effects of therapeutic hypothermia, which mainly result from the modulation of inflammatory glial dynamics, are limited. We argue that decompressive craniectomy can be used to overcome the limitations of local brain hypothermia without causing histological abnormalities or other detrimental effects to the cooled area. Therefore, delayed and prolonged local brain hypothermia at the site of craniectomy is a promising intervention that may prove effective in the clinical setting.
Astrocytes ; Brain Injuries ; Brain* ; Decompressive Craniectomy* ; Hypothermia* ; Microglia ; Rodentia ; Stroke

Hydrocephalus is usually defined as the condition of ventricular dilatation due to the overproduction of cerebrospinal fluid(CSF) or dysfunction of absorption. The pattern of the CSF circulation may change after a cranioplasty secondary to previous decompressive craniectomy for refractory intracranial hypertension after head injury. The effect of the cranioplasty on CSF hydrodynamics has not been explored exactly. We report two cases of acute hydrocephalus developed after cranioplasty and discuss about the clinical importance with review of literatures.
Absorption ; Craniocerebral Trauma ; Decompressive Craniectomy ; Dilatation ; Hydrocephalus* ; Hydrodynamics ; Intracranial Hypertension

OBJECTIVE: After a rigorous management of increased intracranial pressure by decompressive craniectomy (DC), cranioplasty (CP) is usually carried out for functional and cosmetic purposes. However, the optimal timing of CP remains controversial. Our study aims to analyze the relationship between the optimal timing of CP and the post-operative complications. METHODS: From January 2013 to December 2015, ninety patients who underwent CP in a single institution were analyzed. We set the independent variables as follows: 1) patient characteristics; 2) the time interval between the DC and CP; 3) operation time; 4) anesthesia time; and 5) pre-operative computed tomography (CT) findings such as a degree of sunken brain by ratio of A (the median length from scalp to midline) to B (the length from midline to inner table of skull at this level). The dependent variables of this study are the event of post-operative complications. RESULTS: The overall complication rate was 33.3%. There was no statistical significance in the time interval between the DC and CP in the groups with and without complications of CP (p=0.632). However, there was a significant statistical difference in the degree of sunken brain by ratio (A/B) between the two groups (p<0.001). CONCLUSION: From this study, we conclude that it is better to determine the optimal timing of CP by the pre-operative CT finding than by the time interval between the DC and CP. Hereby, we suggest a potentially useful determinant of optimal timing of CP.
Anesthesia ; Brain* ; Decompressive Craniectomy ; Humans ; Intracranial Pressure ; Scalp ; Skull

OBJECTIVETo investigate the occurrence of posttraumatic hydrocephalus (PTH) in severe brain- injured patients who underwent decompressive craniectomy (DC) and to discuss the management.

METHODSA total of 389 patients suffering from severe head trauma between January 2004 and May 2010 were enrolled in this study. Clinical data were analyzed retrospectively. Of them, 149 patients who underwent DC were divided into two groups according to the presence of PTH: hydrocephalus group and nonhydrocephalus group. Clinical factors including preoperative Glasgow Coma Score (GCS), bilateral or unilateral decompression, and duraplasty in DC were assessed by single factor analysis to determine its relationship with the occurrence of PTH.

RESULTSOf the 149 patients undergoing DC, 25 (16.8%) developed PTH; while 23 developed PTH (9.6%) among the rest 240 patients without DC. Preoperative GCS, bilateral or unilateral decompression, duraplasty in DC were significantly associated with the development of PTH. Ventriculoperitoneal shunt was performed on 23 of 25 patients with PTH after DC. Frontal horn was preferred for the placement of the catheter. Sixteen of them were operated upon via frontal approach and 7 via occipital approach. After shunt surgery, both radiological and clinical improvements were confirmed in 19 patients. Radiological improvement was found in 2 patients. One patient died eventually of severe pneumonia. Shunt-related infection occurred in 1 patient, which led to the removal of the catheter.

CONCLUSIONSIt is demonstrated that the occurrence of PTH is high in patients with large decompressive skull defect. Patients with low GCS and bilateral decompression tend to develop PTH after DC. Duraplasty in DC might facilitate reducing the occurrence of PTH. Patients with PTH concomitant skull defect should be managed deliberately to restore the anatomical and physiological integrity so as to facilitate the neurological resuscitation.

The syndrome of the sinking skin flap was introduced to explain the phenomenon of neurological deterioration after decompressive craniectomy. A 37-year-old man was admitted with acute subdural hematoma and traumatic intraparenchymal hematoma. After decompressive craniectomy, the patient suffered from hydrocephalus for which a ventriculoperitoneal (V-P) shunt was inserted. Following this procedure, the depression of the skin flap became remarkable and his mentation was deteriorated. The patient recovered uneventfully after temporary elevating of valve pressure and cranioplasty. We present a patient who was successfully managed with elevation of valve pressure and cranioplasty for the syndrome of the sinking scalp flap with review of a pertinent literature.
Adult ; Decompressive Craniectomy ; Depression ; Hematoma ; Hematoma, Subdural, Acute ; Humans ; Hydrocephalus ; Scalp ; Skin ; Ventriculoperitoneal Shunt

OBJECTIVE: After decompressive craniectomy was performed in patients with severe brain swelling, we were able to preserve autologous bone flap as freeze-preserved state or within abdominal subcutaneous tissue. The aim of this study was to compare the freeze-preservation with the subcutaneous abdominal preservation regarding the effectiveness and safety. METHODS: The clinical data of 53 patients who underwent decompressive craniectomy with autologous bone flap cranioplasty in our department were studied retrospectively. 43 patients underwent cranial reconstruction using autologous bone flap stored in deep freezer. In 10 patients cranioplasty was performed to repair bone defect using autologous bone flap preserved in subcutaneous abdomen. The analysis included the rates of infection, bone absorption and other complications and operation time to compare these two methods. RESULTS: Cranioplasty using deep-freezing bone flap showed a low infection rate (2.3%), low bone absorption (2.3%) and no cosmetic problem. The average time of operation is 146 minutes. Cranioplasty using a bone flap banked in the patient's abdominal wall revealed no case of complications. The average time of operation is 130 minutes. The longer period the bone flap was preserved for, the longer time the operation took in both methods. CONCLUSION: This study may be worth considering that both methods of cryoconservation and subcutaneous abdominal preservetion are feasible for the repair of skull defect although abdominal preservation seems to show better result a little. If the deep-freezer is not available, a bone flap banked in the patient's abdominal wall can be used.
Abdomen ; Abdominal Wall ; Absorption ; Brain Edema ; Cosmetics ; Cryopreservation ; Decompressive Craniectomy ; Humans ; Retrospective Studies ; Skull ; Subcutaneous Tissue

The intracranial hemorrhage in regions remote from the site of initial operations is unusual but may present as fatal surgical complication. We report a rare case of multiple, sequential, remote intracranial hematomas after cranioplasty in a patient who did not have any prior risk factors. A 51-years-old man was transferred to the hospital after a head trauma. The brain computed tomography (CT) revealed acute subdural hemorrhage on the right hemisphere with prominent midline shifting. After performing decompressive craniectomy and hematoma removal, the patient recovered without any complications. However, the patient showed neurological deterioration immediately after cranioplasty, which was done three months after the first surgery. There was extensive hemorrhage in the posterior fossa remote from the site of the initial operation site. The brain CT taken soon after removing this hematoma evacuation displayed large epidural hematoma on the left hemisphere. This case represents posterior fossa hemorrhage after supratentorial procedure and sequential delayed hematoma on the contralateral supratentorial region thus seems very rare surgical complications. Despite several possible pathogenetic mechanisms for such remote hematomas, there are usually no clear cut relationships with each case as in our patient. However, for the successful outcome, prompt evaluation and intensive management seem mandatory.
Brain ; Craniocerebral Trauma ; Decompressive Craniectomy ; Hematoma* ; Hematoma, Subdural ; Hemorrhage ; Humans ; Intracranial Hemorrhages ; Risk Factors