PURPOSE: Traumatic brain injury (TBI) is a significant public health issue that impacts individuals all over the world and is one of the main causes of mortality and morbidity. Decompressive craniectomy is the usual course of treatment. Basal cisternostomy has been shown to be highly effective as an alternative procedure to decompressive craniectomy. METHODS: We conducted a retrospective cohort of patients who received surgery for severe TBI between January 2019 and March 2023. Inclusion criterias were patients between the ages of 18 and 70 years who met the diagnostic criteria for severe TBI at first presentation and who underwent surgical intervention. The exclusion criteria were patients who have severe multiple injuries at the time of admission; preoperative intracranial pressure > 60 mmHg; cognitive impairment before the onset of the disease; hematologic disorders; or impaired functioning of the heart, liver, kidneys, or other visceral organs. Depending on the surgical approach, the patients were categorized into decompressive craniectomy group as well as basal cisternostomy group. General data and postoperative indicators, including Glasgow coma scale, intracranial pressure, etc., were recorded for both groups of patients. Among them, the Glasgow outcome scale extended assessment at 6 months served as the primary outcome. After that, the data were statistically analyzed using SPSS software. RESULTS: The trial enrolled 41 patients (32 men and 9 women) who met the inclusion criteria. Among them, 25 patients received decompressive decompressive craniectomy, and 16 patients received basal cisternostomy. Three days postoperative intracranial pressure levels were 10.07 ± 2.94 mmHg and 17.15 ± 14.65 mmHg (p = 0.013), respectively. The 6 months following discharge Glasgow outcome scale extended of patients was 4.73 ± 2.28 and 3.14 ± 2.15 (p = 0.027), respectively. CONCLUSION Our study reveals that basal cisternostomy in patients with surgically treated severe TBI has demonstrated significant efficacy in reducing intracranial pressure as well as patient prognosis follow-up and avoids removal of the bone flap. The efficacy of cisternostomy has to be studied in larger, multi-clinical center randomized trials.
Humans ; Brain Injuries, Traumatic/surgery* ; Retrospective Studies ; Male ; Female ; Adult ; Middle Aged ; Decompressive Craniectomy/methods* ; Aged ; Young Adult ; Adolescent ; Glasgow Coma Scale ; Treatment Outcome

In subarachnoid hemorrhage following traumatic brain injury (TBI), the high intracisternal pressure drives the cerebrospinal fluid into the brain parenchyma, causing cerebral edema. Basal cisternostomy involves opening the basal cisterns to atmospheric pressure and draining cerebrospinal fluid in an attempt to reverse the edema. We describe a case of basal cisternostomy combined with decompressive craniectomy. A 35-year-old man with severe TBI following a road vehicle accident presented with acute subdural hematoma, Glasgow coma scale score of 6, fixed pupils and no corneal response. Opening of the basal cisterns and placement of a temporary cisternal drain led to immediate relaxation of the brain. The patient had a Glasgow coma scale score of 15 on postoperative day 6 and was discharged on day 10. We think basal cisternostomy is a feasible and effective procedure that should be considered in the management of TBI.
Adult ; Brain ; Brain Edema ; Brain Injuries, Traumatic/surgery* ; Decompressive Craniectomy/methods* ; Glasgow Coma Scale ; Humans ; Male ; Treatment Outcome

PURPOSE: Rapid decompressive craniectomy (DC) was the most effective method for the treatment of hypertensive intracerebral hemorrhage (HICH) with cerebral hernia, but the mortality and disability rate is still high. We suspected that hematoma puncture drainage (PD) + DC may improve the therapeutic effect and thus compared the combined surgery with DC alone. METHODS: From December 2013 to July 2019, patients with HICH from Linzhi, Tibet and Honghe, Yunnan Province were retrospectively analyzed. The selection criteria were as follows: (1) altitude ≥1500 m; (2) HICH patients with cerebral hernia; (3) Glascow coma scale score of 4-8 and time from onset to admission ≤3 h; (4) good liver and kidney function; and (5) complete case data. The included patients were divided into DC group and PD + DC group. The patients were followed up for 6 months. The outcome was assessed by Glasgow outcome scale (GOS) score, Kaplan-Meier survival curve and correlation between time from admission to operation and prognosis. A good outcome was defined as independent (GOS score, 4-5) and poor outcome defined as dependent (GOS score, 3-1). All data analyses were performed using SPSS 19, and comparison between two groups was conducted using separate t-tests or Chi-square tests. RESULTS: A total of 65 patients was included. The age ranged 34-90 years (mean, 63.00 ± 14.04 years). Among them, 31 patients had the operation of PD + DC, whereas 34 patients underwent DC. The two groups had no significant difference in the basic characteristics. After 6 months of follow-up, in the PD + DC group there were 8 death, 4 vegetative state, 4 severe disability (GOS score 1-3, poor outcome 51.6 %); 8 moderate disability, and 7 good recovery (GOS score 4-5, good outcome 48.4 %); while in the DC group the result was 15 death, 6 vegetative state, 5 severe disability (poor outcome 76.5 %), 4 moderate disability and 4 good recovery (good outcome 23.5 %). The GOS score and good outcome were significantly less in DC group than in PD + DC group (Z = -1.993, p = 0.046; χ CONCLUSION PD + DC treatment can improve the good outcomes better than DC treatment for HICH with cerebral hernia at a high altitude.
Adult ; Aged ; Aged, 80 and over ; Altitude ; China ; Decompressive Craniectomy ; Drainage ; Encephalocele/surgery* ; Hematoma ; Humans ; Intracranial Hemorrhage, Hypertensive/surgery* ; Middle Aged ; Prognosis ; Punctures ; Retrospective Studies ; Treatment Outcome

Decompressive craniectomy (DC) is commonly performed in patients with intracranial hypertension or brain edema due to traumatic brain injury. Infrequently, neurologic deteriorations accompanied by sunken scalp may occur after DC. We report two patients with traumatic subdural hemorrhage who had neurologic deteriorations accompanied by sunken scalp after DC. Neurologic function improved dramatically in both patients after cranioplasty. Monitoring for neurologic deterioration after craniectomy is advised. For patients showing neurologic deficit with a sunken scalp, early cranioplasty should be considered.
Brain Edema ; Brain Injuries ; Decompressive Craniectomy ; Hematoma, Subdural ; Humans ; Intracranial Hypertension ; Neurologic Manifestations ; Scalp ; Skin

PURPOSE: Bone flap resorption (BFR) after cranioplasty with an autologous bone flap (ABF) is well known. However, the prevalences and degrees of BFR remain unclear. This study aimed to evaluate changes in ABFs following cranioplasty and to investigate factors related with BFR. MATERIALS AND METHODS: We retrospectively reviewed 97 patients who underwent cranioplasty with frozen ABF between January 2007 and December 2016. Brain CT images of these patients were reconstructed to form three-dimensional (3D) images, and 3D images of ABF were separated using medical image editing software. ABF volumes on images were measured using 3D image editing software and were compared between images in the immediate postoperative period and at postoperative 12 months. Risk factors related with BFR were also analyzed. RESULTS: The volumes of bone flaps calculated from CT images immediately after cranioplasty ranged from 55.3 cm³ to 175 cm³. Remnant bone flap volumes at postoperative 12 months ranged from 14.2% to 102.5% of the original volume. Seventy-five patients (77.3%) had a BFR rate exceeding 10% at 12 months after cranioplasty, and 26 patients (26.8%) presented severe BFR over 40%. Ten patients (10.3%) underwent repeated cranioplasty due to severe BFR. The use of a 5-mm burr for central tack-up sutures was significantly associated with BFR (p<0.001). CONCLUSION: Most ABFs after cranioplasty are absorbed. Thus, when using frozen ABF, patients should be adequately informed. To prevent BFR, making holes must be kept to a minimum during ABF grafting.
Autografts ; Bone Resorption ; Brain ; Decompressive Craniectomy ; Humans ; Postoperative Period ; Prevalence ; Retrospective Studies ; Risk Factors ; Skull ; Sutures ; Transplants

A 35-year-old female visited emergency department for a sudden onset of headache with vomiting after management for abortion at local department. Neurological examination revealed drowsy mentality without focal neurological deficits. CT showed 3.2×3.4 cm hyperdense intraventricular mass with intraventricular hemorrhage. The intraventricular hemorrhage was found in lateral, 3rd, and 4th ventricles. MRI showed well enhancing intraventricular mass abutting choroid plexus in the trigone of the right lateral ventricle. CT angiography showed tortuous prominent arteries from choroidal artery in tumor. Her neurological status deteriorated to stupor and contralateral hemiparesis during planned preoperative workup. Urgent transtemporal and transcortical approach with decompressive craniectomy for removal of intraventricular meningioma with hemorrhage was done. Grossly total removal of ventricular mass was achieved. Pathological finding was meningotheliomatous meningioma of World Health Organization (WHO) grade I. The patient recovered to alert mentality and no motor deficit after intensive care for increased intracranial pressure. However, visual field defect was developed due to posterior cerebral artery territory infarction. The visual deficit did not resolve during follow up period. Lateral ventricular meningioma with spontaneous intraventricular hemorrhage in pregnant woman is very uncommon. We report a surgical case of lateral ventricular meningioma with rapid neurological deterioration for intraventricular hemorrhage.
Adult ; Angiography ; Arteries ; Choroid ; Choroid Plexus ; Critical Care ; Decompressive Craniectomy ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Fourth Ventricle ; Headache ; Hemorrhage ; Humans ; Infarction ; Intracranial Pressure ; Lateral Ventricles ; Magnetic Resonance Imaging ; Meningioma ; Neurologic Examination ; Paresis ; Posterior Cerebral Artery ; Pregnancy ; Pregnant Women ; Stupor ; Visual Fields ; Vomiting ; World Health Organization

BACKGROUND: Acute ischemic stroke patients with malignant infarct cores were primarily treated with neurocritical care based on reperfusion and hypothermia. We evaluated the predictors for malignant progression and functional outcomes. METHODS: From January 2010 to March 2015 ischemic stroke patients with large vessel occlusion of the anterior circulation with infarct volume >82 mL on baseline diffusion weighted image (DWI) within 6 hours from onset, with National Institutes of Health Stroke Scale ≥15 were included. All patients were managed with intent for reperfusion and neurocritical care. Malignant progression was defined as clinical signs of progressive herniation. Predictive factors for malignant progression and outcomes of decompressive hemicraniectomy (DHC) were evaluated. RESULTS: In total, 49 patients were included in the study. Among them, 33 (67.3%) could be managed with neurocritical care and malignant progression was observed in the remainder. Decompressive surgery was performed in nine patients (18.4%). Factors predictive of malignant progression were initial DWI volumes (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00 to 1.02; P=0.046) and parenchymal hematoma (OR, 6.77; 95% CI, 1.50 to 30.53; P=0.013) on computed tomography taken at Day 1. Infarct volume of >210 mL predicted malignant progression with 56.3% sensitivity and 90.9% specificity. Among the malignant progressors, 77.7% resulted in grave outcomes even with DHC, while all patients who declined surgery died. CONCLUSION: Acute ischemic stroke patients with malignant cores between 82 to 209 mL can be primarily treated with neurocritical care based on reperfusion and hypothermia with feasible results. In patients undergoing surgical decompression due to malignant progression, the functional outcomes were not satisfactory.
Brain Edema ; Critical Care ; Decompression, Surgical ; Decompressive Craniectomy ; Diffusion ; Hematoma ; Humans ; Hypothermia ; Hypothermia, Induced ; Infarction, Middle Cerebral Artery ; National Institutes of Health (U.S.) ; Reperfusion ; Sensitivity and Specificity ; Stroke ; Thrombectomy

OBJECTIVE: Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance.METHODS: One hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality.RESULTS: Initial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007).CONCLUSION: The results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.
Brain ; Cerebral Hemorrhage ; Cerebral Infarction ; Decompression ; Decompressive Craniectomy ; Glasgow Coma Scale ; Hematoma ; Humans ; Infarction ; Intracranial Hemorrhages ; Intracranial Pressure ; Male ; Mortality ; Punctures ; Retrospective Studies ; Stroke ; Vascular Diseases

OBJECTIVE: Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranial hypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not require DC after craniotomy. METHODS: The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primary craniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors were analyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. RESULTS: Five factors showed significant differences between the two groups. They were the length of midline shifting to maximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p < 0.001), coexistence of intraventricular hemorrhage (IVH) (p < 0.001), traumatic intracerebral hemorrhage (TICH) (p=0.001), intraoperative findings showing intracranial hypertension combined with brain edema (p < 0.001), and bleeding tendency (p=0.02). An average value of 2.74±1.52 was obtained for these factors for group A, which was significantly different from that for group B (p < 0.001). CONCLUSION: An MT ratio >1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signs of intracranial hypertension, brain edema, and bleeding tendency were identified as factors indicating that DC would be required. The necessity for preemptive DC must be carefully considered in patients with such risk factors.
Brain ; Brain Edema ; Cerebral Hemorrhage, Traumatic ; Craniotomy* ; Decompressive Craniectomy* ; Hematoma ; Hematoma, Subdural ; Hematoma, Subdural, Acute* ; Hemorrhage ; Humans ; Intracranial Hypertension ; Multivariate Analysis ; Reoperation ; Risk Factors

Cerebral venous sinus thrombosis (CVST) is a rare disease. Early diagnosis and treatment are important, as CVST is potentially fatal. Pregnancy and puerperium are known risk factors for CVST. Here, we report the case of a patient who developed superior sagittal sinus thrombosis after a normal vaginal delivery. A 20-year-old woman presented with a headache and seizures two days after a normal vaginal delivery. Initially, brain computed tomography (CT) showed a subarachnoid hemorrhage in the right parietal lobe and sylvian fissure, together with mild cerebral edema. CT angiography revealed superior sagittal sinus thrombosis. Multiple micro-infarctions were seen on diffusion-weighted magnetic resonance images. An intravenous infusion of heparin and mannitol was administered immediately. Two days after treatment initiation, the patient showed sudden neurological deterioration, with left-sided hemiplegia. Brain CT showed moderate brain edema and hemorrhagic densities. Emergency decompressive craniectomy was performed, and heparin was re-administered on post-operative day (POD) 1. On POD 9, the patient's mental state improved from stupor to drowsy, but the left-sided hemiplegia persisted. CT angiography showed that the superior sinus thrombosis had decreased. Superior sagittal sinus thrombosis is an uncommon complication, with an unfavorable outcome, after delivery. Timely diagnosis and treatment are important for preventing neurological deterioration.
Angiography ; Brain ; Brain Edema ; Cerebral Infarction ; Decompressive Craniectomy ; Diagnosis ; Early Diagnosis ; Emergencies ; Female ; Headache ; Hemiplegia ; Heparin ; Humans ; Infusions, Intravenous ; Mannitol ; Parietal Lobe ; Postpartum Period* ; Pregnancy ; Rare Diseases ; Risk Factors ; Seizures ; Sinus Thrombosis, Intracranial ; Stupor ; Subarachnoid Hemorrhage ; Superior Sagittal Sinus* ; Thrombosis* ; Young Adult