Efficacy and safety of durotomy after decompressive hemicraniectomy in traumatic brain injury.

Decompressive hemicraniectomy (DH) plus duroplasty was demonstrated to be effective for treating critically elevated intracranial pressure (ICP). In order to shorten operation time and to avoid the use of autologous or heterologous material, durotomy has been introduced as an alternative to duroplasty. Only limited data is available on the effect of DH and durotomy on the increased ICP in traumatic brain injury (TBI). Therefore, we collected consecutive intraoperative ICP readings during the different steps of DH and durotomy in TBI patients. Eighteen patients with TBI and uncontrollable ICP increase (measured by either an intraparenchymal or an intraventricular ICP probe) underwent DH and durotomy. ICP readings as well as mean arterial blood pressure (MAP) and arterial PCO2 were obtained during defined stages of the operation. Surgical complications of the durotomy itself and of cranioplasty after 3 months were recorded. The outcome was assessed prior to cranioplasty using the Glasgow Outcome Scale (GOS). ICP dropped significantly during surgery from a mean of 41 ( ± 16.2) mmHg at the beginning to a mean of 11.8 ( ± 7.5) mmHg at the end (p ≤ 0.001). A first significant ICP-decrease to a mean of 18 ( ± 10.8) mmHg (p ≤ 0.001) was detected after removal of the bone flap, and a second significant ICP-decrease to a mean of 10.6 ( ± 5.3) mmHg (p < 0.001) during durotomy. The mean operation time was 115.3 min ( ± 49.6). Five patients (28%) died; seven patients (39%) had a good outcome (GOS 5). There were no relevant complications associated to durotomy. Durotomy after DH is a safe and straightforward procedure, which significantly lowers critically increased ICP in patients with TBI. Although no graft is used, dural preparation for cranioplasty at 3 months is easily possible.

[Catheter-related thrombosis during intravascular temperature management]. / Katheterthrombose während intravaskulärem Temperaturmanagement.

We report on a case of catheter-related thrombosis after 7­day catheter placement during intravascular temperature management (IVTM), in spite of the use of prophylactic anticoagulants. There were no clinical sequelae. According to the literature, occult thrombosis during ITVM could be more frequent than previously reported and dedicated monitoring for potential thrombosis may be indicated. However, a study comparing IVTM with surface cooling found no differences in clinical outcome. Therefore, n either of the methods can be recommended over the other. Further studies should evaluate the rate of occult thrombosis during the use of both cooling methods.