Cerebral swelling caused by deep venous thrombosis immediately after cranioplasty.

Recently, different groups have reported a rare, unexplained complication of sudden death with massive cerebral oedema immediately after cranioplasty.Case presentation: A 34-year-old woman underwent decompressive hemicraniectomy after traumatic brain injury. She was reportedly on oral contraceptives. She developed massive cerebral swelling immediately after an uneventful cranioplasty. After surgery, her pupils became fixed and dilated, and brain MRI revealed massive brain oedema. Magnetic resonance venography displayed occlusion in the deep venous sinus. The oedema was believed to be caused by venous sinus thrombosis. The patient's family declined to avail any surgical and medical treatment, and the patient died on the second postoperative day.Conclusions: Fatal massive cerebral oedema is an uncommon complication after cranioplasty in patients who had previously undergone decompressive craniectomy. Our patient was using oral contraceptives and was thus susceptible to the development of venous sinus thrombosis. Neurosurgeons must be aware of the complications associated with venous sinus thrombosis and discuss it with the patients and their families.

Risk Factors Associated With Inadequate Brain Relaxation in Craniotomy for Surgery of Supratentorial Tumors.

INTRODUCTION: Cerebral swelling often occurs during craniotomy for cerebral tumors. Poor brain relaxation can increase the risk of cerebral ischemia, possibly worsening the outcome. The surgical team should identify any risk factors that could cause perioperative brain swelling and decide which therapies are indicated for improving it. The present investigation aimed to elucidate the risk factors associated with brain swelling during elective craniotomy for supratentorial brain tumors. METHODS: This prospective, nonrandomized, observational study included 52 patients scheduled for elective supratentorial tumor surgery. The degree of brain relaxation was classified upon the opening of the dura according to a four-point scale (brain relaxation score: 1, perfectly relaxed; 2, satisfactorily relaxed; 3, firm brain; and 4, bulging brain). Moreover, hemodynamic and respiratory parameters, arterial blood gas, and plasma osmolality were recorded after the removal of the bone flap. RESULTS: This study showed that the use of preoperative dexamethasone was associated with a brain relaxation score of ≤2 (p = 0.005). The median midline shift of 6 (3-0) mm and median hemoglobin level of >13 g/dL were associated with a brain relaxation score of ≥3 (p = 0.02 and p = 0.01, respectively). The dosage of mannitol (0.25 g/kg versus 0.5 g/kg), physical status, intraoperative position, tumor diameter and volume, peritumoral edema and mass effect, World Health Organization (WHO) grading, mean arterial pressure, PaCO2, osmolality, and core temperature were not identified as risk factors associated with poor relaxation. CONCLUSION: The use of preoperative dexamethasone was associated with improved brain relaxation, whereas the presence of a preoperative midline shift and a higher level of hemoglobin were associated with poor brain relaxation.

Aggressive internal and external decompression as a life-saving surgery in a deeply comatose patient with fixed dilated pupils after severe traumatic brain injury: A case report.

BACKGROUND: To maximize control of the intracranial pressure in deeply comatose patients with malignant cerebral swelling, combination of the surgical techniques for internal and external brain decompression may be reasonable, as demonstrated in the presented case. CASE DESCRIPTION: A 55-year-old man was admitted with Glasgow Coma Scale (GCS) score 4, maximally dilated pupils, and absence of the pupillary light and vestibulo-ocular reflexes. Head CT revealed massive acute subdural hematoma, prominent brain shift with subfalcine and transtentorial herniation, and diffuse subarachnoid hemorrhage. Large size decompressive craniectomy and evacuation of subdural hematoma were done, however, prominent swelling of the brain and its protrusion through the bone defect remained. Therefore, extensive temporal lobectomy and removal of the bulk of temporal muscle were additionally attained followed by lax duraplasty. Gradual recovery of the patient was noted from the 1st postoperative day, and on the 70th day, his GCS score was 4T4. Three months later, his condition corresponded to the Glasgow Outcome Scale score 3 (severe disability). CONCLUSION: Aggressive internal and external decompression with combination of large size craniectomy, extensive temporal lobectomy, removal of the bulk of temporal muscle, and lax duraplasty should be considered as possible life-saving option in cases of neurosurgical emergencies with malignant cerebral swelling.

Contemporary Management of Increased Intraoperative Intracranial Pressure: Evidence-Based Anesthetic and Surgical Review.

Increased intracranial pressure (ICP) is frequently encountered in the neurosurgical setting. A multitude of tactics exists to reduce ICP, ranging from patient position and medications to cerebrospinal fluid diversion and surgical decompression. A vast amount of literature has been published regarding ICP management in the critical care setting, but studies specifically tailored toward the management of intraoperative acute increases in ICP or brain bulk are lacking. Compartmentalizing the intracranial space into blood, brain tissue, and cerebrospinal fluid and understanding the numerous techniques available to affect these individual compartments can guide the surgical team to quickly identify increased brain bulk and respond appropriately. Rapidly instituting measures for brain relaxation in the operating room is essential in optimizing patient outcomes. Knowledge of the efficacy, rapidity, feasibility, and risks of the various available interventions can aid the team to properly tailor their approach to each individual patient. In this article, we present the first evidence-based review of intraoperative management of ICP and brain bulk.

Malignant Cerebral Swelling After Cranioplasty: Case Report and Literature Review.

BACKGROUND: Cranioplasty is considered a low-risk operation in the field of neurosurgery following decompression craniectomy. Well-known complications after cranioplasty, such as infection, seizure, and titanium plate exposure, may not threaten the lives of patients. Unfortunately, there are many fatal complications that are underreported. In this study, we report a case and perform a literature review to introduce malignant cerebral swelling, which is regarded as a devastating complication. CASE DESCRIPTION: A 51-year-old man who was a victim of traumatic brain injury underwent emergency clot removal and decompression craniectomy. His neurologic condition improved with subsequent rehabilitation therapy, and he had left sinking skin flap syndrome where the skull was defective. Six months after the initial surgery, he underwent a cranioplasty; however, he did not recover from the uneventful anesthesia. A vacuum suction drain showed 300 mL of flow outflow had drained when his pupils dilated and fixed. An immediate computed tomography scan showed ipsilateral diffuse cerebral swelling with diffuse cerebral hemorrhage. Despite all approaches that were considered, the cerebral swelling continued to worsen until death. CONCLUSION: Cranioplasty is a high-risk procedure in some cases. Sinking skin flap syndrome and vacuum suction drain may be the main risks of a postoperative venous congestion and stasis, which may result in diffuse cerebral swelling. Once the computed tomography scan shows malignant cerebral swelling, the patient is expected to have a poor prognosis.

Fatal cerebral swelling immediately after cranioplasty: A case report.

BACKGROUND: Cranioplasty is a standard neurosurgical procedure which is performed after decompressive craniotomy. Fatal complications associated with this procedure are not well documented. Here, we report a case of fatal cerebral swelling after cranioplasty and discuss the possible mechanism of this complication. CASE DESCRIPTION: A 64-year-old man was admitted with the diagnosis of cerebral hemorrhage, and emergency surgery for hemorrhage removal and decompressive craniotomy were performed. One month after surgery, cranioplasty was performed using a titanium mesh plate. Sixteen hours after the surgery, the patient became comatose with bilateral dilated pupils followed by blood pressure lowering. Computed tomography of the brain showed bilateral massive cerebral edema. The titanium mesh plate was immediately removed, however, the patient's neurological condition did not recover and he died 7 days after the surgery. We speculated that the negative pressure difference and increase in cerebral blood flow after cranioplasty may have attributed to the fatal cerebral swelling. CONCLUSION: Fatal cerebral swelling after cranioplasty is a rare but devastating complication. Although it is rare, neurosurgeons should keep in mind that this fatal complication can follow cranioplasty.

Malignant Cerebral Swelling After Cranioplasty due to Ipsilateral Intracranial Vasculopathy: Case Report and Literature Review.

BACKGROUND: Cranioplasty is a well-established surgical operation that is used worldwide for patients with skull defects following decompressive craniectomy (DC). However, in some cases, potentially fatal complications may occur, such as malignant cerebral swelling after uneventful cranioplasty. CASE DESCRIPTION: We present a rare case of massive malignant ipsilateral cerebral swelling following uneventful titanium mesh cranioplasty due to rare ipsilateral intracranial vasculopathy confirmed by magnetic resonance angiography (MRA) and magnetic resonance venography (MRV). Fortunately, we performed titanium mesh explantation and extended DC in time, and the patient survived. Malignant cerebral swelling after uneventful cranioplasty is an unpredictable but fatal complication. Most reported cases have had an unfavorable prognosis. To the best of our knowledge, the mechanism was first confirmed by MRA and MRV, which demonstrated that the cerebral swelling was due to unilateral intracranial vasculopathy, including a rare ipsilateral intracranial internal carotid artery occlusion, as well as extremely thin lateral and sigmoid sinuses. CONCLUSIONS: Our case demonstrates for the first time that ipsilateral intracranial vasculopathy is a risk factor for malignant cerebral swelling after cranioplasty. Patients with traumatic brain injury with suspected intracranial vasculopathy should undergo a comprehensive vascular evaluation before cranioplasty to help prevent malignant cerebral swelling.

Malignant cerebral swelling following cranioplasty.

Over the past few years there have been a number of case reports and small cohort studies that have described so called "malignant" cerebral swelling following an uneventful cranioplasty procedure. The pathophysiology remains to be established however it has been suggested that it may be related to a combination of failure of autoregulation and the use of closed vacuum suction drainage. The current study presents three further patients who had had a decompressive hemicraniectomy for ischaemic stroke. If decompressive craniectomy is utilised in the management of neurological emergencies, close attention and wider reporting of this type of complication is required not only to focus attention on possible management strategies, but also to determine which patients are at most risk of this devastating complication.

Brain Fluid Content Related to Body Position and Postmortem Interval - An Animal Model.

Adult male Sprague Dawley rats were euthanized and placed in a horizontal or vertical (head-down) position at room temperature, after which brain fluid content was measured by a moisture analysis technique at variable time points. No significant difference in brain fluid content was observed between horizontal and vertical postmortem positions. A significant increase in brain fluid content was demonstrated 3, 6, and 24 h after death, with maximal fluid content observed at 24 h. Specifically, the brain fluid content of control animals was 77.79 ± 0.36%, increasing to 80.05 ± 0.22% at 24 h (p < 0.0001). This study has demonstrated no significant differences in brain fluid content related to postmortem position, suggesting that a head-down position is not associated with increased brain fluid content or swelling. However, significant temporal increases in brain fluid content after death, most likely related to cerebral liquefaction, occur.

Dynamic telescopic craniotomy: a cadaveric study of a novel device and technique.

OBJECT The authors assessed the feasibility of the dynamic decompressive craniotomy technique using a novel cranial fixation plate with a telescopic component. Following a craniotomy in human cadaver skulls, the telescopic plates were placed to cover the bur holes. The plates allow constrained outward movement of the bone flap upon an increase in intracranial pressure (ICP) and also prevent the bone flap from sinking once the ICP normalizes. The authors compared the extent of postcraniotomy ICP control after an abrupt increase in intracranial volume using the dynamic craniotomy technique versus the standard craniotomy or hinge craniotomy techniques. METHODS Fixation of the bone flap after craniotomy was performed in 5 cadaver skulls using 3 techniques: 1) dynamic telescopic craniotomy, 2) hinge craniotomy, and 3) standard craniotomy with fixed plates. The ability of each technique to allow for expansion during intracranial hypertension was evaluated by progressively increasing intracranial volume. Biomechanical evaluation of the telescopic plates with load-bearing tests was also undertaken. RESULTS Both the dynamic craniotomy and the hinge craniotomy techniques provided significant control of ICP during increases in intracranial volume as compared with the standard craniotomy technique. With the standard craniotomy, ICP increased from a mean of 11.4 to 100.1 mm Hg with the addition of 120 ml of intracranial volume. However, with the dynamic craniotomy, the addition of 120 ml of intracranial volume increased the ICP from a mean of 2.8 to 13.4 mm Hg, maintaining ICP within the normal range as compared with the standard craniotomy (p = 0.04). The dynamic craniotomy was also superior in controlling ICP as compared with the hinge craniotomy, providing expansion for an additional 40 ml of intracranial volume while maintaining ICP within a normal range (p = 0.008). Biomechanical load-bearing tests for the dynamic telescopic plates revealed rigid restriction of bone-flap sinking as compared with standard fixation plates and clamps. CONCLUSIONS The dynamic telescopic craniotomy technique with the novel cranial fixation plate provides superior control of ICP after an abrupt increase in intracranial volume as compared with the standard craniotomy and hinge craniotomy techniques.

Speed of development of cerebral swelling following blunt cranial trauma.

A 22-year-old male suffered severe injuries to the head, chest and abdominal cavities in a vehicle crash, with death occurring at the scene. At autopsy, the cranial cavity was opened and markedly disrupted with compound and comminuted fracturing of all bones of the skull and facial skeleton. The brain showed extensive lacerations with almost complete parenchymal disruption. However, a preserved fragment of right frontal lobe exhibited marked swelling with gyral flattening. This case could provide further evidence for prompt cerebral swelling after blunt head trauma, and is supportive of animal studies that have demonstrated rapid swelling that is most likely is related to reactive vasodilation rather than to vasogenic oedema.

Beware of delayed severe brain swelling after intracerebral haematoma in HELLP syndrome.

Haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome is a condition associated with increased risk of adverse outcomes during pregnancy and peripartum, including neurological complications. We report the third case in the world literature of delayed brain swelling following cerebral haemorrhage as a complication of HELLP syndrome. A 36-year-old woman in labour developed HELLP, which was complicated with intracerebral haematoma. This was evacuated, but motor impairment persisted after surgery and unfortunately the patient died unexpectedly during the 11th postoperative day. Computer tomographic brain scans documented diffuse cerebral swelling, which we think may have been caused by cerebral vasospasm. Cerebral vasospasm should always be considered when managing patients who suffered from stroke complicating HELLP syndrome. Close monitoring is advised even in later stages of recovery.