Decompressive craniectomy in the acute fulminant cerebral edema.

Acute fulminant cerebral edema is a type of rapidly progressive encephalitis that occurs in children and is associated with significant morbidity and mortality. We present a clinical case with seizures, rapid neurological deterioration and the early appearance of cerebral herniation signs. Although the radiological tests were initially normal and there are no established parameters that predict the evolution of encephalitis to a rapidly progressive subtype, the clinical evolution forced to consider the decompressive craniectomy due to the lack of response to the medical management of the cerebral edema. It may be necessary take a brain biopsy to confirm the etiology of the encephalitis origin of acute fulminant cerebral edema. The objective of surgery should be not only to increase survival, but also to reduce subsequent neurological sequelae.

Perioperative risk factors for major complications after bone replacement in decompressive craniectomy.

INTRODUCTION: Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS: A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS: A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS: Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.

Craniectomía descompresiva como alternativa terapéutica en la hipertensión intracraneal pediátrica incontrolable por traumatismo craneoencefálico grave / Decompressive craniectomy as a therapeutic alternative in uncontrollable intracranial hypertension in pediatric severe head injury

Introducción: El traumatismo craneoencefálico grave presenta una elevada incidencia en pacientes pediátricos. Es una importante causa de muerte y discapacidad. Sus causas más comunes en este grupo etario son los accidentes domésticos y de tránsito, caídas, violencia y actividades deportivas. Se realizó una revisión bibliográfica en julio y agosto de 2023 con un total de 38 bibliografías en idioma español, inglés y portugués en las bases de datos de SciElo, Elsevier, Pubmed y el motor de búsqueda Google Académico. Se consideró como criterio de selección aquella literatura publicada con mayor actualidad en concordancia con lo novedoso de esta enfermedad. Objetivo: Describir la craniectomía descompresiva como una alternativa a la hipertensión intracraneal pediátrica producida por traumatismo craneoencefálico grave. Desarrollo: Ante un traumatismo craneoencefálico grave, la presión intracraneal aumenta, lo que causa hipertensión intracraneal. Cuando esta hipertensión no se logra controlar, se convierte en refractaria, se requieren otros tratamientos más agresivos como la craniectomía descompresiva. Este procedimiento es invasivo, consiste en remover parte del cráneo para disminuir la presión dentro de la cavidad craneana. Conclusiones: Es necesario continuar los estudios de craniectomía descompresiva en el manejo de la hipertensión craneal pediátrica en la población infanto-juvenil, pues los estudios enfocados en ellos no abundan; estos constituyen una intervención de rescate. A pesar de los adelantos científicos, logros terapéuticos alcanzados y conocimientos de la hipertensión craneal pediátrica, se considera la craniectomía descompresiva como una elección terapéutica óptima, con una justa predicción y no brindarla cuando las opciones reales de éxito sean insuficientes(AU)

Introduction: Severe head trauma has a high incidence in pediatric patients. It is a major cause of death and disability. Its most common causes in this age group are domestic and traffic accidents, falls, violence and sports activities. A bibliographic review was carried out in July and August 2023 with a total of 38 bibliographies in Spanish, English and Portuguese from the SciElo, Elsevier, Pubmed databases and the Google Scholar search engine. The most recent published literature in accordance with the novelty of this disease was considered as a selection criterion. Objective: To describe decompressive craniectomy as an alternative to pediatric intracranial hypertension caused by severe head trauma. Development: In the event of severe head trauma, intracranial pressure increases, causing intracranial hypertension. When this hypertension cannot be controlled, it becomes refractory, other more aggressive treatments such as decompressive craniectomy are required. This procedure is invasive, it consists of removing part of the skull to reduce the pressure inside the cranial cavity. Conclusions: It is necessary to continue studies of decompressive craniectomy in the management of pediatric cranial hypertension in the child and adolescent population, since studies focused on them are not abundant; these constitute a rescue intervention. Despite scientific advances, therapeutic achievements and knowledge of pediatric cranial hypertension, decompressive craniectomy is considered an optimal therapeutic choice, with fair prediction and not provided when the real options for success are insufficient(AU)

Craniectomía descompresiva en infarto de arteria cerebral media bilateral asociado a COVID-19. Reporte de caso / Decompressive Craniectomy in Bilateral Middle Cerebral Artery Infarction Associated with COVID-19: A Case Report

Resumen El nuevo síndrome respiratorio agudo severo por coronavirus tipo 2 (SARS-CoV-2) que causa la enfermedad por COVID-19, se detectó por primera vez en diciembre de 2019. En donde se ha visto que existe un estado protrombótico con afección al sistema nervioso central, con afectación a vasos de gran calibre como la arteria cerebral media, se debe a mecanismos inducidos por la propia infección, estado de hipercoagulabilidad y daño endotelial. Las manifestaciones neurológicas en el COVID-19 se encuentran en el 36% de los pacientes. Descripción del caso: Se trata de un paciente del sexo masculino, de 36 años de edad, con fiebre, tos y malestar general, a quien se le realizó una prueba COVID que resultó positiva, con empeoramiento del cuadro al que se agregó fotofobia, hemiparesia derecha y desviación de la comisura labial hacia la izquierda, por lo que fue llevado a un facultativo 8 horas después del inicio del cuadro clínico. Ahí se realizó una tomografía de cráneo simple que evidenció infarto extenso de la arteria cerebral media izquierda, con edema cerebral maligno, el cual se derivó a manejo quirúrgico de urgencia donde se le realizó una craniectomía descompresiva izquierda extensa. Después de esto, se mantuvo con asistencia respiratoria por intubación mecánica y medidas antiedema cerebral, y se logró que hubiera progresión ventilatoria; sin embargo, se le realizó traqueostomía y gastrostomía por presentar malos predictores de extubación. Se mantuvo en observación posquirúrgica y quedó con hemiparesia 3/5 derecha, sin algún otro déficit, por lo que se dio egreso a domicilio. Discusión: El caso presentado fue manejado con craniectomía descompresiva extensa, y se obtuvo mejoría en la supervivencia y pronóstico funcional, al igual que lo reportado en la literatura médica, en donde se recomienda que dicho manejo se realice de forma temprana. Conclusiones: El presente informe nos revela que aquellos pacientes hombres jóvenes en la cuarta y quinta década de la vida, con COVID-19 e infarto de arteria cerebral media, se presentan sin comorbilidades al darse tratamiento temprano con hemicraniectomía descompresiva, el cual mejora su pronóstico de vida, concordando con los casos presentados en la literatura médica.

Abstract The new severe acute respiratory syndrome due to coronavirus type 2 (SARS-CoV-2), which causes COVID-19 disease, was detected for the first time in December 2019. Where it has been seen that there is a prothrombotic state with involvement of the Central Nervous, with involvement of large vessels such as the middle cerebral artery, is due to mechanisms induced by the infection itself, hypercoagulable state and endothelial damage. Neurological manifestations in COVID-19 are found in 36% of patients. Case description: This is a 36-year-old male patient with fever, cough and general malaise. A COVID test was performed, which came out positive. His condition was getting worse adding photophobia, right hemiparesis and deviation of the corner of the mouth to the left, which is why he went to the doctor, arriving 8 hours after the onset of the clinical picture, where a simple skull tomography was performed, showing extensive infarction of the left middle cerebral artery with malignant cerebral edema. He was transferred to emergency surgical management where a left decompressive craniectomy was performed. After this, mechanical respiratory assistance with intubation and anti-cerebral edema measures were maintained, achieving ventilatory progression; however, a tracheostomy and gastrostomy were performed due to poor predictors of extubation. He was kept under post-surgical observation, leaving him with 3/5 right hemiparesis, without any other deficit, therefore, he was discharged home. Discussion: The case presented was managed with decompressive craniectomy, resulting in an improvement in survival, as reported in the literature where it is recommended that such management should be performed early. Conclusions: This report reveals that patients with COVID-19 present in young men in the fourth and fifth decade of life, without comorbidities, that recieved early treatment with decompressive hemicraniectomy, improved their life prognosis, consistent with the cases presented in the literature.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy.

INTRODUCTION: Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC. MATERIALS AND METHODS: Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed. RESULTS: Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization. CONCLUSION: In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Cranioplasty with cryopreserved autologous bone in craniectomized patients due to brain trauma, a current and safe option: Experience of 97 cases.

BACKGROUND: Cranioplasty is the used method in neurosurgery for repairing cranial bone defects. In our environment, the most widely used material is cryopreserved autologous bone (ABCp). OBJECTIVE: A retrospective observational study was proposed in order to analyze complications in patients who underwent decompressive craniectomy for brain trauma, with subsequent cranioplasty with ABCp. METHOD: Patients who underwent cranioplasties with consecutive ABCp performed at our institution over a four-year period (2016-2019) with subsequent follow-up were included, collecting multiple variables in relation to the appearance of complications. RESULTS: 113 cranioplasties were performed, of which 85.8% (n = 97) were performed with ABCp. Mainly with frontotemporoparietal bone defect (94.84%) performed late (> 3 months) in 91.76%. The complication rate was 16.49%, the most significant being the infection of the surgical site (n = 8, 8.24%), the presence of intracranial hematoma (n = 3, 3.09%) and the reabsorption of the autologous bone (n = 2, 2.06%), meriting surgical management in nine of them (9.27%). CONCLUSIONS: ABCp is a valid and safe option, which meets the basic characteristics to consider it the ideal material, with an acceptable rate of complications, biocompatible, with osteogenic potential, adequate protection of the brain and decrease in surgery costs.

ANTECEDENTES: La craneoplastia es el método utilizado en neurocirugía para reparar los defectos óseos craneanos. En nuestro medio, el material utilizado mayormente es el hueso autólogo criopreservado (HACp). OBJETIVO: Realizamos un estudio retrospectivo observacional para analizar las complicaciones en pacientes sometidos a craniectomía descompresiva por trauma craneoencefálico y realización de craneoplastia con HACp. MÉTODO: Se incluyeron pacientes que fueron sometidos a craneoplastias con HACp consecutivas realizadas en un periodo de 4 años (2016-2019) con seguimiento posterior, recabando múltiples variables en relación con la aparición de complicaciones. RESULTADOS: Se realizaron 113 craneoplastias, de las cuales el 85.8% (n = 97) fueron realizadas con HACp, principalmente con defecto óseo frontotemporoparietal (94.84%), realizadas de forma tardía (> 3 meses) en el 91.76%. El índice de complicaciones fue del 16.49%, siendo las más significativas la infección del sitio quirúrgico (n = 8, 8.24%), la presencia de hematoma endocraneano (n = 3, 3.09%) y la reabsorción del hueso autólogo (n = 2, 2.06%), ameritando manejo quirúrgico en nueve ocasiones (9.27%). CONCLUSIONES: El HACp es una opción válida y segura, la cual cumple con las características para considerarlo el material ideal, con un aceptable índice de complicaciones, biocompatible, con potencial osteogénico, adecuada protección encefálica y disminución de los costos de la cirugía.

Infarto cerebeloso bilateral agudo en territorio de la arteria cerebelosa posterior inferior: reporte de caso / Acute bilateral cerebellar infarction in territory of the posterior inferior cerebellar artery: a case report

Antecedentes: Los infartos cerebelosos suponen una entidad rara con una incidencia baja del total de ictus isquémicos. El territorio más prevalente de los infartos cerebelosos son los de la arteria cerebelosa posterior inferior (PICA). Cuando los infartos se limitan al cerebelo, los pacientes típicamente experimentan síntomas no específicos, esto hace considerar otros diagnósticos de forma errónea. Descripción del caso clínico: paciente femenina de 54 años, con antecedente de hipertensión arterial, quien presentaba cefalea insidiosa y progresiva acompañado de vértigo, alteración en la marcha y deterioro progresivo del estado de conciencia. Se realizó imagen de Resonancia Magnética Cerebral (IRM), la cual reveló zonas hiper intensas bilaterales en región cerebelosa que delimitaban territorio vascular de la arteria cerebelosa posterior inferior además dilatación moderada del sistema ventricular. Fue intervenida quirúrgicamente, realizándose craniectomía suboccipital descompresiva; posterior a la cirugía presentó mejoría clínica. Conclusiones: El ictus isquémico cerebeloso bilateral es una forma infrecuente de ictus y su presentación clínica es muy diversa. El desarrollo de las neuroimágenes, juegan un papel importante para ayudar a los médicos a seleccionar el tratamiento adecuado. Alrededor de la mitad de los pacientes con infartos cerebelosos que presentan deterioro neurológico progresivo y son tratados con craniectomía suboccipital descompresiva tienen buenos resultados. El pilar fundamental de este caso fue el hacer un diagnóstico temprano de esta entidad, ya que permitió prevenir las posibles complicaciones graves asociadas al infarto cerebeloso, las cuales ocurren durante la primera semana del ictus y, por lo tanto, asegurar un pronóstico favorable para el paciente...(AU)

Decompressive craniectomy for malignant middle cerebral artery infarction at an emergency hospital in Peru / Craniectomía descompresiva en infarto maligno de la arteria cerebral media en un hospital de emergencias en Perú

SUMMARY Objective : To describe clinical, surgical and post-operative characteristics of patients with the diagnosis of malignant infarction of the middle cerebral artery who underwent decompressive craniectomy. Methods : Descriptive, retrospective case series study, performed between March 2017 and March 2020. Data from consecutive patients with the diagnosis of malignant middle cerebral artery infarction were collected. Results : Ten cases were reviewed. Eighty percent of the patients were men, the mean age was 64 years and 60% of the patients were older than 60 years. At admission, the mean Glasgow was 11 points and the mean mRS was 4. The mean time from diagnosis to surgery was 89.7 hours. The anterior cerebral artery was comprised in two cases. Hemorrhagic transformation occurred in three cases. The mean anterior-posterior diameter of the skull flap was 116 mm. The mean ICU and hospital length of stay were 14.1 and 27.5 days, respectively. Three patients died. Conclusions : Decompressive craniectomy is a life-saving procedure in an emergency hospital-setting with an acceptable in-hospital mortality rate within one-month follow-up.

RESUMEN Objetivo : Describir las características clínicas, quirúrgicas y postoperatorias en pacientes con diagnóstico de infarto maligno de la arteria cerebral media sometidos a craniectomía descompresiva. Material y métodos : Estudio observacional, descriptivo, retrospectivo, tipo serie de casos, realizado entre marzo 2017 y marzo 2020. Se recolectaron los datos de pacientes consecutivos con diagnóstico de infarto maligno de arteria cerebral. Resultados : Diez casos fueron revisados. Ochenta por ciento fueron hombres, la edad promedio fue 64 años y 60% de los pacientes fueron mayores de 60 años. En la admisión, el Glasgow promedio fue de 11 puntos y el mRS fue de 4. El tiempo promedio desde el diagnostico hasta la cirugía fue de 89,7 horas. La arteria cerebral anterior estuvo comprometida en dos casos. La transformación hemorrágica ocurrió en tres casos. El diámetro anteroposterior promedio de la plaqueta ósea fue de 116 mm. El tiempo promedio de estancia en UCI y estancia hospitalaria fueron de 14,1 días y 27,5 días, respectivamente. Tres pacientes murieron. Conclusiones : La craniectomía descompresiva es un procedimiento que salva vidas en un ambiente hospitalario de emergencia con una aceptable mortalidad intrahospitalaria dentro del primer mes de seguimiento.

Decompressive craniectomy: A salvage treatment for patients with central nervous system tumors.

BACKGROUND: Decompressive craniectomy (DC) has been used for the treatment of refractory increased intracranial pressure (ICP) in patients with brain trauma and stroke; its beneficial role is still a matter of debate. Little has been written on the role of DC in the setting of patients with intracranial tumors. METHODS: We retrospectively reviewed our institutional tumor registry for all adult patients treated with a DC as an emergency treatment between January 2012 and June 2019. RESULTS: A total of 61 patients were taken into surgery for a DC secondary to raised ICP related to a central nervous system tumor. The Kaplan-Meier curves in the study showed that 18.9 months was the mean survival time (MST) of the global population, 40 patients died (65.5%) during the follow-up period. Patients in the group of over 60 years had a worst survival time than younger patients (p = 0.01). Patients with intracerebral hemorrhage had the worst MST compared with the patients with other etiologies (p = 0.04). CONCLUSION: Our data show that in some selected cases DC is a viable option as a salvage treatment for patients with intracranial tumors.

ANTECEDENTES: la craniectomía Descompresiva (CD) se ha utilizado para el tratamiento del aumento de la presión intracraneal en pacientes con traumatismo cerebral y accidente cerebrovascular; su papel beneficioso sigue siendo un tema de debate. Poco se ha escrito sobre el papel de la CD en el contexto de pacientes con tumores intracraneales. MÉTODOS: Revisamos retrospectivamente nuestro registro institucional de tumores para todos los pacientes adultos tratados con craniectomía descompresiva como tratamiento de emergencia entre enero de 2012 y junio de 2019. RESULTADOS: Un total de 61 pacientes fueron llevados a cirugía por una CD secundaria a elevación de ICP secundario a un tumor del sistema nervioso central. Las curvas de Kaplan-Meyer mostraron que 18.9 meses fue el tiempo medio de supervivencia de la población global, 40 pacientes murieron (65.5%) durante el período de seguimiento. Los pacientes del grupo de más de 60 años tuvieron un peor tiempo de supervivencia que los pacientes menores (p = 0,01). Los pacientes con hemorragia intracerebral tuvieron la peor sobrevida en comparación con los pacientes con otras etiologías (p = 0,04). CONCLUSIÓN: Nuestros datos muestran que en algunos casos seleccionados, la CD es una opción viable como tratamiento de rescate para pacientes con tumores intracraneales.

Desenlace de craniectomía descompresiva primaria y secundaria en pacientes con trauma craneoencefálico severo en la Clínica Universidad de La Sabana / Outcomes of Primary and Secondary Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury at Clínica de la Universidad de La Sabana

RESUMEN Objetivos: El propósito de este estudio fue determinar el desenlace en el egreso y en el seguimiento a un año de los pacientes con trauma craneoencefálico severo sometidos a craniectomía descompresiva primaria y secundaria en la Clínica de la Universidad de La Sabana, en un periodo de cinco años. Pacientes y métodos: Se llevó a cabo una serie de casos retrospectiva de pacientes con trauma craneoencefálico severo sometidos a craniectomía descompresiva entre 2008 y 2013. Los desenlaces primarios fueron la sobrevida y el estado funcional medido por la escala de desenlace de Glasgow al momento del egreso hospitalario y al año de seguimiento. Como desenlaces secundarios se incluyeron el tiempo de latencia para la realización de la craniectomía, las complicaciones intra- y postoperatorias, días de hospitalización y estancia en la unidad de cuidados intensivos, tiempo de ventilación, resultados de la craneoplastia y causa de muerte. Resultados: Treinta y cinco pacientes con trauma craneoencefálico severo fueron sometidos a craniectomía descompresiva en el periodo de estudio, 29 primarias y 6 secundarias, con una latencia mediana de 5 horas y 57 horas, respectivamente. Se observó una sobrevida del 51,4 % de los pacientes, de los cuales 39 % presentó recuperación funcional satisfactoria en la escala de desenlace de Glasgow en el momento del egreso y al año. Conclusiones: En este grupo de pacientes sometidos a craniectomía descompresiva primaria o secundaria, junto con un manejo interdisciplinario y rehabilitación precoz, se presentaron desenlaces funcionales favorables en el seguimiento a largo plazo.

ABSTRACT Aim: The purpose of this study was to determine the outcome, at discharge and at one-year follow-up, of patients with severe traumatic brain injury undergoing primary and secondary decompressive craniectomy at Clinica Universidad de La Sabana, over a period of five years. Patients and methods: We conducted a retrospective case series of patients with severe traumatic brain injury undergoing decompressive craniectomy between 2008 and 2013. Te primary outcomes were survival and functional status, measured by the Glasgow Outcome Scale, both at discharge, and at the one year follow-up. Secondary outcomes included latency time for craniectomy, intra and postoperative complications, days of hospitalization and intensive care unit stay, ventilation time, cranioplasty results, and cause of death. Results: Thirty-five patients with severe traumatic brain injury underwent decompressive craniectomy in the study period, 29 of which were primary and 6, secondary, with a median latency of 5 hours and 57 hours, respectively. A survival of 51.4% of the patients was observed, of which 39% presented satisfactory functional recovery on the Glasgow outcome scale at the time of discharge and one year later. Conclusions: In this group of patients who underwent primary or secondary decompressive craniectomy, together with interdisciplinary management and early rehabilitation, favorable functional outcomes were found in the long-term follow-up.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy.

INTRODUCTION: Despite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC. MATERIALS AND METHODS: Consecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed. RESULTS: Twenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization. CONCLUSION: In patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Craniectomía descompresiva como tratamiento primario de la hipertensión intracraneal por traumatismo encefalocraneano: Experiencia observacional en 24 pacientes

Introducción: el traumatismo encéfalo craneano es una de las principales causas de muerte en nuestro medio, El tratamiento médico y quirúrgico en la etapa inicial de un TEC severo se enfoca en evitar la elevación de la Presión Intracraneana. Objetivo : describir características asociados y sus principales complicaciones en aquellos pacientes sometidos a Craniectomía Descompresiva. Métodos : Estudio retrospectivo observacional descriptivo, realizado entre febrero de 2018 a julio de 2020 de pacientes operados de Craniectomía Descompresiva unilateral, admitidos por traumatismo encefalocraneano. Resultados : 66.7% fueron personas menores de 40 años; 87,5% fueron de sexo masculino; 16,7% de la población ingresaron con una ECG de 13-15, 37,5% de la población con una ECG de 9-12; 42.9% presentaron asimetría pupilar; 33,3% ingresaron por accidente de tránsito; 21,7% fueron Marshall II, 65,2% Marshall III y en 13,0% se halló un Marshall IV. Conclusiones : Los resultados sugieren que las características asociadas a la Craniectomía Descompresiva por TEC contribuyen en el manejo de esta patología.

Introduction: Head trauma is one of the main causes of death in Peru. Medical and surgical therapy during the initial stages of severe head trauma focus in preventing the elevation of intracranial pressure. Objective: To describe the associated characteristics and main complications in patients undergoing decompressive craniectomy. Methods: This is a retrospective observational study performed between February 2018 and July 2020 in patients who had been admitted because of head trauma and who had undergone unilateral decompressive craniectomy. Results: Two-thirds (66.7%) of patients were persons less than 40 years of age; 87.5% were males; 16.7% were admitted with Glasgow Coma Score (GCS) scores between 13 and 15; 37.5% were admitted with GCS between 9 and 12; 42.9% had asymmetric pupils; 33.3% were admitted because of traffic accidents; 21.7% were Marshall II, 65.2% were Marshall III, and 13.0% were Marshall IV. Conclusions: Our results suggest that characteristics associated to decompressive craniectomy because of head trauma contribute for its proper management.

Decompressive craniectomy in malignant middle cerebral artery infarction: family perception, outcome and prognostic factors. / Craniectomía descompresiva en el infarto maligno de arteria cerebral media: percepción familiar, resultados y factores pronósticos.

OBJECTIVE: The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. MATERIAL AND METHODS: In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). RESULTS: Patient age was shown to be directly related to the mRS (r=0.56; p=0.035) and 37.5% achieved a good outcome (mRS≤3); 78.9% of the interviewed relatives would repeat the surgical decision. CONCLUSIONS: We present a 21 patients group where the best outcome was achieved in patients ≤60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients.

Controversias de la craniectomía descompresiva en el tratamiento de la hipertensión endocraneana / Controversies of decompressive craniotomy in the treatment of intracranial hypertension

RESUMEN La hipertensión intracraneal influye negativamente en el pronóstico del traumatismo craneoencefálico grave y del infarto maligno de la arteria cerebral media. La craniectomía descompresiva constituye una opción de tratamiento. Con esta revisión se persigue valorar las controversias de la craniectomía descompresiva en el tratamiento de la hipertensión endocraneana. Para lo cual se realizó una exhaustiva revisión de la literatura donde se tuvieron en cuenta diversos estudios multicéntricos y multinacionales que plasmaron aspectos polémicos acerca de la utilización de este proceder neuroquirúrgico como terapia en el manejo de la hipertensión endocraneana refractaria a tratamiento conservador. Se concluye que la craniectomía descompresiva se considera beneficiosa en el infarto maligno de la arteria cerebral media, mientras que en el trauma craneoencefálico grave su utilidad es controvertida (AU).

SUMMARY Intracranial hypertension negatively influences the prognosis of severe craniaencephalic trauma and malignant infarction of the middle cerebral artery. Decompressive craniotomy is a treatment option. The aim of this review is to assess the controversies of decompressive craniotomy in the treatment of intracranial hypertension. For this purpose, an exhaustive review of the literature was carried out, taking into account several multicentric and multinational studies revealing controversial aspects on the use of this neurosurgical procedure as therapy in the management of intracranial hypertension refractory to conservative treatment. It is concluded that decompressive craniotomy is considered beneficial in the malignant infarction of the middle cerebral artery, while in the case of severe craniaencephalic trauma its utility is controversial (AU).

Rescatando al RescueICP: ¿Quién decide que es favorable o no? / Rescuing the RescueICP: Who decides what is favorable or not?

Tipo de Estudio: Internacional, multicéntrico, controlado y randomizado, Objetivo: Evaluar efectividad de la craniectomía descompresiva (CD) en el manejo de la hipertensión intracraneal refractaria en pacientes con lesión cerebral traumática. Material y Métodos: Incluyó 408 pacientes entre 10 y 65 años desde el 2004 hasta 2014. 202 pacientes en el grupo quirúrgico y 196 en el grupo de manejo médico fueron enrolados, 10 pacientes fueron excluidos por falta de consentimiento informado válido y retiro voluntario. Una vez enrolados se randomizó en 02 grupos: 1) craniectomía descompresiva (CD), debía realizarse 4 a 6 horas después de la randomización (hemicraniectomía frontotémporoparietal o craniectomía bifrontal) y 2) tratamiento médico, la cual dentro sus medidas de manejo (línea 1 y línea 2) incluía también el uso de barbitúricos e hipotermia. Resultados: La mortalidad en grupo quirúrgico fue 26,9% vs 48,9% en el grupo médico, estado vegetativo 8,5% vs 2,1%, dependencia completa de otros 21,9% vs 14,4%, buena recuperación sin déficit 4% vs 6,9% a los 6 meses. Mortalidad en grupo quirúrgico a 12 meses fue 30,% vs 52% en el grupo médico, estado vegetativo 6,2% vs 1,7%, dependencia completa de otros 18% vs 14%, buena recuperación sin déficit 9,8% vs 8,4%. Conclusión: La CD como tratamiento de la hipertensión endocraneana grave y refractaria, disminuyó la mortalidad en un 22%, comparado con el grupo de tratamiento médico (p< 0,001), pero se asoció con mayores casos de pacientes en estado vegetativo y discapacidad severa. Las tasas de discapacidad moderada y buena recuperación, fueron similares en ambos grupos.

Coma secundario a síndrome del trefinado / Coma due to syndrome of the trephined

El síndrome del trefinado o craniectomizado abarca manifestaciones neurológicas asociadas a la depresión del flap cutáneo y se distingue del síndrome postraumático por su reversibilidad con el tratamiento reparador del defecto craneano. El coma no es una forma habitual de presentación. Comunicamos un caso de presentación atípica en un hombre de 36 años de edad con antecedente de craniectomía descompresiva, que presentó un cuadro de deterioro neurológico profundo atribuible al síndrome del trefinado, el cual revirtió tras la craneoplastía. En la fisiopatología del síndrome intervienen trastornos cerebrovasculares, metabólicos, hidrodinámicos del líquido cefalorraquídeo e hiperdinamismo de las estructuras encefálicas. El gold standard terapéutico es la craneoplastía. Se requieren estudios de mayor peso estadístico para determinar el tiempo quirúrgico apropiado.

The syndrome of the trephined or craniectomized is commonly referred as neurological manifestations associated to skin flap depression and reversible after craneoplasty, which allows its differentiation from post-traumatic syndrome. We present the case of a male patient, 36 years old, with history of decompressive craniectomy. He evolved with sudden neurological worsening associated to syndrome of the trephined and recovery after craneoplasty. Physiopathology of the syndrome involves cerebrovascular, metabolic and cerebrospinal fluid hydrodynamic disturbances as well as parenchymal hyperdynamic mechanisms. Cranioplasty is the gold standard treatment. Still, studies with statistical power are needed to assess correct surgical timing.

[Trends in computed tomography characteristics, intracranial pressure monitoring and surgical management in severe traumatic brain injury: Analysis of a data base of the past 25 years in a neurosurgery department]. / Evolución temporal en las características de la tomografía computarizada, presión intracraneal y tratamiento quirúrgico en el traumatismo craneal grave: análisis de la base de datos de los últimos 25 años en un servicio de neurocirugía.

OBJECTIVE: To describe the radiological characteristics, surgical indications, procedures, and intracranial pressure monitoring of a representative cohort of severe traumatic brain injury (sTBI) cases collected over the past 25years, and to analyse the changes that have occurred by dividing the period into 3 equal time periods. METHODS: An observational cohort study was conducted on consecutive adult patients (>14years of age) with severe closed TBI (Glasgow Coma Scale score [GCS]≤8) who were admitted during the first 48hours after injury to the Hospital 12 de Octubre from 1987 to 2012. The most relevant radiological findings, surgical procedures, and intracranial monitoring indications reported in the literature were defined and compared in 3 equal time periods (1987-1995, 1996-2004, and 2005-2014). RESULTS: A significant increase was observed in subdural haematomas with lesions over 25cc, and midline shift in the last period of time. The incidence of subarachnoid haemorrhage increased significantly with time. There was a progression to a worse computed tomography (CT) classification from the initial CT scan in 33% of cases. Surgery was performed on 721 (39.4%) patients. Early surgery (<12hours) was performed on 585 (81.1%) patients, with the most frequent being for extra-cerebral mass lesions (subdural and epidural haematomas), whereas delayed surgery (>12hours) was most frequently performed due to an intracerebral haematoma. Surgical treatment, both early and late was significantly lower with respect to the first time period. Decompressive craniectomy with evacuation of the mass lesion was the preferred procedure in the last time period. Intracranial pressure monitoring (ICP) was carried out on 1049 (57.3%) patients, with a significantly higher frequency in the second period of time. There was adherence to Guidelines in 64.4% of cases. Elevated/uncontrolled ICP was more significant in the first time period. CONCLUSIONS: As a result of the epidemiological changes seen in traumatic brain injury, a different pattern of morphological injury is described, as depicted in the CT, leading to a difference in practice during this period of observation.

Valoración ética de la craneoplastia con vendaje compresivo como forma de limitación de tratamientos de soporte vital / Valoração ética da cranioplastia com curativo compressivo como forma de limitação de tratamentos de suporte vital / Ethical value of cranioplasty with oppressive binder as a way of limiting life support treatments

Este artículo analiza, desde una postura crítica, la utilización de la craneoplastia de compresión con vendaje como método de limitación de tratamiento de soporte vital (LTSV). Con esta técnica activa, algunos autores han propuesto provocar la muerte encefálica, posibilitando la donación de órganos. Al contrastar este procedimiento con las recomendaciones del documento de consenso sobre el tratamiento al final de la vida del paciente crítico, elaborado por el grupo de bioética de la SEMICYUC, se comprueba que los medios y fines de esta técnica no encajan con las actuaciones propias de la LTSV, que se basan en la retirada de medios de soporte vital o en su no inicio, al considerar dichos medios desproporcionados o extraordinarios en algunos casos, evitando así la obstinación terapéutica. La definición de LTSV permite clarificar los límites en los que, de un modo éticamente correcto y consensuado, las actuaciones al final de la vida se circunscriben a los fines de la medicina, evitando la sospecha de que dichas actuaciones puedan ser malinterpretadas como justificación para una obtención de órganos abusiva. El artículo concluye que la provocación directa de la muerte encefálica mediante la técnica de craneoplastia con vendaje no parece cumplir los criterios propios de la LTSV.

This article analyzes, from a critical perspective, the use of cranioplasty with oppressive binder as a method to limit life support treatment (LLST). Some authors have proposed that this active technique provokes encephalic death, allowing organ donation. Contrasting this procedure with the recommendations of the consent document about treatment of critical patients at the end of life, elaborated by the bioethics group of SEMICYUC, it is shown that the means and ends of this technique do not match with the proper actions of LLST, based on the withdrawal of life support means or in not starting them, considering such means disproportionate or extraordinary in some cases, thus avoiding the therapeutic obstinacy. The definition of LLST allows to clarify the limits in which, in a way ethically fair and with a consensus, the acts at the end of life are included in the medical goals, avoiding the suspicion that these acts may be misinterpreted as justifying an abusive extraction of organs. This article concludes that the direct provocation of encephalic death by the technique of cranioplasty with binder does not appear to fulfill the criteria proper of LLST.

Este artigo analisa, a partir de uma postura crítica, a utilização da cranioplastia de compressão com curativo como método de limitação de tratamento de suporte vital (LTSV). Com esta técnica ativa, alguns autores têm proposto provocar a morte encefálica, possibilitando a doação de órgãos. Ao contrastar este procedimento com as recomendações do documento de consenso sobre o tratamento do final de vida do paciente crítico, elaborado pelo grupo de bioética da SEMICYUC, se comprova que os meios e fins desta técnica não encaixam com as atuações próprias da LTSV, que se baseiam na retirada de meios de suporte vital ou em seu não início, ao considerar os ditos meios desproporcionados ou extraordinários em alguns casos, evitando assim a obstinação terapêutica. A definição de LTSV permite esclarecer os limites nos quais, de um modo eticamente correto e aceito, as atuações ao final da vida se circunscrevem às finalidades da medicina, evitando a suspeita de que ditas atuações podem ser mal interpretadas como justificativa para uma obtenção de órgãos abusiva. O artigo conclui que a provocação direta da morte encefálica mediante a técnica da cranioplastia com curativo não parece cumprir os critérios próprios da LTSV.

Craniectomía descompresiva en el trauma encefalocraneano grave: factores pronósticos y complicaciones / Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications

RESUMEN Objetivo: Análisis de las características clínicas, las complicaciones y los factores asociados al pronóstico de los pacientes con trauma encefalocraneano grave en los que se realizó craniectomía descompresiva. Métodos: Estudio retrospectivo de los pacientes asistidos en una Unidad de Cuidados Intensivos, con trauma encefalocraneano grave en los que se realizó craniectomía descompresiva, entre los años 2003 y 2012. Se siguieron los pacientes hasta el egreso de la unidad de cuidados intensivos, analizándose sus características clínico-tomográficas, las complicaciones y los factores asociados al pronóstico (análisis uni y multivariado). Resultados: Se estudiaron 64 pacientes. Se realizó craniectomía descompresiva primaria y lateral en la mayoría de los pacientes. Se halló una alta incidencia de complicaciones (78% neurológicas y 52% no neurológicas). 42 pacientes (66%) presentaron mala evolución y 22 (34%) tuvieron una buena evolución neurológica. De los pacientes que sobrevivieron, el 61% tuvo una buena evolución neurológica. En el análisis univariado, los factores asociados significativamente con mala evolución neurológica fueron: la hipertensión intracraneana post-craniectomía descompresiva, la mayor gravedad y el peor estado neurológico al ingreso. En el análisis multivariado, solo la hipertensión intracraneana post-craniectomía descompresiva se asoció significativamente con mala evolución. Conclusión: Se trata de un grupo de pacientes muy grave, de difícil manejo, con elevada morbimortalidad, donde la hipertensión intracraneana es un factor principal de mala evolución. .

ABSTRACT Objective: To analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy. Methods: Retrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed. Results: A total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome. Conclusion: This study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population. .

[Craniocerebral gunshot wounds in civilian population: Analysis of experience in a single center in Monterrey, México]. / Heridas craneales por proyectil de arma de fuego en población civil: análisis de la experiencia de un centro en Monterrey, México.

BACKGROUND: Gunshot wounds in civilian population of México were quite rare. Currently, conflicts amongst organized crime groups are carried out with weapons, which are considered as exclusive use by the nations army. OBJECTIVES: Describe the experience of our institution and share results of clinical and radiological factors influencing the prognosis of the patients. MATERIAL AND METHODS: Observational and retrospective study of patients with cranial gunshot wounds (GSW), which penetrated the duramater, treated from January 2009 - January 2013. We considered several demographic variables, Glasgow Coma Scale (GCS), upon admission, state of pupils, type of surgery and size of decompression, Glasgow Outcome Score (GOS) upon discharge, and after 6 months. RESULTS: Of 68 patients, we excluded those whose duramater was not penetrated, leaving 52 patients. The average age was 28.7 years, and 80.8% were males. All were surgically intervened, with 8% of general mortality. Mortality in the GCS 3 to 5 points group was 43%, from the 6 to 8 points it was 6%, and no deaths in the 9 to 15 points. In patients with both pupils fixed, anisocoric and isocoric, mortality was 67%, 7%, and 3%, respectively. Bihemispheric, multilobar and unihemispheric trajectory of the bullet plus ventricular compromise was related to a Glasgow Outcome Score ≤ 3 upon discharge in 90.9% of the cases. CONCLUSIONS: GCS upon admission and state of the pupils are the most influential factors in the prognosis. Patients with a GCS > 8 < 13 points upon admission, normal pupillary response, without ventricular compromise can benefit with early and aggressive surgical treatment.