Letter to editor: Exploring complications following cranioplasty after decompressive hemicraniectomy: A retrospective bicenter assessment of autologous, PMMA and CAD implants.

This study presents a critical analysis of complications following cranioplasty (CP) after decompressive hemicraniectomy, focusing on autologous, polymethylmethacrylate (PMMA), and computer-aided design (CAD) implants. The analysis encompasses a retrospective bicenter assessment, evaluating factors influencing surgical outcomes and emphasizing the significance of material selection in minimizing postoperative complications. The study's comprehensive examination of complication rates associated with various implant materials contributes significantly to understanding CP outcomes. While polymethylmethacrylate (PMMA) and autologous bone flaps (ABFs) exhibited higher rates of surgical site infection (SSI) and explantation, a meta-analysis revealed a contrasting lower infection rate for polyether ether ketone (PEEK) implants. The study underscores the critical role of material selection in mitigating postoperative complications. Despite its strengths, the study's retrospective design, reliance on data from two centers, and limited sample size pose limitations. Future research should prioritize prospective, multicenter studies with standardized protocols to enhance diagnostic accuracy and treatment efficacy in CP procedures.

Assessment of Midline Shift in Postdecompressive Craniectomy Patients in Neurocritical Care: Comparison between Transcranial Ultrasonography and Computerized Tomography.

Background: Monitoring and evaluation of intracranial structures remain a fundamental element in the neurointensive care unit. Most used technique to monitor progression is the use of computed tomography (CT) in intracranial hemorrhage (ICH) or stroke. Rapid assessment of brain pathology can be made using CT to analyze the midline shift (MLS), hematoma expansion, and ventricular size, but transferring a patient who is intubated is time and resource-consuming task. Ultrasonography is a noninvasive technique, portable, and has the possibility of fast interpretation. Aims and Objectives: To measure the brain MLS in decompressive craniectomy patients using transcranial ultrasonography (TCS) and compare the correlation of these results with CT scan measurements of MLS in the same patient. Materials and Methods: Patients who have undergone decompressive craniectomy due to various reasons like ICH, traumatic brain injury, etc., and have a MLS. Trans cranial ultrasonography was assessed by a single consultant (Neuro Critical Care Intensivist) who was blinded for the CT scan measurement. CT scan measurement of MLS was assessed by a neuroradiologist using standard guidelines, who was blinded for the TCS results of MLS. The finding of a MLS >0.5 cm in the CT scan was considered a significant MLS. Results: A total of 31 patients were recruited for the study. MLS measured using CT was 0.91 ± 0.67 cm. MLS via TCS was 0.91 ± 0.66 cm. A significant MLS via TCS was found in 77.4%. Intraclass correlation coefficient (ICC) was calculated between CT-MLS and TCS MLS and obtained the value of ICC as 0.996, indicating an almost perfect agreement. Conclusion: Patients after decompressive craniectomy may present as an ideal candidate to visualize intracerebral anatomy with a high resolution. TCS might be considered as an alternative to CT to measure MLS in decompressive craniectomy patients.

Role of Bedside Transcranial Ultrasonography in the Assessment of Cerebral Hemodynamics in Decompressive Craniectomy Patients with Cranioplasty: A Single Centre Experience.

Background: Intracerebral hemorrhage is a leading cause of death and disability worldwide. After intracerebral hemorrhage, cerebral blood flow (CBF) becomes extremely low approaching ischemic thresholds. Concurrently, CBF velocities become strongly correlated to CBF itself post-injury. Identification of such hemodynamic disturbances can be used to predict outcome immediately post-injury when indices are measured using transcranial doppler ultrasonography (TCD). TCD permits non-invasive assessment of different CBF velocities as well as pulsatility index (PI). Abnormal measurement of such indices is believed to correlate to poor outcome. Aim: To investigate the effect of cerebral hemodynamics after cranioplasty in decompressive craniectomy patients using pre and postoperative TCD. Materials and Methods: This study is a prospective study of 3 years duration undertaken on 64 patients. All the patients were evaluated by TCDbefore and after decompressive craniectomy.All patients were evaluated by transcranial Doppler (TCD) 1 week before and 7-15 days after cranioplasty. TCD results were obtained though trans-temporal approach. Results: Statistically significant differences between the values before and after craniectomy were detected in Peak Systolic Volume (PSV) for the Anterior Cerebral Artery (ACA) (P = 0.001), in PSV for the Middle Cerebral Artery (MCA) (P < 0.004), in Mean Bloodflow Velocity (MV) for the MCA (P < 0.003), and in PSV for the Posterior Cerebral artery (PCA) (P = 0.001) on the ipsilateral side. There were statistically significant differences between the values before and after cranioplasty in PSV for the PCA (P = 0.004), on contralateral side.After decompressive craniectomy, the PI values for the MCA decreased, on average, to 31+/- 33% of the pre-surgical value in the treated side and to 28+/- 31% on the opposite side. On the other hand, the mean PI values for the extracranial ICA reduced to 34+/- 21% of the initial values in the treated side, and to 21+/- 31% on the opposite side.Cranioplasty improved CBF velocities in all major intracrainal arteries, not only on the side of the lesion adjacent to the cranioplasty, but also in distant regions, such as in the contralateral hemisphere. Conclusion: Decompressive craniectomy significantly improves cerebral hemodynamics both on ipsilateral and contralateral cerebral hemispheres.Concomitantly, PI values on TCD decrease significantly postoperatively, mainly in the decompressed cerebral hemisphere, indicating reduction in cerebrovascular resistance. We conclude that cranioplasty improves neurological status and the mechanism of postoperative improvement of neurological status may be due to increased CBF velocity.

Decompressive hemicraniectomy and cranioplasty using subcutaneously preserved autologous bone flaps versus synthetic implants: perioperative outcomes and cost analysis.

OBJECTIVE: It has not been well-elucidated whether there are advantages to preserving bone flaps in abdominal subcutaneous (SQ) tissue after decompressive hemicraniectomy (DHC), compared to discarding bone flaps. The authors aimed to compare perioperative outcomes and costs for patients undergoing autologous cranioplasty (AC) after DHC with the bone flap preserved in abdominal SQ tissue, and for patients undergoing synthetic cranioplasty (SC). METHODS: A retrospective review was performed of all patients undergoing DHC procedures between January 2017 and July 2021 at two tertiary care institutions. Patients were divided into two groups: those with flaps preserved in SQ tissue (SQ group), and those with the flap discarded (discarded group). Additional analysis was performed between patients undergoing AC versus SC. Primary end points included postoperative and surgical site complications. Secondary endpoints included operative costs, length of stay, and blood loss. RESULTS: A total of 248 patients who underwent DHC were included in the study, with 155 patients (62.5%) in the SQ group and 93 (37.5%) in the discarded group. Patients in the discarded group were more likely to have a diagnosis of severe TBI (57.0%), while the most prevalent diagnosis in the SQ group was malignant stroke (35.5%, p < 0.05). There were 8 (5.2%) abdominal surgical site infections and 9 (5.8%) abdominal hematomas. The AC group had a significantly higher reoperation rate (23.2% vs 12.9%, p = 0.046), with 11% attributable to abdominal reoperations. The average cost of a reoperation for an abdominal complication was $40,408.75 ± $2273. When comparing the AC group to the SC group after cranioplasty, there were no significant differences in complications or surgical site infections. There were 6 cases of significant bone resorption requiring cement supplementation or discarding of the bone flap. Increased mean operative charges were found for the SC group compared to the AC group ($72,362 vs $59,726, p < 0.001). CONCLUSIONS: Autologous bone flaps may offer a cost-effective option compared to synthetic flaps. However, when preserved in abdominal SQ tissue, they pose the risk of resorption over time as well as abdominal surgical site complications with increased reoperation rates. Further studies and methodologies such as cryopreservation of the bone flap may be beneficial to reduce costs and eliminate complications associated with abdominal SQ storage.

Endoscopic Surgery Without Decompressive Craniectomy in Large Putaminal Intracerebral Hemorrhage: Assessment of Efficacy and Safety.

BACKGROUND: Decompressive craniectomy (DC) is performed conventionally for large putaminal intracerebral hemorrhage (ICH). However, DC causes local skull defect and leads to post-surgical cranioplasty. The aim of this study is to investigate the effectiveness and safety of an endoscopic procedure to treat large putaminal ICH without DC. METHODS: This retrospective study included 112 large putaminal ICH patients who underwent hematoma evacuations with either an endoscopic procedure (group A) or with DC (group B) between January 2009 and June 2017. The efficacy was evaluated by mean modified Rankin Scale (mRS) three months after surgery. Safety was evaluated by mortality rate and postoperative complications. Univariate and multivariate logistic regression analyses were performed to determine the risk factors for clinical outcomes. RESULTS: The study included 49 patients in group A and 63 in group B. The mRS scores in both groups were similar after 3 months' follow-up (p = 0.709). There was no difference in the mortality rate between the two groups (p = 0.538). The rate of complications was lower in group A than that in group B (p = 0.024). Smaller preoperative midline shift (p = 0.008) and absent intraventricular extension (p = 0.044) have contributed significantly to better outcomes. CONCLUSION: Endoscopic hematoma evacuation without DC is safe and effective for patients with large putaminal ICH and deserves further investigation, preferably in a randomized controlled setting.

Assessment of Skin Flaps Above Cranial Defects Following Craniectomy: A Proposed Classification System.

OBJECTIVE: The assessment of the skin flap above cranial defects (SCD) following craniectomy is routine in neurosurgical practice, and a change in the consistency of the skin flap may indicate raised intracranial pressure or the occurrence of a complication necessitating intervention. The purpose of this study was to develop a clinically useful classification system based on clinical assessment of the degree of skin flap bulging or sinking and its firmness. PATIENTS AND METHODS: This was a prospective single-center study. The SCDs of consecutive patients who underwent craniectomy were assessed daily by two trained independent examiners. The consistency of the flap and its bulging or sinking in comparison with the level of the cranium were noted. Testing conditions including the positioning of the patient and examiner were standardized. RESULTS: A total of 520 examinations were conducted in 24 patients during their hospital stay. There was 100% interrater reliability (Cohen's κ = 1.0). In 66.6% of all patients (n = 16/24), a change of the SCD classification in comparison with that recorded on the previous day was noted. CONCLUSIONS: The SCD classification facilitates the reproducible and objective assessment of SCDs, enabling reliable monitoring over time and between individuals.

Polymethylmethacrylate cranioplasty using low-cost customised 3D printed moulds for cranial defects - a single Centre experience: technical note.

We report our experience with 3D customised cranioplasties for large cranial defects. They were made by casting bone cement in custom made moulds at the time of surgery. Between October 2015 and January 2018, 29 patients underwent the procedure; 25 underwent elective cranioplasties for large cranial defects and four were bone tumour resection and reconstruction cases. The majority of patients (96.5%) reported a satisfactory aesthetic outcome. No infections related to the surgical procedure were observed in the follow-up period. The method proved to be effective and affordable.

Subcutaneous bone flap storage after emergency craniectomy: cost-effectiveness and rate of resorption.

OBJECTIVEDecompressive craniectomy is used for uncontrolled intracranial pressure in traumatic brain injury and malignant hemispheric stroke. Subcutaneous preservation of the autologous bone flap in the abdomen is a simple, portable technique but has largely been abandoned due to perceived concerns of resorption. The authors sought to characterize their experience with subcutaneous preservation of the bone flap and cranioplasty.METHODSThe authors performed a retrospective single-institution review of subcutaneous preservation of the autologous bone flap after decompressive craniectomy from 2005 to 2015. The primary outcome was clinically significant bone resorption, defined as requiring a complete mesh implant at the time of cranioplasty, or delayed revision. The outcome also combined cases with any minor bone resorption to determine predictors of this outcome. Logistic regression modeling was used to determine the risk factors for predicting resorption. A cost comparison analysis was also used via the 2-sided t-test to compare the cost of cranioplasty using an autologous bone flap with standard custom implant costs.RESULTSA total of 193 patients with craniectomy were identified, 108 of whom received a cranioplasty. The mean time to cranioplasty was 104.31 days. Severe resorption occurred in 10 cases (9.26%): 4 were clinically significant (2 early and 2 late) and 6 demonstrated type II (severe) necrosis on CT, but did not require revision. Early resorption of any kind (mild or severe) occurred in 28 (25.93%) of 108 cases. Of the 108 patients, 26 (24.07%) required supplemental cranioplasty material. Late resorption of any kind (mild or severe) occurred in 6 (5.88%) of 102 cases. Of these, a clinically noticeable but nonoperative deformity was noted in 4 (3.92%) and minor (type I) necrosis on CT in 37 (37%) of 100. Bivariate analysis identified fragmentation of bone (OR 3.90, 95% CI 1.03-14.8), shunt-dependent hydrocephalus (OR 7.97, 95% CI 1.57-40.46), and presence of post-cranioplasty drain (OR 9.39, 95% CI 1.14-1000) to be significant risk factors for bone resorption. A binary logistic regression optimized using Fisher's scoring determined the optimal multivariable combination of factors. Fragmentation of bone (OR 5.84, 95% CI 1.38-28.78), diabetes (OR 7.61, 95% CI 1.37-44.56), and shunt-dependent hydrocephalus (OR 9.35, 95% CI 1.64-56.21) were found to be most predictive of resorption, with a C value of 0.78. Infections occurred in the subcutaneous pocket in 5 (2.60%) of the 193 cases and after cranioplasty in 10 (9.26%) of the 108 who underwent cranioplasty. The average cost of cranioplasty with autologous bone was $2156.28 ± $1144.60 (n = 15), and of a custom implant was $35,118.60 ± $2067.51 (3 different sizes; p < 0.0001).CONCLUSIONSCraniectomy with autologous bone cranioplasty using subcutaneous pocket storage is safe and compares favorably to cryopreservation in terms of resorption and favorably to a custom synthetic implant in terms of cost. While randomized data are required to definitively prove the superiority of one method, subcutaneous preservation has enough practical advantages with low risk to warrant routine use for most patients.

Intraoperative Indocyanine Green-Based Cortical Perfusion Assessment in Patients Suffering from Severe Traumatic Brain Injury.

OBJECTIVES: The pathophysiology of traumatic brain injury (TBI) largely involves the brains vascular structural integrity. We analyzed the value of an intraoperative cortical indocyanine green (ICG) angiography in patients with severe TBI and acute subdural hematoma who underwent decompressive craniectomy. METHODS: ICG-derived fluorescence curves of cortex and cerebral vessels were recorded by the use of software integrated into a surgical microscope in 10 patients. The maximum intensity, rise time (RT), time to peak, and residual fluorescence intensity (FI) were estimated from cortical arteries, the parenchyma, and veins. RESULTS: ICG-derived fluorescence parameters were correlated with the short-term outcome 3 months after discharge. Five patients had a favorable and 5 an unfavorable outcome. Patients with a favorable outcome showed a significant longer RT in the arteries and a trend towards a significant longer RT in the veins. Overall mean residual FI was 47.5 ± 6.8% for the arteries, 45.0 ± 7% for the parenchyma and 57.6 ± 6% for the veins. The residual FI of the parenchyma and the veins was significantly greater in patients with an unfavorable clinical outcome. CONCLUSIONS: Patients with an unfavorable clinical outcome showed an altered shape of the ICG-derived fluorescence curve, a shorter increase of the ICG-derived fluorescence intensity in the cortical arteries, and significantly greater residual fluorescence intensity. These observations are likely a correlate of an increased intracranial pressure, a capillary leak, and venous congestion. Intraoperative quantification of the ICG-derived fluorescence might help to appreciate the clinical outcome in patients with severe TBI.

Assessment of the effect of short-term factors on surgical treatments for hypertensive intracerebral haemorrhage.

BACKGROUND: Hypertension is the most common cause of intracerebral haemorrhages (ICHs), yet the short-term impact factors associated with hypertensive intracerebral haemorrhages (HICHs) in patients who undergo different surgical treatments are still unknown. MATERIALS AND METHODS: All consecutive patients with acute HICHs admitted to our hospital from January 2012 to March 2015 were enrolled in the study. Patients were either randomly divided or assigned according to their family's preference into three groups (those undergoing minimally invasive aspiration, keyhole craniotomy or haematoma aspiration with extended pterional and decompressive craniotomy). Patients' information and clinical characteristics were collected to identify risk factors influencing the short-term effects of the procedures. RESULTS: There were significant differences among the groups: haematoma aspiration with extended pterional and decompressive craniotomy was the optimal method, resulting in fewer complications, higher Glasgow Outcome Scale (GOS) scores and better short-term outcomes. Surgical treatment, Glasgow Coma Scale (GCS) scores, haemorrhage volume and degree of midline shift were risk factors for the short-term effects associated with HICH. CONCLUSIONS: Haematoma aspiration with extended pterional and decompressive craniotomy is suitable for treating HICH patients. Surgical treatment, GCS score, haemorrhage volume and degree of midline shift influence the short-term effects observed following HICH surgery.

Clinical and Radiologic Outcome of a Less Invasive, Low-Cost Surgical Technique of Osteoplastic Decompressive Craniectomy.

BACKGROUND: Decompressive craniectomy (DC) has many technical details with significant constraining logistic/economic considerations in low-resource practice areas. We present a less invasive, cost-saving, and evidence-based technique of DC evolving in our practice. METHODS: Earlier, we reported a technique of hinge decompressive craniectomy (hDC), in which the frontotemporoparietal skull flap is hinged on the temporal muscle. In this article we describe further refinements of this temporal muscle hDC : The scalp flap is raised in a galeal-skeletonizing plane preserving the subgaleal fascia on the pericranium, ready for use for duraplasty after durotomy. We performed a descriptive analysis of the clinical outcome of this surgical technique in a prospective consecutive cohort of patients with traumatic brain injury (TBI). The primary and secondary clinical outcome measures were in-hospital mortality and survival, respectively, and the immediate as well as long-term surgical wound issues. RESULTS: There were 40 cases, 38 men (95%) and 2 women over a 40-month period with a mild (n = 8), moderate (n = 17), or severe TBI (n = 15). As assessed by the computed tomography Rotterdam score, life-threatening significant brain injury was present in 90%. Poor clinical outcome occurred in about a third of cases (32.5%) mainly in the severe TBI group (77% of poor outcome) and not in the mild TBI group. Surgical site complications occurred in four patients (10%) CONCLUSIONS: The presented modified temporal muscle hDC technique offers significant economic advantages over the traditional surgical method of DC without added complications. Analysis of the clinical data in a consecutive prospective cohort of patients with potentially fatal TBI who underwent this surgical procedure showed a good outcome in at least two thirds.

Bone flap resorption following cranioplasty in a cost-constrained scenario.

Bone flap resorption is an infrequently reported yet significant late complication of autologous bone cranioplasty. It requires serial imaging both to pick up and to monitor progression. Custom-made implants avoid this complication, but are expensive. In a resource-limited situation, when bone flaps placed in the abdomen undergo demineralisation and sutures are used to fix the flap as opposed to plates, where artificial cranial flap substitutes are prohibitively expensive and frequent postoperative imaging may not be feasible, prevention and management of this complication will continue to remain a problem.

Outcomes of cranioplasty with synthetic materials and autologous bone grafts.

OBJECTIVE: Using current surgical methods, cranioplasty is associated with a high complication rate. We analyzed if there are preexisting medical conditions associated with complications and compared the effect of different implant materials on the degree of complications. METHODS: A retrospective review of the medical records of all patients who underwent cranioplasty for cranial bone defects during the period 2002-2012 was conducted, and 100 consecutive cranioplasty procedures that met eligibility criteria were identified. Patients were analyzed in 4 groups, which were created based on the cranioplasty material: autograft (n = 20), bioactive fiber-reinforced composite (n = 20), hydroxyapatite (n = 31), and other synthetic materials (n = 29). Survival estimates were constructed with Kaplan-Meier curves, and the differences between categorical variable levels were determined using a log-rank test. Multiple comparisons were adjusted using a Sidák correction. RESULTS: During a median follow-up time of 14 months (interquartile range 3-39 months), 32 of 100 patients (32.0%) developed at least 1 complication. A minor complication occurred in 13 patients (13.0%), whereas 19 patients (19.0%) developed a major complication, which required reoperation or removal of the implant. In the autograft subgroup, 40.0% of patients required removal of the cranioplasty. The 3-year survival of the autograft subgroup was lower compared with other subgroups of synthetic materials. In hydroxyapatite and bioactive fiber-reinforced composite groups, fewer complications were observed compared with the autograft group. CONCLUSIONS: Based on these results, synthetic materials for cranial bone defect reconstruction exhibit more promising outcomes compared with autograft. There were differences in survival rates among synthetic materials.

Quantitative assessment of post-operative recurrence of chronic subdural haematoma using mean haematoma density.

PURPOSE: The purpose of this study was to establish a quantitative method with which to assess the post-operative recurrence of chronic subdural haematoma (CSDH). METHODS: CT scans were reviewed from 44 consecutive patients with CSDHs who underwent burr hole drainage between July 2008 and January 2012. The area of the haematoma was quantified according to the mean haematoma density (MHD) using computer-based image analysis of pre-operative brain CT scans. MHD as well as other variables of patients with and without post-operative recurrences was statistically compared. RESULTS: Post-operative recurrence was noted in six of the 44 patients that underwent surgical procedures. Among these variables, high MHD, separated type and bilateral and skull base involvement of CSDHs were shown to be significantly related to post-operative recurrence (p < 0.05). Controlling for separated type in logistic regression analysis revealed the OR of MHD as statistically significant indicators with a p value of less than 0.05 (OR = 1.243; 95% CI = 1.003-1.54). CONCLUSION: This study provides statistical proof that MHD is a significant, independent, prognostic factor for the post-operative recurrence of CSDH. As such, consideration of MHD could aid in the prediction of post-operative prognosis of CSDHs.

Comprehensive assessment of 1-year outcomes and determination of minimum clinically important difference in pain, disability, and quality of life after suboccipital decompression for Chiari malformation I in adults.

BACKGROUND: To date, there has been no study to comprehensively assess the effectiveness of suboccipital craniectomy (SOC) for Chiari malformation I (CMI) using validated patient-reported outcome measures. OBJECTIVE: To determine the effectiveness and minimum clinically important difference thresholds of SOC for the treatment of adult patients with CMI using patient-reported outcome metrics. METHODS: Fifty patients undergoing first-time SOC and C1 laminectomy for CMI at a single institution were followed up for 1 year. Baseline and 1-year postoperative pain, disability, quality of life, patient satisfaction, and return to work were assessed. Minimum clinically important difference thresholds were calculated with 2 anchors: the Health Transition Index and North American Spine Society satisfaction questionnaire. RESULTS: The severity of headaches improved in 37 patients (74%). Improvement in syrinx size was seen in 12 patients (63%) and myelopathy in 12 patients (60%). All patient-reported outcomes showed significant improvement 1 year postoperatively (P < .05). Of the 38 patients (76%) employed preoperatively, 29 (76%) returned to work postoperatively at a median time of 6 weeks (interquartile range, 4-12 weeks). Minimum clinically important difference thresholds after SOC for CMI were 4.4 points for numeric rating scale for headache, 0.7 points for numeric rating scale for neck pain, 13.8 percentage points for Headache Disability Index, 14.2 percentage points for Neck Disability Index, 7.0 points for Short Form-12 Physical Component Summary, 6.1 points for Short Form-12 Mental Component Summary, 4.5 points for Zung depression, 1.7 points for modified Japanese Orthopaedic Association, and 0.34 quality-adjusted life-years for Euro-Qol-5D. CONCLUSION: Surgical management of CMI in adults via SOC provides significant and sustained improvement in pain, disability, general health, and quality of life as assessed by patient-reported outcomes. This patient-centered assessment suggests that suboccipital decompression for CMI in adults is an effective treatment strategy.

Autologous bone flap versus hydroxyapatite prosthesis in first intention in secondary cranioplasty after decompressive craniectomy: a French medico-economical study.

BACKGROUND AND PURPOSE: Decompressive craniectomy is the most common justification for cranioplasty. A medico-economial study based on the effective cost of the hydroxyapatite prosthesis, the percentage of autologous bone graft's loss due to bacterial contamination and the healthcare reimbursment, will allow us to define the best strategy in term of Healthcare economy management for the cranioplasties. A comparison was made between the two groups of patients, autologous bone flap versus custom-made prosthesis in first intention, based on the clinical experience of our department of neurosurgery. RESULTS: No differences was shown between the two groups of patients, in terms of lenght of in-hospital stay and population's characteristics or medical codification. The mean cost of a cranioplasty using the autologous bone graft in first intention was €4045, while the use of hydroxyapatite prosthesis led to a cost of €8000 per cranioplasty. CONCLUSION: In term of Healthcare expenses, autologous bone flap should be used in first intention for cranioplasties, unless the flap is contaminated or in specific indications, when the 3D custom-made hydroxyapatite prosthesis should be privilegied.

Decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a mixed methods exploration of carer experience and level of burden.

PURPOSE: This study explores the experiences and sense of burden of family carers of survivors of malignant middle cerebral artery infarctions who had undergone decompressive hemicraniectomy. To date, there have been no studies examining carer outcomes among this unique population. This study, taken alongside an already published study of survivor outcomes, provides a more holistic picture with regard to sequelae within the sample. METHOD: Six family carers completed the Sense of Competence Questionnaire and the Hospital Anxiety and Depression Scale. These results were compared with existing normative data. Carers also consented to a semi-structured interview. Interview data were examined using thematic content analysis. Consistent with the mixed methods design, quantitative and qualitative findings were integrated for further analysis. RESULTS: While carers experienced many losses, their overall sense of burden was not outside 'Average' limits, nor did they experience clinically significant symptoms of depression. All carers identified methods of coping with the demands of caregiving. These included intrapersonal, interpersonal and practical strategies. All carers apart from one were able to identify areas of post-traumatic growth. CONCLUSION: Carers will benefit from information, support and care. In addition, problem solving skills are essential in managing the myriad difficulties that arise in the aftermath of stroke.

Cost-effectiveness of decompressive craniectomy as a lifesaving rescue procedure for patients with severe traumatic brain injury.

BACKGROUND: Decompressive craniectomy has been traditionally used as a lifesaving rescue procedure for patients with refractory intracranial hypertension after severe traumatic brain injury (TBI), but its cost-effectiveness remains uncertain. METHODS: Using data on length of stay in hospital, rehabilitation facility, procedural costs, and Glasgow Outcome Scale (GOS) up to 18 months after surgery, the average total hospital costs per life-year and quality-adjusted life-year (QALY) were calculated for patients who had decompressive craniectomy for TBI between 2004 and 2010 in Western Australia. The Corticosteroid Randomisation After Significant Head Injury prediction model was used to quantify the severity of TBI. RESULTS: Of the 168 patients who had 18-month follow-up data available after the procedure, 70 (42%) achieved a good outcome (GOS-5), 27 (16%) had moderate disability (GOS-4), 34 (20%) had severe disability (GOS-3), 5 (3%) were in vegetative state (GOS-2), and 32 (19%) died (GOS-1). The hospital costs increased with the severity of TBI and peaked when the predicted risk of an unfavorable outcome was about 80%. The average cost per life-year gained (US$671,000 per life-year) and QALY (US$682,000 per QALY) increased substantially and became much more than the usual acceptable cost-effective limit (US$100,000 per QALY) when the predicted risk of an unfavorable outcome was >80%. Changing different underlying assumptions of the analysis did not change the results significantly. CONCLUSIONS: Severity of TBI had an important effect on cost-effectiveness of decompressive craniectomy. As a lifesaving procedure, decompressive craniectomy was not cost-effective for patients with extremely severe TBI.

Placement of silicone sheeting at decompressive craniectomy to prevent adhesions at cranioplasty.

Adhesion formation between dura mater and cortex, and the overlying temporalis muscle and galea following decompressive craniectomy, can make subsequent cranioplasty difficult and adds to the risks of the procedure. We describe the implantation of sterile silicone sheeting at decompressive craniectomy to prevent adhesion formation and facilitate subsequent cranioplasty, potentially reducing surgical time, improving outcome and reducing risk.