Surgical Strategy for Mitral Valve Infective Endocarditis with Concomitant Cerebral Hemorrhage and Disseminated Intravascular Coagulation Syndrome : Decompressive Craniotomy before Open-Heart Surgery / 日本心臓血管外科学会雑誌

A 51-year-old woman presented with a high fever and weakness and was diagnosed with mitral valve infective endocarditis. Medical treatment was unsuccessful, and the patient developed disseminated intravascular coagulation syndrome, multiple cerebral infarctions, and massive cerebral hemorrhage. She was transferred to our hospital for surgical treatment. On admission, she had motor aphasia and right-sided hemiplegia. Echocardiography showed mild mitral regurgitation with a huge mobile vegetation measuring greater than 20 mm on the anterior leaflets. Head CT showed a huge cerebral hemorrhage in the left frontal lobe. Chest radiography revealed severe pulmonary congestion, and laboratory data showed disseminated intravascular coagulation syndrome. Despite medical treatment, the pulmonary congestion worsened. There were concerns that a fatal cerebral infarction would develop, and so urgent open-heart surgery was performed. On the day after the cerebral hemorrhage had occurred, hematoma removal and decompressive craniotomy were performed to reduce the risks associated with cardiopulmonary bypass. Four days after the craniotomy, mitral valve plasty was performed following the complete excision of the infected tissue. Heparin was administered at our normal dosage as an anticoagulant during cardiopulmonary bypass. Postoperative head CT showed no aggravation of the preoperative cerebral lesion. The patient still had symptomatic epilepsy and difficulty performing exact movements with her right hand, but she was able to walk unaided after 1 year of rehabilitation. Generally, early surgery for infective endocarditis is not recommended if the patient has concomitant cerebral hemorrhage ; our strategy may be the safest option for patients in such a serious condition.

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).

The clinical analysis of two different surgical treatment on unilateral middle cerebral artery infarction / 中国基层医药

Objective To study the different effects on unilateral middle cerebral artery infarction with standard large trauma craniotomy and frontotemporal craniectomy and decompression treatment.Methods The clinical data of 56 patients with unilateral middle cerebral artery infarction were retrospectively analyzed.They were divided into the two groups according to the different operation methods,and compared the incidence of postoperative complications and GCS score after 1 week,GOS score after 1 month,and ADL score after 6 months and so on.Results The differences were significant between the two groups in incidence of postoperative complications [ incidence of rebleeding after the operation(A group 5 cases,B group 4 cases),showing of brain pools(A group 23 cases,B group 14 cases),lung infection(A group 7 cases,B group 13 cases),gastrointestinal bleeding(A group 8 cases,B group 17 cases),χ2 =0.579,4.703,8.606,7.081] and postoperative GCS score after a week[12 -15points(A group 5 cases,B group 2 cases),9-11points(A group 15 cases,B group 10 cases),5-8points(A group 6 cases,B group 8 cases),3-4points(A group 2 cases,B group 4 cases),death(A group 1 case,B group 3 cases),W value was 599.500,P=0.028] (all P0.05).Conclusion Standard large trauma craniotomy has features as decompression full,low early complication rate,and can improve the short-term efficacy of unilateral middle cerebral artery infarction in patients,and promote recovery.

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.

Value of standard large decompressive craniotomy in treating lateral fissure area damage of severe traumatic brain injury / 重庆医学

Objective To explore the standard large decompressive craniotomy in treatment severe traumatic brain injury lateral fissure area damage to the clinical curative effect and application value .Methods 56 patients with severe craniocerebral trauma lat-eral fissure area injury in our hospital from February 2010 to December 2012 were randomly divided into the standard group and the conventional group ,28 cases in each group ,and treated by the standard large decompressive craniotomy and routine big bone flap craniotomy hematoma removal respectively .The various index of clinical effect and prognosis were observed and compared between the two groups .Results The Glasgow coma score(GCS) on postoperative 3 ,7 d in the standard group were obviously higher than those in the conventional group ,but the intracranial pressure (ICP) ,midline shift and cerebral edema volume were significantly low-er than those in the the conventional group ,the differences had statistical significance (P< 0 .05) ,after 1 -year follow -up ,the GOS score and the survival rate in the standar group were significantly higher than those in the conventional group (P<0 .05) . Conclusion The effect of the standard large decompressive craniotomy for treating severe craniocerebral trauma lateral fissure area damage is superior to the conventional big bone flap craniotomy hematoma removal ,can effectively remove the hematoma ,reduce the intracranial pressure ,save the patient′s life and improve the quality of life ,which is worthy of clinical attention and promotion .

Decompressive craniotomy: prognostic factors and complications in 89 patients / Craniotomia descompressiva: análise de fatores prognósticos e complicações em 89 pacientes

Decompressive craniotomy (DC) is applied to treat post-traumatic intracranial hypertension (ICH). The purpose of this study is to identify prognostic factors and complications of unilateral DC. Eighty-nine patients submited to unilateral DC were retrospectively analyzed over a period of 30 months. Qui square independent test and Fisher test were used to identify prognostic factors. The majority of patients were male (87 percent). Traffic accidents had occurred in 47 percent of the cases. 64 percent of the patients had suffered severe head injury, while pupillary abnormalities were already present in 34 percent. Brain swelling plus acute subdural hematoma were the most common tomographic findings (64 percent). Complications occurred in 34.8 percent of the patients: subdural effusions in 10 (11.2 percent), hydrocephalus in 7 (7.9 percent) and infection in 14 (15.7 percent). The admittance Glasgow coma scale was a statistically significant predictor of outcome ( p=0.0309).

A craniotomia descompressiva (CD) é técnica utilizada para tratamento da hipertensão intracraniana (HIC) pós-traumática. O objetivo do estudo foi determinar fatores prognósticos e complicações nos pacientes submetidos a esta técnica. Realizou-se estudo retrospectivo de 89 pacientes submetidos à CD unilateral para tratamento da HIC pós-traumática durante 30 meses. Utilizou-se testes do Qui-quadrado de independência e teste exato de Fisher para análise de fatores independentes de prognóstico. A maioria dos pacientes era do sexo masculino (87 por cento). A causa mais comum foi o acidente de trânsito (47 por cento). A maioria apresentava traumatismo cranioencefálico grave (64 por cento), 34 por cento já apresentavam anisocoria. O achado tomográfico mais comum foi a associação entre tumefação cerebral e hematoma subdural agudo (64 por cento). Em 34,8 por cento dos pacientes houve complicações inerentes à técnica: coleção subdural (11,2 por cento), hidrocefalia (7,9 por cento) e infecção (15,7 por cento). A escala de coma de Glasgow à admissão correlacionou-se estatisticamente como fator prognóstico (p=0,0309).

Modified Decompressive Craniotomy for Control of Intracranial Pressure

OBJECTIVE: Various surgical techniques were developed for control of intracranial pressure such as extraventricular drainage, temporal lobectomy or decompressive craniectomy. We now describe our clinical experience by using the modified decompressive craniotomy. METHODS: Modified decompressive craniotomy was performed in 8 patients with severe cerebral edema from July 2000 to April 2001. The indication of this operation was severe intracranial hypertension and edema in operative field. We analyzed the result(Glasgow coma scale, GCS score, Glasgow outcome scale, GOS score) with the variables(age, sex, mid line shift on brain computed tomography scan) RESULTS: The overall rate of good recovery(GOS score 4 or 5) was 75%(6 of 8 patients), poor recovery(GOS score 2 or 3) was 12.5%(1 of 8 patients), and mortality rate was 12.5%(1 of 8 patients). All of survived patients had improved GCS score(mean: 10.02) compared to preoperative GCS score(mean: 7.82). CONCLUSION: The authors would like to recommend modified decompressive craniotomy for the patient of traumatic brain swelling in appropriate indication. This new operative technique has advantages such as decompressive effect and no need of delayed cranioplasty.