Decompressive Craniectomy with or Without Dural Closure: Systematic Review and Meta-analysis.

Decompressive craniectomy is used to alleviate intracranial pressure in cases of traumatic brain injury and stroke by removing part of the skull to allow brain expansion. Traditionally, this procedure is followed by a watertight dural suture, although evidence supporting this method is not strong. This meta-analysis examines the feasibility of the open-dura (OD) approach versus the traditional closed-dura (CD) technique with watertight suturing. A systematic review and comparative meta-analysis were conducted on OD and CD dural closure techniques. Medline, Embase, and Cochrane were searched for relevant trials. The primary end point was the rate of complications, with specific analyses for infection and cerebrospinal fluid (CSF) leaks. Mortality, poor neurological outcomes, and operation duration were also assessed. Odds ratios with 95% confidence intervals (CIs) were calculated using a random-effects model. Following a comprehensive search, 930 studies were screened, from which four studies and a total of 368 patients were ultimately selected. The primary outcome analysis showed a reduced likelihood of complications in the OD group when compared with the CD group (368 patients, odds ratio 0.54 [95% CI 0.32-0.90]; I2 = 17%; p < 0.05). Specific analysis of infections and CSF leaks did not show statistically significant results, as well as the evaluation of the mortality rates and poor neurological outcome differences between groups. Assessment of operation duration, however, demonstrated a significant difference between techniques, with a mean reduction of 52.50 min favoring the OD approach (mean difference - 52.50 [95% CI - 92.13 to - 12.87]; I2 = 96%). This study supports the viability of decompressive craniectomy without the conventional time-spending watertight duraplasty closure, exhibiting no differences in the rate of infections or CSF leaks. Furthermore, this approach has been associated with improved rates of complications and faster surgery, which are important aspects of this technique, particularly in its potential to reduce both costs and procedure length.

Decompressive Craniectomy in Patients with Malignant Stroke with Additional Vascular Territory.

BACKGROUND: Decompressive craniectomy substantially reduces mortality and disability rates following a malignant stroke. This procedure remains a life-saving option, especially in contexts with little access to mechanical thrombectomy despite downward trends in the performance of decompressive craniectomy due to discussions on the acceptance of living with severe disabilities. However, the outcomes of the surgery in cases involving concomitant occlusion of anterior or posterior cerebral arteries have not been extensively studied. METHODS: In this retrospective cohort study, spanning January 2010 to December 2022 and including patients who underwent decompressive craniectomy, we compared outcomes between patients with and without additional vascular territory involvement. Independent variables included age, sex, comorbidities, admission National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, time elapsed between stroke and surgery, laterality of the stroke, midline shift, and postoperative infarction volume. Outcomes included mortality and modified Rankin Score at the 3-month follow-up. RESULTS: Of the 86 patients analyzed, 61 (70.9%) and 25 (29.1%) demonstrated no territory and additional territory involvement, respectively. Patients with involvement of additional territories exhibited lower admission Glasgow Coma Scale scores, higher National Institutes of Health Stroke Scale scores, and larger postoperative infarction volumes. However, these variables were not associated with poor outcomes. Univariate analyses revealed no differences in mortality or severe disability. Even after adjustment, the differences remained insignificant for mortality and severe disability. Age emerged as the sole variable linked to increased mortality. CONCLUSIONS: Our data suggest that, for patients with malignant stroke undergoing decompressive craniectomy, the outcomes for patients with and without involvement of additional vascular territory are similar.

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)

New perspectives on assessment and understanding of the patient with cranial bone defect: a morphometric and cerebral radiodensity assessment.

Background: Skull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis. Methods: This is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis. Results: There was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = -0.4) and Barthel index (p = 0.035; r = -0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = -0.37). Conclusion: Morphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.

Partial Cranial Reconstruction Using Titanium Mesh after Craniectomy: An Antiadhesive and Protective Barrier with Improved Aesthetic Outcomes.

OBJECTIVE: Describe a new, safe, technique that uses titanium mesh to partially cover skull defects immediately after decompressive craniectomy (DC). METHODS: This study is a retrospective review of 8 patients who underwent DC and placement of a titanium mesh. The mesh partially covered the defect and was placed between the temporalis muscle and the dura graft. The muscle was sutured to the mesh. All patients underwent cranioplasty at a later time. The study recorded and analyzed demographic information, time between surgeries, extra-axial fluid collections, postoperative infections, need for reoperation, cortical hemorrhages, and functional and aesthetic outcomes. RESULTS: After craniectomy, all patients underwent cranioplasty within an average of 112.5 days (30-240 days). One patient reported temporalis muscle atrophy, which was the only complication observed. During the cranioplasties, no adhesions were found between temporalis muscle, titanium mesh, and underlying dura. None of the patients showed complications in the follow-up computerized tomography scans. All patients had favorable aesthetic and functional results. CONCLUSIONS: Placing a titanium mesh as an extra step during DC could have antiadhesive and protective properties, facilitating subsequent cranioplasty by preventing adhesions and providing a clear surgical plane between the temporalis muscle and intracranial tissues. This technique also helps preserve the temporalis muscle and enhances functional and aesthetic outcomes postcranioplasty. Therefore, it represents a safe alternative to other synthetic anti-adhesive materials. Further studies are necessary to draw definitive conclusions and elucidate long-term outcomes, however, the results obtained hold great promise for the safety and efficacy of this technique.

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.

Decompressive Craniectomy in Extensive Ischemic Stroke. An Experience in a Single Institution / Craniectomia descompressiva no acidente vascular cerebral isquêmico extenso. Uma experiência em uma única instituição

Introduction Decompressive craniectomy (DC) is a valuable treatment for reducing early lethality in malignant intracranial hypertension (IH); however, it has been shown that the decision to implement DC in patients with extensive ischemic stroke should not be based solely on the detection of IH with the use of intracranial pressure (ICP) devices. Objective To establish the usefulness of DC in patients with extensive ischemic stroke who came to the emergency room during the period between May 2018 and March 2019. Methods This was an analytical, prospective, and longitudinal study whose population corresponded to all patients with a diagnosis of extensive ischemic stroke. Results The sample consisted of 5 patients, of which 3 were female and 2 males, the average age was 62.2 years old (minimum 49 years old, maximum 77 years old). Of all the patients who underwent DC, it was found that 80% of the patients did not present an increase in intracranial pressure. Decompressive craniectomy was not performed in a case that responded adequately to medical treatment. The mean values of ICP were 25 mmHg with a minimum value of 20 mmHg and a maximum value of 25 mmHg; in patients with a moderate value, the ICP averages were < 20 mmHg. The mortality was of 40% (RANKIN of 6 points). Conclusions Decompressive craniectomy is useful in extensive ischemic stroke. The decision to implement DC in patients with extensive stroke rests on clinicoradiological parameters. The monitoring of the IPC was not particularly useful in the early detection of the neurological deterioration of the patients studied.

Fundamento A craniectomia descompressiva (CD) é um tratamento valioso para reduzir a letalidade precoce na hipertensão intracraniana (HI) maligna; no entanto, foi demonstrado que a decisão de implementar a CD em pacientes com acidente vascular cerebral (AVC) isquêmico extenso não deve ser baseada apenas na detecção de HI com o uso de dispositivos de pressão intracraniana (PIC). Objetivo Estabelecer a utilidade da CD em pacientes com AVC isquêmico extenso que chegaram ao pronto-socorro no período entre maio de 2018 e março de 2019. Métodos Foi realizado um estudo analítico, prospectivo e longitudinal cuja população correspondeu a todos os pacientes com diagnóstico de AVC isquêmico extenso. Resultados A amostra foi composta por 5 pacientes, sendo 3 do sexo feminino e 2 do sexo masculino, com média de idade de 62,2 anos (mínimo 49 anos, máximo 77 anos). De todos os pacientes que realizaram CD, verificou-se que 80% dos pacientes não apresentaram aumento da pressão intracraniana. Não foi realizada uma CD que tenha respondido adequadamente ao tratamento médico. Os valores médios de pressão intracraniana foram de 25 mmHg, com o valor mínimo de 20 mmHg e o valor máximo de 25 mmHg; em pacientes com escala moderada, as médias de PIC foram < 20 mm Hg. A mortalidade foi de 40% (RANKIN de 6 pontos). Conclusões A DC é útil no AVC isquêmico extenso. A decisão de implementar uma CD em pacientes com AVC extenso depende de parâmetros clínico-radiológicos. O monitoramento do PCI não foi muito útil na detecção precoce da deterioração neurológica dos pacientes estudados.

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.

Outcomes of decompressive craniectomy for malignant middle cerebral artery stroke in an academic hospital in Brazil / Desfechos da craniectomia descompressiva para infarto maligno da artéria cerebral média em um hospital acadêmico no Brasil

Abstract Background Ischemic stroke is an important cause of death in the world. The malignant middle cerebral artery infarction (MMCAI) has mortality as high as 80% when clinically treated. In this setting, decompressive craniectomy is a life-saving measure, in spite of high morbidity among survivors. Objective To evaluate the outcomes of patients with MMCAI treated with decompressive craniectomy in a Brazilian academic tertiary stroke center. Methods A prospective stroke database was retrospectively evaluated, and all patients treated with decompressive craniectomy for MMCAI between January 2014 and December 2017 were included. The demographics and clinical characteristics were evaluated. The functional outcome, measured by the modified Rankin Scale (mRS), was assessed at hospital discharge, after 3-months and 1-year of follow-up. Results We included 53 patients on the final analysis. The mean age was 54.6 ± 11.6 years and 64.2% were males. The median time from symptoms to admission was 4.8 (3-9.7) hours and the mean time from symptoms to surgery was 36 ± 17 hours. The left hemisphere was the affected in 39.6%. The median NIHSS at admission was 20 (16-24). The in-hospital mortality was 30.2%. After a median of 337 [157-393] days, 47.1% of patients had achieved favorable outcome (mRS ≤ 4) and 39.6% had died. Conclusion Decompressive craniectomy is a life-saving measure in the setting of MMCAI, and its effects remains important in the scenario of a middle-income country in real-world situations.

Resumo Antecedentes O acidente vascular cerebral (AVC) isquêmico é uma causa importante da morte em todo o mundo. O infarto maligno da artéria cerebral média (IMACM) tem mortalidade de até 80% quando tratado clinicamente. Nesse contexto, a craniectomia descompressiva é uma medida salvadora de vidas, apesar da alta morbidade entre os sobreviventes. Objetivo Avaliar os desfechos dos pacientes com IMACM tratados com craniectomia descompressiva em um centro acadêmico terciário de AVC no Brasil. Métodos Um banco de dados prospectivo de AVC foi avaliado retrospectivamente e todos os pacientes tratados com craniectomia descompressiva para IMACM entre janeiro de 2014 e dezembro de 2017 foram incluídos. As características clínicas e demográficas foram avaliadas. Os desfechos funcionais, medidos pela escala modificada da Rankin (mRS), foram avaliados na alta hospitalar, após 3 meses e após 1 ano de seguimento. Resultados Foram incluídos 53 pacientes na análise final. A idade média foi 54,6 ± 11,6 anos e 64,2% eram homens. A mediana do tempo dos sintomas à admissão foi 4,8 (3-9,7) horas e o tempo médio dos sintomas à cirurgia foi 36 ± 17 horas. O hemisfério esquerdo foi o afetado em 39,6%. A pontuação na escala de AVC do National Institute of Health (NIHSS) à admissão foi 20 (16-24). A mortalidade hospitalar foi 30,2%. Após uma mediana de 337 (157-393) dias, 47,1% dos pacientes tinham atingido um desfecho favorável (mRS ≤ 4) e 39,6% tinham morrido. Conclusão Craniectomia descompressiva é uma medida salvadora de vidas no contexto do IMACM e seus efeitos permanecem importantes no cenário de um país em desenvolvimento em situação de vida real.

Long-Term Pediatric Outcomes of Decompressive Craniectomy after Severe Traumatic Brain Injury.

OBJECTIVE: There is no consensus on the use of decompressive craniectomy (DC) to manage severe traumatic brain injury (sTBI). We evaluated the profile of pediatric patients admitted with sTBI and assessed functional outcomes, 6 months posttrauma, in patients who had a DC and in those who had not, and the functional outcomes of early versus late DCs. PATIENTS AND METHODS: This case-control observational study evaluated pediatric patients admitted for sTBI in Puerto Rico (June 2016-October 2018); we included patients admitted within 24 hours of injury and had a Glasgow Coma Scale (GCS) of 8 or lower. 6-month post trauma outcomes were measured with the Glasgow Outcome Scale Extended Pediatric (GOS-E Peds). RESULTS: 20 patients were included; 15 underwent a DC and 5 comprised the control group. We found no differences in terms of sex, age, GCS score, Pediatric Risk of Mortality score, or Pediatric Trauma Score. However, in the DC group, a higher percentage of patients presented significant cerebral herniation in the initial computed tomography scan (CT) (DC: 73%; control: 0%; P = .005). No differences were found regarding intracranial pressure (ICP), cerebral perfusion pressure, mean arterial pressure, PaCO2, or temperature. Patients in the DC group had longer hospital stay (DC: 41; control: 17 days; P = .0005). All patients with DC survived, with an early procedure being associated with favorable outcomes. CONCLUSION: As determined 6 months post-trauma, this study showed that early DC increased survival and improved functionality.

Time course of hemispheric cerebral volume after decompressive craniectomy in malignant middle cerebral artery stroke / Evolução temporal do volume hemisférico cerebral após craniectomia descompressiva em infarto maligno de artéria cerebral média

Abstract Background Brain edema is the leading cause of death in patients with malignant middle cerebral artery (MCA) infarction. Midline shift (MLS) has been used as a monohemispheric brain edema marker in several studies; however, it does not precisely measure brain edema. It is now possible to directly measure hemisphere brain volume. Knowledge about the time course of brain edema after malignant middle cerebral artery infarction may contribute to the condition's management. Objective Therefore, our goal was to evaluate the course of brain edema in patients with malignant MCA infarction treated with decompressive craniectomy (DC) using hemispheric volumetric measurements. Methods Patients were selected consecutively from a single tertiary hospital between 2013 and 2019. All patients were diagnosed with malignant middle cerebral artery infarction and underwent a decompressive craniectomy (DC) to treat the ischemic event. All computed tomography (CT) exams performed during the clinical care of these patients were analyzed, and the whole ischemic hemisphere volume was calculated for each CT scan. Results We analyzed 43 patients (197 CT exams). Patients' mean age at DC was 51.72 [range: 42-68] years. The mean time between the ischemic ictus and DC was 41.88 (range: 6-77) hours. The mean time between the ischemic event and the peak of hemisphere volume was 168.84 (95% confidence interval [142.08, 195.59]) hours. Conclusion In conclusion, the peak of cerebral edema in malignant MCA infarction after DC occurred on the 7th day (168.84 h) after stroke symptoms onset. Further studies evaluating therapies for brain edema even after DC should be investigated.

Resumo Antecedentes O edema cerebral é a principal causa de morte em pacientes com infarto maligno de artéria cerebral média. O desvio da linha média tem sido utilizado como marcador de edema cerebral mono-hemisférico em alguns estudos; porém, ele não mede de forma precisa o edema cerebral. Atualmente é possível mensurar diretamente o volume do hemisfério cerebral. O conhecimento sobre a evolução temporal do edema cerebral após infartos malignos da artéria cerebral média pode contribuir para o cuidado clínico desta condição. Objetivo Nosso objetivo é avaliar o edema hemisférico ao longo do tempo, em pacientes com infarto maligno da artéria cerebral média, tratados com craniectomia descompressiva. Métodos Os pacientes foram selecionados de forma consecutiva, em um hospital terciário, entre 2013 e 2019. Todos os pacientes apresentavam diagnóstico de infarto maligno de artéria cerebral média e foram submetidos a craniectomia descompressiva. Todas as tomografias computadorizadas de crânio destes pacientes foram analizadas, e o volume do hemisfério cerebral infartado foi mensurado. Resultados Analisamos 43 pacientes (197 tomografias de crânio). A idade média dos pacientes na craniectomia descompressiva foi 51,72 (42-68) anos. O tempo médio entre o ictus e a craniectomia descompressiva foi 41,88 (6-77) horas. O tempo médio entre o ictus e o pico do volume hemisférico foi 168,84 (142,08-195,59) horas. Conclusão O pico do volume cerebral em pacientes com infarto maligno de artéria cerebral média submetidos a craniectomia descompressiva ocorreu no 7o dia (168,84 horas) após o infarto. Mais estudos avaliando terapêuticas direcionadas ao edema cerebral seriam úteis neste contexto.

Functional improvements associated with cranioplasty after stroke and traumatic brain injury: a cohort study.

OBJECTIVE: Decompressive craniectomy is part of the acute management of several neurosurgical illnesses, and is commonly followed by cranioplasty. Data are still scarce on the functional and cognitive outcomes following cranioplasty. We aim to evaluate these outcomes in patients who underwent cranioplasty following traumatic brain injury (TBI) or stroke. METHODS: In this prospective cohort, we assessed 1-month and 6-month neuropsychological and functional outcomes in TBI and stroke patients who underwent cranioplasty at a Brazilian tertiary center. The primary outcome was the change in the Digits Test at 1 and 6 months after cranioplasty. Repeated measures general linear models were employed to assess the patients' evolution and interactions with baseline characteristics. Effect size was estimated by the partial η2. RESULTS: A total of 20 TBI and 14 stroke patients were included (mean age 42 ± 14 years; 52.9% male; average schooling 9.5 ± 3.8 years; 91.2% right-handed). We found significant improvements in the Digits Tests up to 6 months after cranioplasty (p = 0.004, partial η2 = 0.183), as well as in attention, episodic memory, verbal fluency, working memory, inhibitory control, visuoconstructive and visuospatial abilities (partial η2 0.106-0.305). We found no interaction between the cranioplasty effect and age, sex or schooling. Patients submitted to cranioplasty earlier (<1 year) after injury had better outcomes. CONCLUSION: Cognitive and functional outcomes improved after cranioplasty following decompressive craniectomy for stroke or TBI. This effect was consistent regardless of age, sex, or education level and persisted after 6 months. Some degree of spontaneous improvement might have contributed to the results.

Intraparenchymal Hemorrhage after Cranioplasty in a Patient with Sinking Flap Syndrome.

Decompressive craniectomy has been increasingly used in recent decades for the treatment of uncontrollable intracranial hypertension caused by trauma, malignant strokes, cerebral venous thrombosis, among others. Sinking flap syndrome (SFS) is a rare complication characterized by neurological deterioration after craniectomy. Here, we report the case of a 73-year-old female patient who presented with disorientation, lip rhyme deviation to the right and left hemiparesis after cardiac catheterization. In view of the presence of a malignant stroke, as well as the willingness of the family members to make a total investment to save the patient's life, decompressive hemicraniectomy was indicated. Subsequently, due to occasional headache attacks, nausea and vomiting, in addition to progressive depression of the subcutaneous flap, the possibility of SFS was suggested and cranioplasty was indicated, which occurred without perioperative intercurrences. Although the patient maintained a stable neurological status, a post-surgical computed tomography (CT) scan of the head showed a right intraparenchymal hemorrhagic lesion, associated with parenchymal expansion and midline deviation. To the best of our knowledge, intraparenchymal hemorrhages are not common complications after performing cranioplasty, and additional studies are needed to understand the reasons why this occurs. The mechanisms responsible for this type of injury are not well understood, but involve reperfusion damage and loss of brain compliance. Despite representing an uncommon complication, post-cranioplasty hemorrhage can cause severe morbidity to the patient, and early diagnosis and intervention are of great importance in these cases.

Clinical evolution of dysphagic patients after malignant infarction and decompressive craniectomy: a case series / Evolução clínica de pacientes disfágicos pós-AVCi maligno e craniectomia descompressiva: série de casos

ABSTRACT This study aimed to characterize clinical-neurological factors and the functional swallowing capacity of patients with malignant infarction submitted to decompressive craniectomy during the hospital stay. This retrospective, descriptive, observational study was conducted between January 2020 and December 2021. The following data regarding up to eight stages were extracted for descriptive analysis: age, location of the lesion, level of awareness according to the Glasgow Coma Scale, neurological impairment according to the National Institutes of Health Stroke Scale, and the functional swallowing capacity according to the Functional Oral Intake Scale. Data on five patients were collected, with a mean of 0.2 days for the first neurological assessment. Decompressive craniectomy was performed in a mean of 2 days after admission. The speech-language-hearing assessment occurred in a mean of 8.2 days, and the speech-language-hearing discharge took a mean of 35.4 days. The neurological impairment score remained the same as in the first neurological assessment after decompressive craniectomy, with a mean score of 16.6. The functional swallowing capacity was the same in the first assessment after decompressive craniectomy, on FOIS level 1, improving considerably by the discharge, with a mean level of 4.8. It is concluded that clinical-neurological factors can interfere with the functional swallowing capacity, although they did not hinder either speech-language-hearing treatment or their evolution to a full oral diet during the hospital stay.

RESUMO O objetivo do presente trabalho é caracterizar fatores clínicos-neurológicos e capacidade funcional de deglutição de pacientes com Acidente Vascular Cerebral Isquêmico Maligno submetidos a craniectomia descompressiva durante internação hospitalar. Trata-se de um estudo observacional, descritivo e retrospectivo, realizado de janeiro de 2020 a dezembro de 2021. Os dados foram extraídos em até oito momentos, incluindo idade, local da lesão, nível de consciência de acordo com Glasgow, comprometimento neurológico pelo National Institutes of Health Stroke Scale e capacidade funcional de deglutição pela Escala Funcional de Ingestão por Via Oral. Realizou-se análise descritiva. Foram coletados dados de 5 pacientes sendo a média de tempo para primeira avaliação neurológica de 0,2 dias. A realização da craniectomia descompressiva levou em média 2 dias após admissão. Avaliação fonoaudiológica ocorreu, em média, 8,2 dias e alta fonoaudiológica levou, em média, 35,4 dias. O comprometimento neurológico manteve-se na pontuação da primeira avaliação neurológica pós-craniectomia descompressiva, média de 16,6. A capacidade funcional de deglutição foi a mesma na primeira avaliação pós-craniectomia descompressiva, com nível 1 na FOIS, melhorando consideravelmente, com média de nível 4,8, na alta. Concluiu-se que fatores clínicos-neurológicos podem interferir na capacidade funcional de deglutição, contudo não limitaram a atuação fonoaudiológica e evolução com dieta oral exclusiva na internação hospitalar.

Characteristics and Long-Term Outcome of Cerebellar Strokes in a Single Health Care Facility in Mexico.

Objective The purpose of this study was to analyze and discuss the clinical characteristics, long-term outcome, and prognostic factors of cerebellar strokes treated in a single health care facility in Mexico. Methods We retrospectively reviewed the medical records of adult patients admitted to our hospital with diagnosis of cerebellar ischemic and hemorrhagic stroke between 2018 and 2020. Baseline data included sociodemographic and radiological variables, treatment (surgical versus conservative), and Glasgow Coma Scale on arrival (GCSOA). The final neurological outcome was evaluated with the Glasgow Outcome Scale (GOS) six months after hospital discharge. Results Ten patients (seven male and three female) with a mean age of 57.9 ± 9.3 years were included, six with cerebellar ischemic infarction and four with cerebellar hemorrhage. Out of the 10 patients, four underwent surgery (suboccipital decompressive craniectomy {SDC} ± ventriculostomy). The outcome was favorable in four cases (40%) and unfavorable in six (60%). Patients who underwent surgical treatment fared worse with all four cases associating poor outcome. The comparison between good and poor outcome groups showed significant differences in the presence of obstructive hydrocephalus (one versus six, p = 0.05) and poorer GCSOA (6.16 ± 1.72 versus 12.5 ± 3.6, p = 0.05), associating poorer outcome. Conclusion There is still controversy regarding the appropriate management of cerebellar strokes. The presence of obstructive hydrocephalus and poorer GCSOA are associated to worse outcomes.

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.

The reverse question mark and L.G. Kempe incisions for decompressive craniectomy: A case series and narrative review of the literature.

Background: Decompressive craniectomy (DC) is a lifesaving procedure, relieving intracranial hypertension. Conventionally, DCs are performed by a reverse question mark (RQM) incision. However, the use of the L. G. Kempe's (LGK) incision has increased in the last decade. We aim to describe the surgical nuances of the LGK and the standard RQM incisions to treat patients with severe traumatic brain injury (TBI), intracranial hemorrhage (ICH), empyema, and malignant ischemic stroke. Furthermore, to describe, surgical limitations, wound healing, and neurological outcomes related to each technique. Methods: To describe a prospective acquired, case series including patients who underwent a DC using either an RQM or an LGK incision in our institution between 2019 and 2020. Results: A total of 27 patients underwent DC. Of those, ten patients were enrolled. The mean age was 42.1 years (26-71), and 60% were male. Five patients underwent DC using a large RQM incision; three had severe TBI, one ICH, and one ischemic stroke. The other five patients underwent DC using an LGK incision (one ICH, one subdural empyema, and one ischemic stroke). About 50% of patients presented severe headaches associated with vomiting, and six presented altered mental status (drowsy or stuporous). Motor deficits were present in four cases. In patients with ischemic or hemorrhagic stroke, symptoms were directly related to the stroke location. Hospital stays varied between 13 and 22 days. No readmissions were recorded, and no fatal outcome was documented during the follow-up. Conclusion: The utility of the LGK incision is comparable with the classic RQM incision to treat acute brain injuries, where an urgent decompression must be performed. Some of these cases include malignant ischemic strokes, ICH, and empyema. No differences were observed between both techniques in terms of prevention of scalp necrosis and general cosmetic outcomes.

Role of the optic nerve sheath diameter in the assessment of the effectiveness of decompressive surgery after malignant middle cerebral artery infarction / Papel do diâmetro da bainha do nervo óptico na avaliação da eficácia da cirurgia descompressiva após infarto maligno da artéria cerebral média

Abstract Background After a case of stroke, intracranial pressure (ICP) must be measured and monitored, and the gold standard method for that is through an invasive technique using an intraventricular or intraparenchymal device. However, The ICP can also be assessed through a non-invasive method, comprised of the measurement of the optic nerve sheath diameter (ONSD) through ultrasound (US). Objective To evaluate the ICP of patients who underwent wide decompressive craniectomy after middle cerebral artery (MCA) infarction via preoperative and postoperative ONSD measurements. Methods A total of 17 patients, aged between 34 and 70 years, diagnosed with malignant MCA infarction with radiological edema and mid-line shift, who underwent decompressive surgery, were eligible. From the records, we collected data on age, sex, preoperative and postoperative Glasgow Coma Scale (GCS) scores, National Institutes of Health Stroke Scale (NIHSS) score, the degree of disability in the preoperative period and three months postoperatively through the scores on the Modified Rankin Scale (MRS), and the preoperative and postoperative midline shift measured by computed tomography (CT) scans of the brain. Results Preoperatively, the mean GCS score was of 8 (range: 7.7-9.2), whereas it was found to be of 12 (range 10-14) on the first postoperative day (p = 0.001). The mean preoperative NIHSS score was of 21.36 ± 2.70 and, on the first postoperative day, it was of 5.30 ± 0.75 (p < 0.001). As for the midline shift, the mean preoperative value was of 1.33 ± 0.75 cm, and, on the first postoperative day, 0.36 ± 0.40 cm (p < 0.001). And, regarding the ONSD, the mean preoperative measurement was of 5.5 ± 0.1 mm, and, on the first postoperative day, it was of 5 ± 0.9 mm (p < 0.001). Conclusion The ocular US measurement of the ONSD for the preoperative and postoperative monitoring of the ICP seems to be a practical and useful method.

Resumo Antecedentes Após um acidente vascular cerebral (AVC), a pressão intracraniana (PIC) deve ser medida e monitorada, e o método padrão-ouro para isso é um procedimento invasivo por meio de um dispositivo intraventricular ou intraparenquimal. No entanto, a PIC também pode ser avaliada por um método não invasivo, composto da medida do diâmetro da bainha do nervo óptico (DBNO) por ultrassom (US). Objetivo Avaliar a PIC de pacientes submetidos a craniectomia descompressiva ampla após infarto da artéria cerebral média (ACM) por meio das medidas do DBNO nos períodos pré e pós-operatório. Métodos Um total de 17 pacientes, com idades entre 34 e 70 anos, diagnosticados com infarto maligno da ACM com edema radiológico e deslocamento da linha média, e que foram submetidos a cirurgia descompressiva, eram elegíveis. A partir dos prontuários, coletamos informações relativas à idade, gênero, pontuações pré e pósoperatória na Escala de Coma de Glasgow (ECG), pontuação na escala de AVC dos National Institutes of Health (NIH), o grau de incapacidade no pré-operatório e após três meses da operação pelas pontuações na Escala de Rankin Modificada (ERM), e o desvio da linha média no pré e pós-operatório medido por tomografia computadorizada (TC) cerebral. Resultados No pré-operatório, a pontuação média na ECG foi de 8 (variação: 7,7-9,2), e, no primeiro dia do pós-operatório, 12 variação 10-14) (p = 0,001). A pontuação média na escala dos NIH foi de 21,36 ± 2,70 no pré-operatório, e de 5,30 ± 0,75 no primeiro dia de pós-operatório (p < 0,00 1). Quanto ao desvio da linha média, no préoperatório ele teve uma média de 1,33 ± 0,75 cm, e de 0,36 ± 0,40 cm no primeiro dia de pós-operatório (p < 0,001). E o DBNO apresentou uma média pré-operatória de 5,5 ± 0,1 mm, e de 5 ± 0,9 mm no primeiro dia de pós-operatório (p < 0,001). Conclusão A mensuração ocular do DBNO por US para o monitoramento da PIC no pré e no pós-operatório parece ser um método prático e útil.

Cerebral venous thrombosis / Trombose venosa cerebral

ABSTRACT Cerebral venous sinus thrombosis (CVT) consists of partial or complete occlusion of a sinus or a cerebral vein. CVT represents 0.5-1% of all strokes and is more frequent in young women. This review discusses particular aspects of CVT diagnosis and management: decompressive craniectomy (DC), anticoagulation with direct oral anticoagulants (DOACs), CVT after coronavirus-disease 19 (COVID-19) and Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT).

RESUMO A trombose venosa cerebral (TVC) consiste na oclusão parcial ou completa de um seio ou de uma veia cerebral. A TVC representa 0,5-1% das doenças cerebrovasculares e é mais frequente em mulheres jovens. Esta revisão discute aspectos específicos do diagnóstico e do manejo da TVC: craniectomia descompressiva (DC), anticoagulação com anticoagulantes orais diretos (DOACs), TVC após infecção por coronavírus (COVID-19) e Trombocitopenia Trombótica Imune Induzida por Vacina (VITT).