Surgical complications of decompressive craniectomy in patients with head injury.

INTRODUCTION: Decompressive craniectomy is an important method for managing refractory intracranial hypertension. Although decompressive craniectomy is a relatively simple procedure, various complications may arise. The aim of our paper was to determine the incidence of complications of decompressive craniectomy in patients with head injury and to analyse their risk factors. METHODS: We retrospectively analysed a group of 94 patients after decompressive craniectomy for head injury between 01 Jan 2014 and 31 Dec 2018. Postoperative complications were evaluated based on clinical examination and postoperative CT scan. The impact of potential risk factors on the occurrence of complications was assessed (age, worse initial clinical condition, any haemocoagulation disorder). RESULTS: Twenty patients died within the first month after surgery. Control CT scan showed one complication in 78 patients (83%), while 46 patients (49%) had more than one complication. We had to reoperate 22 patients (23.4%) due to a complication. The following complications were found: postoperative acute subgaleal/subdural haematoma (30× - 32%), subgaleal/subdural cerebrospinal fluid effusion (29× - 31%), soft tissues oedema (29× - 31%), haemorrhagic progression of brain contusion (17× - 18%), malignant brain oedema (8× - 8.5%), hydrocephalus (8× - 8.5%), temporal muscle atrophy (7× - 7.5%), peroperative massive bleeding ( 6× - 6.4%), epilepsy (4× - 4.3%), syndrome of the trephined (2× - 2.1%), skin necrosis (2× - 2.1%). Patients with a haemocoagulation disorder had a significantly higher incidence of complications (p=0.01). CONCLUSION: Complications of decompressive craniectomy after head injury are frequent. The potential benefit of decompressive craniectomy can be adversely affected by the occurrence of many complications.

[Radiation Necrosis in the Upper Cervical Spinal Cord in a Patient Treated with Proton Therapy after Radical Resection of the Fourth Ventricle Ependymoma]. / Radionekróza horní krcní míchy po protonovém ozárení u nemocné po radikální resekci ependymomu IV. komory mozkové.

BACKGROUND: Radiation necrosis in eloquent areas of the central nervous system (CNS) is one of the most serious forms of toxicity from radiation therapy. The occurrence of radiation necrosis in the CNS is described in a wide range of 3 months to 13 years after radiation therapy. The incidence of this complication covers a wide range of 3-47%. The potential advantage of proton therapy is the ability to reduce dose to normal tissue and escalate tumor dose. Proton beams enter and pass through the tissue with minimal dose deposition until they reach the end of their paths, where the peak of dose, known as the Bragg peak, occurs. Thereafter, a steep dose fall-off is evident. Such a precisely-distributed dose should reduce the toxicity of the treatment. PATIENT: A 23 year-old female patient underwent radical microsurgical resection of anaplastic ependymoma that originated from the floor of the fourth ventricle. The tumor was growing into the foramen magnum dorsally from the medulla oblongata. Taking into account the age of the patient, the localization of the tumor and the required dose of 60 Gy, proton therapy was chosen due to the lower risk of damage to the brain stem. Radiation therapy was performed using pencil beam scanning and one dorsal field. Following this course of treatment, radiation necrosis of the medulla oblongata and the upper cervical spinal cord occurred with fatal clinical impact on the patient. The article analyses possible causes of this complication and a review of the current literature is given. CONCLUSION: Despite the theoretical advantages of proton therapy, no clinical benefit in CNS tumors has yet been proven in comparison with modern methods of photon therapy. Proton therapy is accompanied by many uncertainties which can cause unpredictable complications, such as radiation necrosis at the edges of the target volume. Following proton therapy, there is not only a higher incidence of radiation necrosis but it occurs both sooner and to a higher degree. In cases of high anatomical complexity, the neurosurgeon should cooperate in the creation of the radiation treatment planning to ensure its optimization.Key words: brain tumors - ependymoma - radiation therapy - proton therapy - necrosis - radiation necrosis This work was partially supported by research project MH CZ - DRO (Faculty Hospital in Pilsen - FNPl, 00669806). The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 29. 6. 2017Accepted: 25. 7. 2017.

[The current technical possibilities of the peroperative safety advancement in the microsurgery of cerebral aneurysms - a review article]. / Soucasné technické moznosti zvýsení peroperacní bezpecnosti pri mikrochirurgii mozkových aneuryzmat - souhrnný referát.

The authors present the technical aspects of perioperative safety during the microsurgery of cerebral aneurysms. We evaluated the advantages and disadvantages of the microvascular Doppler ultrasonography, the intraoperative digital subtraction angiography, the intraoperative transit time flowmetry, the intraoperative monitoring - motor evoked potentials and somatosensory evoked potentials, and the ICG videoangiography. The authors, based on their own experience, recommend combining different methods to eliminate the weak points of the individual specific methods. Combining the ICG with the flowmetry and the motor evoked potentials enhances safety during the surgery of cerebral aneurysms with the resultant reduction of the perioperative morbidity/mortality.

[Current microsurgical and neurointerventional therapy of cerebral aneurysms]. / Soucasná mikrochirurgická a neurointervencní terapie mozkových aneuryzmat.

Cerebral aneurysms occur in 5% of the adult population. Their most severe clinical manifestation is subarachnoid haemorrhage occurring in half of the patients. Morbidity and mortality of subarachnoid hemorrhage is relatively high. Stopping blood flow into the aneurysmal sac is the treatment objective. The basic techniques to achieve this are closing the aneurysmal neck with a clip - clipping - and the induction of intraaneurysmal thrombosis using platinum coils - coiling. Fusiform and giant aneurysms represent a technical challenge. The solution for indicated cases is the occlusion of the magistral artery along with a high-flow bypass. A new option is the use of special stents - flow-diverters - in unruptured aneurysms. The authors present the current view on the treatment of both ruptured and unruptured aneurysms. At the same time the authors focus on factors that influence the application of up-to-date knowledge on everyday activities in their departments.

[Simultaneous carotid endarterectomy and coronary revascularization: indications and results]. / Simultánní karotická endarterektomie a koronární revaskularizace: indikace a výsledky.

AIM: Evaluation of operative results and complications in high-risk patients who underwent combined carotid and coronary revascularization. PATIENTS AND METHODS: Combined operation--carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) was performed in the period 2000-2009 in 68 patients. Simultaneous operation was indicated in patients with unstable angina pectoris and 1. symtomatic internal carotid artery (ICA) stenosis > or = 50%, or 2. bilateral asymptomatic ICA stenosis > or = 60% or 3. asymptomatic ICA stenosis > or = 60% combined with contralateral ICA occlusion. Combined operations represented 5.8% of whole CEA series. Mean age was 69.9 (51-82) years, men were 46, women 22. Carotid angiography proved unilateral (always symptomatic) ICA stenosis in 25 patients, bilateral ICA stenosis in 35 patients and ICA stenosis combined with contralateral carotid occlusion in 8 patients. Neurological preoperative symptomatology: TIA was present in u 20 patients, minor stroke in 6 and major stroke in 5 patients. 37 patients were asymptomatic. One CABG was performed in 5 patients, 2 CABG in 20 patients, 3 CABG in 19 patients and 4 CABG in 6 patients. The rest of 18 patients had CABG operation combined with valve procedure. Comorbidity: hypertension 100%, diabetes mellitus 57.3%, hyperlipidemia 60.3%. Shunt was selectively used in 4.4%. The need for shunt was established using back stump pressure and near infrared spectroscopy. RESULTS: Mortality was 8.8% (6/68). The cause of death were multiorgan failure in two cases, ipsilateral stroke in two patients, respiratory insufficiency and cardiac failure due to graft occlusion both in one patient. Good recovery was recorded in 91.2%. CONCLUSION: Combined carotid and coronary revascularization has acceptable neurological morbidity/mortality in high risk patients. Strict requirement is thorough selection of patients.

Endarterectomy for asymptomatic carotid artery stenosis under local anaesthesia.

BACKGROUND: In this article, we present our experience with such operations performed under local anaesthesia. METHODS: From January 1997 to November 2007, there were 387 patients operated on for asymptomatic carotid stenosis. Patient data were retrospectively evaluated. Thirty-day neurological morbidity and mortality from six different subgroups were analysed and compared. The numbers of perioperative transient ischaemic attacks, as well as surgical and other perioperative complications were also evaluated. RESULTS: Overall morbidity and mortality was 1.8% (seven patients). Stroke was noted in 1.3% (five patients). Transitory ischaemic attacks within the first 30 days were observed in 1.6% (six patients). Only those patients who had intraluminal shunt insertion were found to have significantly higher morbidity and mortality. (p = 0.000018). Myocardial infarction was observed in 0.5% (two patients), one fatal. CONCLUSION: We have achieved acceptable morbidity and mortality rates (1.8%) according to the parameters set by previous studies such as Asymptomatic Carotid Atherosclerosis Study and Asymptomatic Carotid Stenosis Trial as well as American Heart Association and European Stroke Organisation guidelines. All surgeries were done under local anaesthesia. Shunts were inserted in 22 cases (5.68%).

[Augmentation of decompressive craniectomy using COM 30 bandage in the treatment of refractory intracranial hypertension]. / Augmentace dekompresivní kraniektomie obvazovou textilií COM 30 v terapii refrakterní nitrolební hypertenze--kazuistika.

Authors present case-report of 29-year old man with acute subdural hematoma and contusions in right basal frontotemporal area. Despite adequate conservative treatment and surgical therapy (hematoma evacuation and decompressive craniectomy) uncontrollable intracranial hypertension occurred 4th postoperative day. Situation has been effectively solved by resection of hemorrhagic temporal muscle together with duroplasty (fascia lata) and skin plastics using combined dressing fabric COM 30. Fabric was removed after eleven days followed skin suturing. Clinical status after four months is favorable, the patient is without neurological deficit. Bone flap return is planned.

[Spinal cord stab injury associated with modified Brown-Séquard syndrome symptoms--a case review and literature overview]. / Bodné poranení míchy s projevy modifikovovaného Brown-Séquardova syndromu--kazuistika a prehled literatury.

Authors present case-report of young man with incomplete spinal cord injury after penetrating stab wound. Knife blade entered the skin in the level C3/4 in the back of the neck and directed to the right and downward. Both dorsal spinal cord columns and right half of spinal cord were transected. Neurological presentation was Brown-Séquard syndrome combined with dorsal columns syndrome. Wound revision was performed followed by dural closure. 18 month after injury significant neurological improvement of right hemiparesis was recorded and the patient is self-sufficient. Spinal cord stab wounds are rare. Typical clinical symptomatology is incomplete spinal cord injury. Clinical improvement of Brown-Séquard syndrome in our patient entirely corelates with literature.

[Ocular symptoms as an indication for carotid endarterectomy]. / Okulární symptomy jako indikace karotické endarterektomie.

Ocular symptoms can be the first sign of carotid artery stenosis. In our carotid endarterectomy patients group were ocular symptoms present in 15%, as the only sign (without accompanying neurological signs) in 10.5%. Amaurosis fugax was a dominant sign in 56 cases, blindness in 5, quadrantanopia in 3; trochlear and oculomotor nerve paresis in one case. Angiography finding of more than 60% ICA stenosis according NASCET criteria was an indication for surgery. The operative technique per se was a microsurgical endarterectomy with selective peroperative shunt application. The 30-d morbidity was 3%--with one case of central retinal artery embolization and subsequent blindness and another case of major residual neurological deficit due to hyperperfusion syndrome and the resultant capsular hemorrhage. Shunt was applied in 3% of cases and microscope was used always since the beginning of the dissection up to the final suture. Considering low perioperative morbidity/mortality rates the carotid endarterectomy represents an important means of brain ischaemia profylaxis. In the process of hemodynamically significant ICA stenosis, indication for surgical management the authors emphasize the role of ocular signs and symptoms and thus the importance of an ophthalmology consultant.

[Compound depressed fracture of occipital bone causing laceration of left occipital lobe and injury of superior sagittal sinus--case report]. / Impresivní zlomenina týlní supiny s lacerací mozku a poranenim sinus sagitalis superior--kazuistika.

A case of compound depressed fracture of occipital bone in 52-years old man caused by crane hook is presented. Bone fragments were depressed 40 millimetres causing blindeness and huge hemorrhage with symptoms of hemorrhagic shock. Laceration of left occipital lobe and penetration of superior sagittal sinus were treated during the operation. Primary elevation, debridement and primary bone replacement with additional covering of bone defect by bone cement were performed. Primary wound healing was achieved. Cortical blindeness subsided to the stage of contralateral homonymous hemianopia.

[Comments on eversion technique of carotid endarterectomy]. / Poznámky k technice everzní karotické endarterektomie.

The authors describe their own modification of carotid endarterectomy by eversion technique which they use in the case of combined stenosis and kinking of internal carotid artery. Complete division of internal carotid artery from the common carotid artery at the bulb is performed in an oblique fashion, following by excision of redundant wall. Added longitudinal incision of common carotid artery enables perfect removal of the atherosclerotic plaque. Proper posterior wall anastomosis of common and internal carotid artery in the bulb is carried out by one-way-up technique. This is an alternative to parachute technique and gives perfect view of operating field, thus decreasing the risk of technical mistake. Eversion technique of carotid endarterectomy represents an ideal operative technique in the case of carotid stenosis combined with kinking.

[A spinal cord injury caused by a migrating Kirschner wire following osteosynthesis of the clavicle: a case review]. / Poranení míchy zpusobené migrujícím kirschnerovým drátem po osteosyntéze klavikuly: kazuistika.

A case of penetrating spinal cord injury in 47 year old man, caused by migration of Kirschner wire is presented. The patient underwent the operation for acromioclavicular luxation 2 years ago--osteosynthesis with the use of 2 Kirschner wires. Admission with clinical symptoms of severe paraparesis of lower limbs. CT proved penetration of the first K-wire transversally through spinal cord in the level C7/T1, the second one stopped in the right transversal foramen T4. Emergent operation--extraction of Kirschner wires, followed by methyl-prednisolon therapy, according NASCIS II study. Gradual partial recovery of neurological deficit, with ability to walk and continence. Permanent sexual dysfunction.

[Carotid microendarterectomy in the aged]. / Karotická mikroendarterektomie ve stárí.

UNLABELLED: The authors evaluate the results of 100 carotid endarterectomies in 88 patients, 70 plus years old, operated between April 1997 and December 2000. Regional anaesthesia was always used. The use of intraluminal shunt was selective (11%), on the basis of consciousness and the neurological status. Operating microscope and microsurgical technique were used in all cases. Neither 30-d morbidity nor mortality has been detected in the group. Medical morbidity has been recorded in 2 patients. CONCLUSION: Carotid microendarterectomy in regional anesthesia represents effective procedure for patients in the old age.

[Advances in carotid endarterectomy--review]. / Pokroky v karotické endarterektomii--prehledný referát.

Atherosclerosis of carotid artery, resulting in stenosis is a common cause of cerebral ischaemia. Ischaemic stroke is cause of death in 10% of patients and the leading cause of disability in adults. The risk of stroke increases with the degree of stenosis. The diagnosis of the degree of stenosis is performed by duplex sonography, MR-angiography, CT-angiography and conventional angiography. Carotid endarterectomy is a method of choice in the treatment in the case of high-grade carotid stenosis. The operation was introduced in 1953. Either regional or general anaesthesia is used for the operation. The different monitoring techniques are used for assessment of the need for shunting. Microsurgical technique enables perfect endarterectomy and fine arterial repair without need for patch grafting. Other techniques of the treatment for carotid stenosis, including carotid angioplasty with or without stenting are subject to the evaluation. Carotid endarterectomy is now the method of choice in the treatment of high-grade carotid stenosis.