Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Decompressive craniectomy (DC) lowers intracranial pressure and improves outcome in patients with malignant middle cerebral artery stroke. Its usefulness in intracerebral hemorrhage (ICH) is unclear. The aim of this study was to analyze feasibility and safety of DC without clot evacuation in ICH. METHODS: We compared consecutive patients (November 2010-January 2012) with supratentorial ICH treated with DC without hematoma evacuation and matched controls treated by best medical treatment. DC measured at least 150 mm and included opening of the dura. We analyzed clinical (age, sex, pathogenesis, Glasgow Coma Scale, National Institutes of Health Stroke Scale), radiological (signs of herniation, side and size of hematoma, midline shift, hematoma expansion, distance to surface), and surgical (time to and indication for surgery) characteristics. Outcome at 6 months was dichotomized into good (modified Rankin Scale 0-4) and poor (modified Rankin Scale 5-6). RESULTS: Twelve patients (median age 48 years; interquartile range 35-58) with ICH were treated by DC. Median hematoma volume was 61.3 mL (interquartile range 37-83.5 mL) and median preoperative Glasgow Coma Scale was 8 (interquartile range 4.3-10). Four patients showed signs of herniation. Nine patients had good and 3 had poor outcomes. Three patients (25%) of the treatment group died versus 8 of 15 (53%) of the control group. There were 3 manageable complications related to DC. CONCLUSIONS: DC is feasible in patients with ICH. Based on this small cohort, DC may reduce mortality. Larger prospective cohorts are warranted to assess safety and efficacy.

High-flow venous pouch aneurysm in the rabbit carotid artery: A model for large aneurysms.

BACKGROUND AND PURPOSE: Currently one of the most widely used models for the development of endovascular techniques and coiling devices for treatment of aneurysm is the elastase-induced aneurysm model in the rabbit carotid artery. Microsurgical techniques for creating an aneurysm with a venous pouch have also been established, although both techniques usually result in aneurysms less than 1 cm in diameter. We investigated whether an increase in blood flow toward the neck would produce larger aneurysms in a microsurgical venous pouch model. MATERIALS AND METHODS: Microsurgical operations were performed on 11 New Zealand white rabbits. Both carotid arteries and the right jugular vein were dissected, and the right carotid artery was temporarily clipped followed by an arteriotomy. The left carotid artery was also clipped proximally, ligated distally, and sutured onto the proximal half of the arteriotomy in the right carotid artery. The venous graft was sutured onto the distal half of the arteriotomy. Digital subtraction angiography was also performed. RESULTS: Angiography showed patent anastomosed vessels and aneurysms in the seven surviving rabbits. Mean aneurysm measurements among surviving rabbits with patent vessels were: 13.9 mm length, 9.3 mm width, and neck diameter 4.7 mm. The resulting mean aspect ratio was 3.35 and the mean bottleneck ratio was 3.05. CONCLUSION: A large venous graft and increased blood flow toward the base of the aneurysm seem to be key factors in the creation of large venous pouch aneurysms. These large aneurysms allow testing of endovascular devices designed for large and giant aneurysms.

Endoscopic temporal ventriculocisternostomy: an option for the treatment of trapped temporal horns.

Entrapment of the temporal horn is a rare form of isolated hydrocephalus. Standard treatment has not yet been established for this condition, and only a few cases have been reported in the literature. The authors reviewed their prospectively maintained database to report their experience with endoscopic temporal ventriculocisternostomy. All endoscopic operations performed in the Department of Neurosurgery at Ernst Moritz Arndt University between March 1993 and August 2012 were reviewed, and a retrospective chart review of all patients with temporal ventriculocisternostomy was performed. Four patients were identified (3 children and 1 adult). In 3 patients, the condition developed after tumor resection, and in 1 patient it developed due to postmeningitic multiloculated hydrocephalus. In 2 patients, a recurrent trapped temporal horn developed. Refenestration was successful in one of these patients, and dilation in the trigone area with a subsequent stomy of the septum pellucidum was successful in the other. In 1 patient, postoperative meningitis developed, which was treated with antibiotics. Endoscopic temporal ventriculocisternostomy is an option in the treatment of trapped temporal horns. However, more experience is required to recommend it as the treatment of choice.