Paradoxical herniation associated with hyperbaric oxygen therapy after decompressive craniectomy: A case report

BACKGROUND Whether hyperbaric oxygen therapy(HBOT)can cause paradoxical herniation is still unclear.CASE SUMMARY A 65-year-old patient who was comatose due to brain trauma underwent decompressive craniotomy and gradually regained consciousness after surgery.HBOT was administered 22 d after surgery due to speech impairment.Paradoxical herniation appeared on the second day after treatment,and the patient’s condition worsened after receiving mannitol treatment at the rehabilitation hospital.After timely skull repair,the paradoxical herniation was resolved,and the patient regained consciousness and had a good recovery as observed at the follow-up visit.CONCLUSION Paradoxical herniation is rare and may be caused by HBOT.However,the underlying mechanism is unknown,and the understanding of this phenomenon is insufficient.The use of mannitol may worsen this condition.Timely skull repair can treat paradoxical herniation and prevent serious complications.

Which Type of Decompressive Craniectomy Is Better? Advantages and Challenges of Fresh Cadaver Practices Based on Experiences from the Last 20 Years. The Effect of Jesus Prayers in Science

Aim of Study: Reviewing the large number of publications about DC in the case of severe traumatic brain swelling, there is no clear position on which one is preferable for the patient. Bifrontal or bilateral fronto-parieto-temporo-partial occipital craniectomy. One of the most critical points, the behaviour of brainstem and its vascular structures during the protrusion of the traumatized swelling brain, which can expand in different directions, depending on where the skull has been opened. Method: After the high ICP created on a simple fresh cadaver model, we examined the brainstem displacements and compressions with the help of an endoscope-guided transnasal transsphenoidal transclival and analyzed their possible harmful effects on brainstem structures and blood vessels. Results: In bilateral bifronto-parieto-temporo-partial occipital craniotomy, no significant bulging or forward movement of the brainstem was detected. In the course of bifrontal craniectomy, significant forward movement and thus compression of vascular structures and pons were detected. Conclusion: Our assumption has been confirmed. In bifrontal craniectomy, the expansion is not parallel to the course of the brainstem, but perpendicular so that the pons and the blood vessels running along its anterior surface are compressed by moving forward against the clivus, which leads to circulatory compression and damage to the brainstem. In bilateral DC, the expansion is axially parallel to the course of the brainstem. Based on the fresh cadaver model, the use of the latter method is preferable for the traumatized swelling brain. In both cases, bridging veins of the protruding brain at the bone edge must be protected by the vascular tunnel method against compression. We examined this scientific question not only from a neurosurgical perspective but also in terms of the general ethical possibilities and psychological difficulties of conducting fresh cadaver practices. Additionally, we provided an answer on how we can ease the work of research doctors practicing on the deceased through the power of spiritual exercises and prayer. The dissection room offers fantastic opportunities for surgeons to discover new paths.

Is decompressive craniectomy for malignant middle cerebral artery infarction of any worth?

Objective: Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients presenting malignant MCA infarction compared with those receiving medical treatment alone. Methods: Patients with malignant MCA infarction treated in our hospital between January 1996 and March 2004 were included in this retrospective analysis. The National Institute of Health Stroke Scale (NIHSS)was used to assess neurological status on admission and at one week after surgery. All patients were followed up for assessment of functional outcome by the Barthel index (BI) and modified Rankin Scale (RS) at 3 months after infarction. Results: Ten out of 24patients underwent decompressive craniectomy. The mean interval between stroke onset and surgery was 62.10 h. The mortality was 10.0% compared with 64.2% in patients who received medical treatment alone (P<0.001). The mean NIHSS score before surgery was 26.0 and 15.4 after surgery (P<0.001). At follow up, patients who underwent surgery had significantly better outcome with mean BI of 53.3, RS of 3.3 as compared to only 16.0 and 4.60 in medically treated patients. Speech function also improved in patients with dominant hemispherical infarction. Conclusion: Decompressive craniectomy in patients with malignant MCA infarction improves both survival rates and functional outcomes compared with medical treatment alone. A randomized controlled trial is required to substantiate those findings.

Combination of dura turning-over and decompressive craniectomy： a new pattern of surgery for cerebral infarction caused by craniocerebral gunshot injury

Background:Craniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue,resulting in the loss of function of a certain area or other fatal damage to the human brain.Craniocerebral gunshot injury is usually life-threatening and is very common in modern warfare,accounting for the majority of battle casualties.Most of the patients suffer from acute cerebral infarction caused by vascular injury.Lack of early and solid battlefield emergency medical interference adds to the risk of death among the wounded.Case presentation:We present a 24-year-old man who was shot with a shotgun from a distance of 15m in an accidental injury.Forty-seven grape shots were found on his body surface by physical examination.A computed tomography(CT)scan demonstrated large areas of low-density shadows in his right parietal lobe and right temporal lobe with the midline shifting to the left side 2 days later.Afterwards,the patient was transferred to our emergency medical center at Changzheng Hospital in Shanghai.Cranial computed tomography angiography(CTA)showed a high-density shadow in the initial part of the right middle cerebral artery.The branches after the initial part were obliterated.Prompt medical attention and decompressive craniotomy(DC)surgery contributed to the final recovery from cerebral infarction of this patient.Conclusion:Bullets can penetrate or be lodged in the brain,causing intracranial hypertension.The bullets lodged in the brain can result in stenosis and embolism of a cerebral artery,causing acute cerebral infarction.Combining dura turning-over surgery with DC surgery can not only decrease intracranial pressure,which can increase the blood supply for hypertension-induced vessel stenosis,but also help vessels outside the dura mater grow into ischemic areas of the cerebral cortex.However,this new pattern of surgery needs further support from evidence-based medicine.

Paradoxical herniation after decompressive craniectomy provoked by mannitol:A case report

BACKGROUND Paradoxical transtentorial herniation is a rare but life-threatening complication of cerebrospinal fluid drainage in patients with large decompressive craniectomy.However,paradoxical transtentorial herniation after rapid intravenous infusion of mannitol has not been reported yet.CASE SUMMARY A 48-year-old male suffered from a right temporal vascular malformation with hemorrhage.In a coma,the patient was given emergency vascular malformation resection,hematoma removal,and the right decompressive craniectomy.The patient woke up on the 1st d after the operation and was given 50 g of 20% mannitol intravenously every 8 h without cerebrospinal fluid drainage.On the morning of the 7th postoperative day,after 50 g of 20% mannitol infusion in the Fowler’s position,the neurological function of the patient continued to deteriorate,and the right pupils dilated to 4 mm and the left to 2 mm.Additionally,computed tomography revealed an increasing midline shift and transtentorial herniation.The patient was placed in a supine position and given 0.9% saline intravenously.A few hours later,the patient was fully awake with purposeful movements on his right side and normal communication.CONCLUSION Paradoxical herniation may occur,although rarely,after infusing high-dose mannitol intravenously in the Fowler’s position in the case of a large craniectomy defect.An attempt should be made to place the patient in the supine position because this simple maneuver may be life-saving.Do not use high-dose mannitol when the flap is severely sunken.

Drainage and Cranioplasty as a Treatment for Traumatic Subdural Hygroma Secondary to Decompressive Craniectomy

Background: Decompressive craniectomy (DC) is performed to accommodate life-threatening brain swelling when medical treatment fails. This procedure carries the risk of developing traumatic subdural hygroma (TSH) that can adversely affect the neurological status of the patient. The treatment for persistence of TSH includes drainage and shunt placement or drainage and membranectomy. In this paper, we present treatment of two patients whose TSH was effectively treated with simple drainage and cranioplasty. Case Presentation: Patient 1: The patient is a 34-year-old female who had bilateral craniectomy for brain swelling. Four weeks later she became less interactive. CT scan showed bilateral subdural hygroma with 2 cm midline shift to the left. Her clinical status improved and CT scans showed resolution of the hygroma after simple evacuation of the hygroma and cranioplasty. Patient 2: The patient is a 57-year-old male who had post-traumatic acute subdural hematoma and brain swelling on the left side. The clot was evacuated and the bone flap was left out. After showing initial improvement, 10 weeks after the initial surgery the patient progressively worsened and became unresponsive. CT scans showed a large subdural hygroma on the right with midline shift to the left. Simple evacuation of the hygroma and cranioplasty was done. This resulted in radiological and clinical improvement of the patient. Conclusions: Both patients underwent simple drainage and cranioplasty, which resulted in clinical and radiological improvement. This finding suggests that other procedures such as membranectomy and shunting may not be necessary to treat TSH.

Mass brain tissue lost after decompressive craniectomy:A case report

BACKGROUND The brain is the most important organ to maintain life.However,the amount of brain tissue required for maintaining life in humans has not been previously reported.CASE SUMMARY A 33-year-old woman fell from the third floor three months before admission to our department.She received a decompressive craniectomy soon after injury.After the operation,operative incision disunion occurred due to the high pressure.Brain tissue flowed from the incision,and intracranial infection occurred.She fell into deep coma and was sent to our hospital.Her right temporal surgical incision was not healed and had a cranial defect of 10 cm×10 cm.Her intracranial cavity was observed from the skull defect,and the brain tissue was largely lost.In addition,no brain tissue was observed by visual inspection.Cranial computed tomography showed that only a small amount of brain tissue density shadow was compressed in the cerebellum and brainstem.Four days after hospitalization in our hospital,her parents transferred her to a hospital near her hometown.The patient died six days after discharge from our hospital.CONCLUSION This rare case provides some proof of the importance of the brainstem in the maintenance of cardiac rhythm and vascular tension.Neurosurgeons should carefully protect brainstem neurons during operations.Clinicians can maintain the cardiac rhythm of patients who lose their major brain tissue with modern technology,but the family of the patients should be aware of death and end-life care.

Clinical significance of large decompressive craniectomy to control intractable increased intracranial pressure in patients with traumatic brain injury

Objective To investigate the role of decompressive craniectomy (DC) to decrease intractable intracranial hypertension(ICH) due to diffuse brain swelling and / or cerebral edema after severe traumatic brain injury and the time window of DC to affect on prognosis. Methods The clinical record of 132 patients who underwent DC for posttraumatic intractable ICH in our hospital from July 2003 to

The effects of decompressive craniectomy on cerebral blood flow volume and brain metabolism in different aged patients with severe traumatic brain injury

Objective To explore effects of decompressive craniectomy on cerebral blood flow volume and brain metabolism in different aged patients with severe traumatic brain injury. Methods 71 cases were divided into three groups according age: group A( 【 30 years) ,group B ( 30 ～ 50 years) 。

The effect of hematoma puncture drainage before decompressive craniectomy on the prognosis of hypertensive intracerebral hemorrhage with cerebral hernia at a high altitude

Purpose:Rapid decompressive craniectomy(DC)was the most effective method for the treatment of hypertensive intracerebral hemorrhage(HICH)with cerebral hernia,but the mortality and disability rate is still high.We suspected that hematoma puncture drainage(PD)+DC may improve the therapeutic effect and thus compared the combined surgery with DC alone.Methods:From December 2013 to July 2019,patients with HICH from Linzhi,Tibet and Honghe,Yunnan Province were retrospectively analyzed.The selection criteria were as follows:(1)altitude≥1500 m;(2)HICH patients with cerebral hernia;(3)Glascow coma scale score of 4-8 and time from onset to admission≤3 h;(4)good liver and kidney function;and(5)complete case data.The included patients were divided into DC group and PD+DC group.The patients were followed up for 6 months.The outcome was assessed by Glasgow outcome scale(GOS)score,Kaplan-Meier survival curve and correlation between time from admission to operation and prognosis.A good outcome was defined as independent(GOS score,4-5)and poor outcome defined as dependent(GOS score,3-1).All data analyses were performed using SPSS 19,and comparison between two groups was conducted using separatet-tests or Chi-square tests.Results:A total of 65 patients was included.The age ranged 34-90 years(mean,63.00±14.04 years).Among them,31 patients had the operation of PD+DC,whereas 34 patients underwent DC.The two groups had no significant difference in the basic characteristics.After 6 months of follow-up,in the PD+DC group there were 8 death,4 vegetative state,4 severe disability(GOS score 1-3,poor outcome 51.6%);8 moderate disability,and 7 good recovery(GOS score 4-5,good outcome 48.4%);while in the DC group the result was 15 death,6 vegetative state,5 severe disability(poor outcome 76.5%),4 moderate disability and 4 good recovery(good outcome 23.5%).The GOS score and good outcome were significantly less in DC group than in PD+DC group(Z=-1.993,p=0.046;χ2=4.38,p=0.043).However,there was no significant difference regarding the survival curve between PD+DC group and DC group.The correlation between the time from admission to operation and GOS at 6 months(r=-0.41,R2=0.002,p=0.829)was not significant in the PD+DC group,but significant in the DC group(r=-0.357,R2=0.128,p=0.038).Conclusion:PD+DC treatment can improve the good outcomes better than DC treatment for HICH with cerebral hernia at a high altitude.

Decompressive craniectomy or not： intraoperative experience in 41 patients with severe traumatic brain injury

Objective： To present our experience in using decompressive craniectomy （DC） among severe trau- matic brain injury （TBI） patients during operation and to discuss its indication. Methods： From October 2008 to May 2009, 41 patients aged between 18 and 75 years with severe TBI were in- cluded in this study. They underwent DC or non-DC （NDC） according to their intraoperative findings. Postoperative intracranial pressure （ICP）, complications, requiring second operation or not and outcomes were observed. Results： Fifteen patients underwent DC and 26 pa- tients did not. The average postoperative ICP of each pa- tient was lower than 20 mm Hg. For patients received DC, 2 had seizures after operation and 1 developed cerebrocele in the follow-up period; only matic seizures, but none of 1 NDC patient had post-trau- them had delayed haematoma, cerebrospinal fluid fistula, cerebrocele or infections. At the end of follow-up, 10 patients died, 6 had the GOS of 2, 2 of 3, 9 of 4 and 14of 5. Conclusions： DC is necessary to manage fulminant intracranial hypertension or intraoperative brain swelling. If there was not brain swelling after removal of the haematoma and necrotized neural tissues, it is safe to replace skull flap. The intraoperative finding is an important factor to decide whether to perform DC or not.

Extensive duraplasty with autologous graft in decompressive craniectomy and subsequent early cranioplasty for severe head trauma

Objective： To compare the effect of extensive duraplasty and subsequent early cranioplasty on the recovery of neurological function in management of patients with severe traumatic brain injuries received decompressive craniectomy. Methods： The computer-aided designation of titanium armor plate was used as a substitute for the repair of skull defect in all the patients. The patients were divided into three groups. Twenty-three patients were in early cranioplasty group who received extensive duraplasty in craniectomy and subsequent cranioplasty within 3 months after previous operation （Group I）. Twenty-one patients whose cranioplasty was performed more than 3 months after the first operation were in the group without duraplasty （Group Ⅱ）; while the other 26 patients in the group with duraplasty in previous craniotomy （Group Ⅲ）. Both the Barthel index of activity of daily living （ADL） 3 months after craniotomy for brain injuries and 1 month after cranioplasty and Kamofsky Performance Score （KPS） at least 6 months aftercranioplasty were assessed respectively. Results： The occurrence of adverse events commonly seen in cranioplasty, such as incision healing disturbance, fluid collection below skin flap, infection and onset of postoperative epilepsy was not significantly higher than other 2 groups. The ADL scores at 3 months after craniotomy in Groups Ⅰ-Ⅱ/were 58.9±26.7, 40.8±20.2 and 49.2±18.6. The ADL scores at 1 month after cranioplasty were 70.2±425.2, 50.8±24.8 and 61.2±21.5. The forward KPS scores were 75.4±19.0, 66.5±24.7 and 57.6±24.7 respectively. The ADL and KPS socres were significantly higher in group I than other 2 groups. Conclusion： The early cranioplasty in those with extensive duraplasty in previous craniotomy is feasible and helpful to improving ADL and long-term quality of life in patients with severe traumatic brain injuries.

Death after discharge:prognostic model of 1-year mortality in traumatic brain injury patients undergoing decompressive craniectomy

Background:Despite advances in decompressive craniectomy(DC)for the treatment of traumatic brain injury(TBI),these patients are at risk of having a poor long-term prognosis.The aim of this study was to predict 1-year mortality in TBI patients undergoing DC using logistic regression and random tree models.Methods:This was a retrospective analysis of TBI patients undergoing DC from January 1,2015,to April 25,2019.Patient demographic characteristics,biochemical tests,and intraoperative factors were collected.One-year mortality prognostic models were developed using multivariate logistic regression and random tree algorithms.The overall accuracy,sensitivity,specificity,and area under the receiver operating characteristic curves(AUCs)were used to evaluate model performance.Results:Of the 230 patients,70(30.4%)died within 1 year.Older age(OR,1.066;95%CI,1.045-1.087;P<0.001),higher Glasgow Coma Score(GCS)(OR,0.737;95%CI,0.660-0.824;P<0.001),higherD-dimer(OR,1.005;95%CI,1.001-1.009;P=0.015),coagulopathy(OR,2.965;95%CI,1.808-4.864;P<0.001),hypotension(OR,3.862;95%CI,2.176-6.855;P<0.001),and completely effaced basal cisterns(OR,3.766;95%CI,2.255-6.290;P<0.001)were independent predictors of 1-year mortality.Random forest demonstrated better performance for 1-year mortality prediction,which achieved an overall accuracy of 0.810,sensitivity of 0.833,specificity of 0.800,and AUC of 0.830 on the testing data compared to the logistic regression model.Conclusions:The random forest model showed relatively good predictive performance for 1-year mortality in TBI patients undergoing DC.Further external tests are required to verify our prognostic model.

Decompressive craniectomy for malignant middle cerebral artery infarctions: a meta-analysis

Background: Decompressive craniectomy (DC) has been the classical management for malignant middle cerebral artery infarctions (mMCAI) in clinical practice. However, the association between DC and mMCAI remains unclear. This review went to evaluate the efficacy of DC in treating mMCAI patients. Methods: Studies were entirely searched since the foundation dates of multiple databases to June 2016. All major databases were involved, including Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and other sources. the bias risk of studies involved were evaluated. Modified Rankin Scale was defined as Primary outcome, Odds Ratio and 95% confidence intervals was taken as measurements. T2 (tau-squared) test, I2 test, and chi-square tests were used for statistical heterogeneity evaluation for each meta-analysis result, followed by fixed-effect model. Mantel-haenszel method was used in the process of summary estimations. All of the meta-analysis was conducted by Review Manager 5.3.Results & Conclusion: One thousand one hundred forty-five records of data were critically identified and collected through databases and 14 studies were finally involved. Result suggested that DC can ameliorate the suboptimal outcome of mMCAI patients.

Decompressive craniectomy in herpes simplex encephalitis

Intracranial hypertension is a common cause of morbidity in herpes simplex encephalitis(HSE).HSE is the most common form of acute viral encephalitis.Hereby we report a case of HSE in which decompressive craniectomy was performed to treat refractory intracranial hypertension.A 32-year-old male presented with headache,vomiting,fever,and focal seizures involving the right upper limb.Cerebrospinal fluid-meningoencephalitic profile was positive for herpes simplex.Magnetic resonance image of the brain showed swollen and edematous right temporal lobe with increased signal in gray matter and subcortical white matter with loss of gray,white differentiation in T2-weighted sequences.Decompressive craniectomy was performed in view of refractory intracranial hypertension.Decompressive surgery for HSE with refractory hypertension can positively affect patient survival,with good outcomes in terms of cognitive functions.

Clinical study of quality of life of traumatic brain injury patients after decompressive craniectomy and related influencing factors

Background:Decompressive craniectomy (DC) in traumatic brain injury (]-BI) patients has been subject of debate for neurosurgeons since long time.Our goal in this study is to evaluate the quality of life of these patients and to look at the problem from their point of view.Methods:Quality of Life after Traumatic Brain injury (QOLIBRI) instrument is was applied to 105 TBI patients who performed DC.Age,gender,the mode of injury and level of education,time from TBI to DC,lowest GCS score post-injury,presence of a corneal reflex,whether patients performed reconstructive cranioplasty or not,blood pressure,patient temperature,midline shift on CT scan,fasting blood glucose,whether patients performed rehabilitation therapy,days of use of mannitol and barbiturates sedation were recorded.Results:Sex of the patient,educational background,time between TBI to perform DC surgery,pupillary response of patient before surgery,systolic and diastolic blood pressures,fasting blood glucose,rehabilitation and use of barbiturates did not prove to have any statistical significant impact on the patient's QOLIBRI score.Young patients were found to be scoring more in the social domain (p =0.02).Higher Glasgow Coma Score (GCS) patients scored statistically better in the cognitive (p=0.00),self (0.00),daily life (p =0.00),social (p =0.00),emotion (p =0.00) and total QOLIBRI (p =0.00) score.Interestingly,the longer the time interval between TBI and time at QOLIBRI instrument application,the lower the score for cognitive (p =0.00),self (p =0.04),daily life (p =0.02),emotion (p =0.05) and total QOLIBRI (p =0.02) score.Reconstructive cranioplasty proved to positively affect the emotion (p =0.05),social life (p =0.01) and total QOLIBRI (p=0.05) score.Temperature had a negative influence on the cognitive (p =0.01),self (p =0.01) and daily life score (p =0.01).Midline shift on CT imaging had a negative influence on cognitive (p =0.00),self (p =0.00),daily life (p =0.00),social (p =0.00),emotion (p =0.05) and total QOLIBRI (p =0.00) score.Conclusion:QOLIBRI proves to be an excellent tool for evaluation of TBI patients who undergone DC.Regular assessment comparisons can help to tailor personalized rehabilitation treatment strategies for patients.

Efficacy of large decompressive craniectomy in severe traumatic brain injury

Objective： To investigate the role of large decompres- sive craniectomy （LDC） in the management of severe and very severe traumatic brain injury （TBI） and compare it with routine decompressive craniectomy （RDC）. Methods： The clinical data of 263 patients with severe TBI （GCS^8） treated by either LDC or RDC in our department were studied retrospectively in this article. One hundred and thirty-five patients with severe TBI, including 54 patients with very severe TBI （GCS ≤ 5）, underwent LDC （LDC group）. The other 128 patients with severe TBI, including 49 patients with very severe TBI, underwent RDC （RDC group）. The treatment outcome and postoperative complications of the two treatment methods were compared and analyzed in a 6-month follow-up period. Results： Ninety-six patients （71.7 %） obtained satisfactory treatment outcome in the LDC group, while only 75 cases （58.6 %） obtained satisfactory outcome in the RDC group （P〈 0.05）. Moreover, the efficacy of LDC in treating very severe TBI was higher than that of RDC （63.0 % vs. 36.7 %, P 〈 0.01）. The chance of reoperation due to refractory intracranial pressure （ICP） in the LDC group was significantly lower than that of the RDC group （P 〈 0.05）, while the incidences of delayed intracranial hematoma and subdural effusion were significantly higher than those of the RDC group （ P 〈 0.05）. Conclusions： LDC is superior to RDC in improving the treatment outcome of severe TBI, especially the very severe ones. LDC can also efficiently reduce the chances of reoperation due to refractory ICP. However, it increases the incidences of delayed intracranial hematoma and contralateral subdural effusion.

Ultrafast power Doppler imaging for ischemic encephalopathy:A case report

BACKGROUND Severely elevated intracranial pressure due to various reasons,such as decreased cerebral perfusion,can lead to devastating neurological outcomes,such as brain herniation.Decompression craniectomy is a life-saving procedure that is commonly performed for such a critical situation,but the changes in cerebral microvessels after brain herniation and decompression are unclear.Ultrafast power Doppler imaging(uPDI)is a new microvascular imaging technology that utilizes high frame rate plane/diverging wave transmission and advanced clutter filters.uPDI significantly improves Doppler sensitivity and can detect microvessels,which are usually invisible using traditional ultrasound Doppler imaging.CASE SUMMARY In this report,uPDI was used for the first time to observe the brain blood flow of a hypoperfusion area in a 4-year-old girl who underwent decompression craniectomy due to refractory intracranial hypertension(ICP)after malignant brain tumor surgery.B-mode imaging was used to verify the increased densities of the cerebral cortex and basal ganglia that were observed by computed tomography.CONCLUSION uPDI showed the local blood supplies and anatomical structures of the patient after decompressive craniectomy.uPDI is potentially a more intuitive and noninvasive method for evaluating the effects of severe ICP on cerebral microvessels.

Minimally invasive puncture and drainage or patients with hypertensive spontaneous basal ganglia intracerebral hemorrhage: A prospective non-randomized comparative study of 198 cases

Background: The treatment of hypertensive spontaneous intracranial hemorrhage(ICH) is still controversial. The purpose of the present study was to investigate whether minimally invasive puncture and drainage(MIPD) could provide improved patient outcome compared with decompressive craniectomy(DC).Methods: Eligible, consecutive patients with ICH(≥30 ml, in basal ganglia, within 24 hours of ictus) were nonrandomly assigned to receive MIPD(group A) or to undergo DC(group B) hematoma evacuation. The primary outcome was death at 30 days after onset. Functional independence was assessed at 1 year using the Glasgow Outcome Scale(GOS, scores range from 1 to 5, score 1 indicating death, ≥4 indicating functional independence, with lower scores indicating greater disability). Results: A total of 198 patients met the per protocol analysis(84 cases in group A and 114 cases in group B), including 9 cases lost during follow-up(2 cases in group A and 7 cases in group B). For these 9 patients, their last observed data were used as their final results for intention-to-treat analysis. The mean age of all patients was 57.1 years(range of 31-95 years), and 114 patients were male. The initial Glasgow Coma Scale(GCS) score was 8.1±3.4, and the National Institutes of Health Stroke Scale(NIHSS) score was 20.8±5.3. The mean hematoma volume(HV) was 56.7±23.0 ml(range of 30-144 ml), and there was extended intraventricular hemorrhage(IVH) in 134 patients(67.7%). There were no significant intergroup differences in the above baseline data, except group A had a higher mean age(59.4±14.5years) than the mean age of group B(55.3±11.1 years, P=0.025). The total cumulative mortalities at 30 days and 1 year were 32.3% and 43.4%, respectively, and there were no significant differences between groups A and B(30 days: 27.4% vs. 36.0%, P=0.203; 1 year: 36.1% vs. 48.2%, P=0.112, respectively). However, the mortality for patients ≤60 years, NIHSS【15 or HV≤60 ml was significantly lower in group A than that in group B(all P【0.05). The total cumulative functional independence at 1 year was 26.8%, and the difference between group A(33/43, 39.3%) and group B(20/144, 17.5%) was significant(absolute difference 21.7%, odds ratio [OR] 0.329, 95% confidence interval [CI] 0.171 to 0.631, P=0.001). For patient with severe IVH, the 30 days and 1 year mortality rates were significant lower in group B than those in group A(P=0.025, P=0.036). However, the number of favorable outcomes had no significant difference between groups at 1 year post ictus. Multivariate logistic regression analysis showed that a favorable outcome after 1 year was associated with the difference in therapies(OR 0.280, 95% CI 0.104–0.752, P=0.012), age(OR 0.215, 95% CI 0.069–0.671, P=0.008), GCS(OR 1.187, 95% CI 1.010–1.395, P=0.037), HV(OR 0.943, 95% CI 0.906–0.982, P=0.005), IVH(OR 0.655, 95% CI 0.506–0.849, P=0.001) and PI(OR 0.211, 95% CI 0.071–0.624, P=0.001). Conclusions: Our results suggest that for patients with hypertensive spontaneous ICH(HV≥30 ml in basal ganglia), MIPD may be a more effective treatment than DC, as assessed by a higher rate of functional independence at 1 year after onset as well as reduced mortality in patients ≤60 years of age, NIHSS【15 or HV≤60 ml. For patients with HV 】60 ml, deep coma and severe IVH, the outcomes of the two therapies were similar.

Posttraumatic hydrocephalus associated with decompressive cranial defect in severe brain-injured patients

Objective： To investigate the occurrence of posttraumatic hydrocephalus （PTH） in severe braininjured patients who underwent decompressive craniectomy （DC） and to discuss the management. Methods： A total of 389 patients suffering from severe head trauma between January 2004 and May 2010 were enrolled in this study. Clinical data were analyzed retrospectively. Of them, 149 patients who underwent DC were divided into two groups according to the presence of PTH： hydrocephalus group and nonhydrocephalus group. Clinical factors including preoperative Glasgow Coma Score （GCS）, bilateral or unilateral decompression, and duraplasty in DC were assessed by single factor analysis to determine its relationship with the occurrence of PTH. Results： Of the 149 patients undergoing DC, 25 （16.8%） developed PTH; while 23 developed PTH （9.6%） among the rest 240 patients without DC. Preoperative GCS, bilateral or unilateral decompression, duraplasty in DC were significantly associated with the development of PTH. Ventriculoperitoneal shunt was performed on 23 of 25 patients with PTH after DC. Frontal horn was preferred for the placement of the catheter. Sixteen of them were operated upon via frontal approach and 7 via occipital approach. After shunt surgery, both radiological and clinical improvemerits were confirmed in 19 patients. Radiological improvement was found in 2 patients. One patient died eventually of severe pneumonia. Shunt-related infection occurred in 1 patient, which led to the removal of the catheter. Conclusions： It is demonstrated that the occurrence of PTH is high in patients with large decompressive skull defect. Patients with low GCS and bilateral decompression tend to develop PTH after DC. Duraplasty in DC might facilitate reducing the occurrence of PTH. Patients with PTH concomitant skull defect should be managed deliberately to restore the anatomical and physiological integrity so as to facilitate the neurological resuscitation.