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.

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.

Surgical Treatment of Poor Grade Middle Cerebral Artery Aneurysms Associated with Large Sylvian Hematomas Following Prophylactic Hinged Craniectomy

The clinical characteristics of patients who presented in poor clinical grade due to ruptured middle cerebral artery aneurysms （MCAAs） associated with large sylvian hematomas （SylH） were ana- lyzed and an ingenious designed prophylactic hinged craniectomy was introduced. Twenty-eight pa- tients were graded into Hunt-Hess grades IV-V and emergency standard micro-neurosurgeries （aneu- rysm clipping, hematoma evacuation and prophylactic hinged craniectomy） were performed, and their clinical data were retrospectively analyzed. 46.43% of the patients reached encouraged favorable out- comes on discharge. The favorable outcome group and the poor outcome group significantly differed in terms of patients＇ anisocoria, Hunt-Hess grade before surgery, extent of the midline shift and time to the surgery after bleeding （P〈0.05）. There were no significant differences in age, sex, volume and location of the hematoma, size of aneurysm between the favorable and poor groups （P〉0.05）. However, ingen- ious designed prophylactic hinged craniectomy efficiently reduced the patients＇ intracranial pressure （ICP） after surgery. It was suggested that preoperative conditions such as Hunt-Hess grading, extent of the midline shift and the occurrence of cerebral hernia affect the prognosis of patients, but time to the surgery after bleeding and prophylactic hinged craniectomy are of significant importance for optimizing the prognosis ofMCAA oatients 19resenting with large SylH.

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.

Intracranial hypotension syndrome in a patient due to suboccipital craniectomy secondary to Chiari type malformation

Intracranial hypotension syndrome(IHS) is a rare disorder characterized by a decrease in cerebrospinal fluid pressure to less than 60 mm H2 O. The syndrome is associated with occipital headache radiating to the frontal and temporal zones. The current clinical case describes the manifestation of IHS in a twenty-five year old female with a history of suboccipital craniectomy due to Chiari I malformation nine years earlier. The patient was admitted to the hospital complaining about postural, mainly occipital, headache during the last three months, aggravated by being in an upright position. The magnetic resonance imaging(MRI) revealed engorgement of the dural venous sinuses, significant enlargement of the pituitary gland and download displacement or sagging of the brain with effacement of the perichiasmatic cisterns and the prepontine cistern, while the spinal T2 W MRI revealed a 7 mm × 2.5 mm dural defect with an extradural cerebrospinal fluid collection at the dorsal soft tissues of the cervical spine. The previous imaging did not reveal subdural effusions.

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.

Clinical Outcome of Decompressive Craniectomy Operation for the Management of Acute Traumatic Brain Injury

Objectives: To evaluate the efficacy of Decompressive Craniectomy (DC) on the postoperative clinical state of the patient to define a line of management of these cases. Take in considerations the surrounding circumstances of the patient till he reaches the ER in Egypt and the hospital resources. Methods: 200 patients suffering from acute traumatic brain injury causing DCL resulted from different pathologies causing increased ICP. In group A, patients with acute TBI were managed by surgical intervention in the form of Decompressive Craniectomy and in the control group B, patients were managed by medical treatment. The age range was from 8 to 65 with no history of associated medical disorders with exclusion criteria of non-traumatic causes of increased ICP. Results: Data collected showed: male to female ratio of 3:1. The most common mode of injury was falling from height. Mean time from injury to operative intervention was 4 hours. The leading initial symptoms were DCL. In group A the overall mortality was 60%, functional recovery rate was 30%, and left severely disabled or vegetative was 10%. 50% of the cases had associated injury. 20% suffered from post-operative complications. Conclusion: DC is the ideal solution for the management of acute TBI with persistent increased ICP when the other medical management fails, given an early intervention and taking into consideration other factors affecting surgical outcome.

Evaluation of Decompressive Craniectomy

Background and Purpose: Decompressive craniectomy is a surgery used to remove a large bone flap and opening the dura to allow edematous brain tissue to bulge extracranially. However, the efficacy of decompressive surgery to reduce the mortality and improve the outcome in patients with refractory intra-cranial pressure is still unclear. We investigated whether decompressive crani-ectomy is associated with improved conscious state and survival in patients with severely raised intracranial pressure and resistant to conservative management. Methods: We studied 20 patients with clinical and radiological evidence of increased intracranial pressure & indicated for decompressive crani-ectomy. All patients were followed postoperatively in ICU with serial follow up (CT). Consciousness level was evaluated using the Glasgow Coma Scale and Glasgow outcome score. Results: The overall mortality was 11 cases (55%), two cases remain in a vegetative state (10%), one case (5%) was severely disabled and six cases (30%) discharged with mild disability. Conclusion: In 20 cases with severely raised intracranial pressure resistant to conservative management Decompressive Craniectomy allowed (30 %) of cases to be discharged from hospitals with mild degree of disability for rehabilitation.

Cranioplasty after Decompressive Craniectomy Caused an Intracerebral Hemorrhage: A Case Report

Decompressive craniectomy is a common practice for patients with intracranial hypertension. Secondary rigid structural reconstruction following craniectomy can release the effects of atmospheric pressure on the brain, and the brain can become dilated. Although some cases with complications induced by cranioplasty, such as intracranial hematoma, have been reported, no clinical cases with intracerebral hemorrhage after rigid reconstruction have been reported. This case report describes a 39-year-old man with a skull defect following clipping with simultaneous decompressive craniectomy for a subarachnoid hemorrhage. About 25 months later, cranioplasty using a custom-made hydroxyapatite (HAP) ceramic implant was performed. Immediately after the operation, intracerebral hemorrhage was detected on the opposite side by computed tomography (CT). However, there were no physical or neurological findings, the hematoma was completely absorbed within 3 weeks postoperatively, and the skull retained a good shape. This case suggests that rigid reconstruction of a skull defect can influence intracranial conditions, and early postoperative CT is important to detect complications.

Decompressive Craniectomy for Posterior Reversible Encephalopathy Syndrome (PRES): Case Report

Background: Posterior reversible encephalopathy syndrome (PRES) is an uncommon clinical-neuroradiological syndrome with an unclear pathophysiology. Correlation between PRES and the use of immunosuppressant drugs have previously been described, as well as correlation between elevated blood pressure and PRES. Characteristic brain MRI manifestations include hyperintense lesions on T2 and FLAIR (fluid-attenuated inversion recovery) images. PRES is usually reversible within a short period of time after discontinuation of the presumably offending drug. Some cases of PRES might complicate with intracranial hemorrhage, refractory status epilepticus or expansive vasogenic brain edema (also regarded as “tumefactive” PRES). Methods: We present a case of a young man diagnosed with Hodgkin’s lymphoma, following a laparotomy due to cecal volvulus. The patient received glucocorticoids and elevated blood pressure values were recorded. Brain imaging studies were performed due to generalized epileptic seizures, demonstrating neuroradiological findings consistent with PRES. Neurological and neuroradiological deterioration was noted, necessitating urgent neurosurgical intervention. A complete neurological and functional rehabilitation was achieved. Conclusion: The uncommon cases of complicated PRES should be taken under consideration whenever clinical deterioration is noted following the diagnosis of PRES. Early neuroradiological evaluation should be sought, together with aggressive medical and surgical treatment in cases of life threatening mass effect.

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.

Decompressive Craniectomy in Posterior Fossa Ischemic Stroke

Ischemic damage produced in the posterior cerebral territory causes significant morbidity and urgently must be considered if the patient need a surgical attitude. Surgical decompression by suboccipital craniectomy seams to be effective to treat secondary edema due to cerebellar damage or in posterior fossa, when medical treatment is not able to control side effects. We report a clinical case of a patient with a subacute ischemic infarction in the vertebro-basilar territory, with perilesional edema, and a posterior fossa decompressive craniectomy (DC) was carried out.

Fasciitis on Abdominal Craniectomy Implantation

Necrotizing fasciitis is an infection of the skin and deep subcutaneous tissue. It is caused by bacteria (group A streptococcus), but may also be idiopathic ora secondary complication of surgery. We report a case of necrotizing fasciitis of the abdominal wall fostering a decompressive cranial flap in a 39-year-old patient.

Comparison of the Efficacy of Standard Decompressive Craniectomy Combined with Cerebrospinal Fluid Circulation Reconstruction in the Treatment of Severe Craniocerebral Injury

Objective:To observe and discuss the clinical effect of standard decompressive craniectomy combined with cerebrospinal fluid circulation reconstruction in the treatment of severe craniocerebral injury.Methods:Seventy patients who underwent surgery in our hospital were selected as subjects for this study.The time was from August 2016 to August 2018,and patients were divided into experimental group(35 cases)and control group(35 cases)according to the random number table method.The control group was treated with a single standard decompressive craniectomy according to clinical symptoms.The experimental group was treated with standard decompressive craniectomy combined with cerebrospinal fluid circulation reconstruction.The surgical treatment effect,GCS(Glasgow Coma Scale)score and operation time were compared between the two groups.Results:After comparison,the surgical treatment effect of the experimental group was higher than that of the control group and there was a significant difference between the two groups(P<0.05).The GCS score and operation time of the experimental group were also better than of the control group and there was a significant difference the two groups(P<0.05).Conclusion:The use of standard decompressive craniectomy combined with cerebrospinal fluid circulation reconstruction in the treatment of severe craniocerebral injury is more effective and worthy of widespread promotion and application.

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.

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.

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.