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.

Ocular decompression retinopathy after phacoemulsification in a patient with primary acute angleclosure glaucoma undergoing chemotherapy

Dear Editor,Ocular decompression retinopathy(ODR),which manifests as diffuse retinal hemorrhage occurring abruptly in multiple locations,including the subretinal,intraretinal,and preretinal spaces,is a rare complication after glaucoma surgery and is caused by sudden,iatrogenic lowering of intraocular pressure(IOP).Implicated procedures include glaucoma drainage implantation,trabeculectomy,iridotomy,and even cataract surgery[1].One report described a case of ocular decompression management following uncomplicated cataract surgery with no posterior capsular rupture or other intraoperative complications[2].Here,we report a rare case of ODR triggered by phacoemulsification and the use of systemic chemotherapeutic drugs in a patient with primary acute angleclosure glaucoma(PACG).The case not only improves our understanding of potential side effects of chemotherapeutic drugs on ophthalmic surgery but may also serve as a reference for clinicians in the management of patients with glaucoma with similar medical histories.

Postoperative pneumocranium after endoscopic transnasal optic canal decompression

Dear Editor,We present the first time,a case of a patient developed cerebrospinal fluid(CSF)leak and pneumocranium following optic canal decompression(OCD).INTRODUCTION Indirect traumatic optic neuropathy(ITON)impairs visual functions and quality of life.Endoscopic transnasal optic canal decompression(ETOCD)is one of the standard treatment strategies for the ITON.During the ETOCD,the optic nerve sheath are usually incised for sufficient decompression of optic nerve after removal of optic canal,which is associated with complications like CSF leakage,ophthalmic artery injury,and optic nerve injury[1].Generally,the mild CSF leak is common and can heal spontaneously using conventional treatment,the severe CSF leak requires surgical repair[2].

Predictive visual field outcomes after optic chiasm decompressive surgery by retinal vessels parameters using optical coherence tomography angiography

AIM:To evaluate the predictive value of superficial retinal capillary plexus(SRCP)and radial peripapillary capillary(RPC)for visual field recovery after optic cross decompression and compare them with peripapillary nerve fiber layer(pRNFL)and ganglion cell complex(GCC).METHODS:This prospective longitudinal observational study included patients with chiasmal compression due to sellar region mass scheduled for decompressive surgery.Generalized estimating equations were used to compare retinal vessel density and retinal layer thickness preand post-operatively and with healthy controls.Logistic regression models were used to assess the relationship between preoperative GCC,pRNFL,SRCP,and RPC parameters and visual field recovery after surgery.RESULTS:The study included 43 eyes of 24 patients and 48 eyes of 24 healthy controls.Preoperative RPC and SRCP vessel density and pRNFL and GCC thickness were lower than healthy controls and higher than postoperative values.The best predictive GCC and pRNFL models were based on the superior GCC[area under the curve(AUC)=0.866]and the tempo-inferior pRNFL(AUC=0.824),and the best predictive SRCP and RPC models were based on the nasal SRCP(AUC=0.718)and tempo-inferior RPC(AUC=0.825).There was no statistical difference in the predictive value of the superior GCC,tempo-inferior pRNFL,and tempo-inferior RPC(all P>0.05).CONCLUSION:Compression of the optic chiasm by tumors in the saddle area can reduce retinal thickness and blood perfusion.This reduction persists despite the recovery of the visual field after decompression surgery.GCC,pRNFL,and RPC can be used as sensitive predictors of visual field recovery after decompression surgery.

Should we perform decompressive laparotomy during severe acute pancreatitis with intra-abdominal hypertension below 25 mmHg:Only the gut knows

We suggest that during severe acute pancreatitis(SAP)with intra-abdominal hypertension,practitioners should consider decompressive laparotomy,even with intra-abdominal pressure(IAP)below 25 mmHg.Indeed,in this setting,non-occlusive mesenteric ischemia(NOMI)may occur even with IAP below this cutoff and lead to transmural necrosis if abdominal perfusion pressure is not promptly restored.We report our experience of 18 critically ill patients with SAP having undergone decompressive laparotomy of which one third had NOMI while IAP was mostly below 25 mmHg.

Factors that influence the results of indirect decompression employing oblique lumbar interbody fusion

BACKGROUND Indirect decompression is one of the potential benefits of anterior reconstruction in patients with spinal stenosis.On the other hand,the reported rate of revision surgery after indirect decompression highlights the necessity of working out prediction models for the radiographic results of indirect decompression with assessing their clinical relevance.AIM To assess factors that influence radiographic and clinical results of the indirect decompression in patients with stenosis of the lumbar spine.METHODS This study is a single-center cross-sectional evaluation of 80 consecutive patients(17 males and 63 females)with lumbar spinal stenosis combined with the instability of the lumbar spinal segment.Patients underwent single level or bisegmental spinal instrumentation employing oblique lumbar interbody fusion(OLIF)with percutaneous pedicle screw fixation.Radiographic results of the indirect decompression were assessed using computerized tomography,while MacNab scale was used to assess clinical results.RESULTS After indirect decompression employing anterior reconstruction using OLIF,the statistically significant increase in the disc space height,vertebral canal square,right and left lateral canal depth were detected(Р<0.0001).The median(M)relative vertebral canal square increase came toМ=24.5%with 25%-75%quartile border(16.3%;33.3%)if indirect decompression was achieved by restoration of the segment height.In patients with the reduction of the upper vertebrae slip,the median of the relative increase in vertebral canal square accounted for 49.5%with 25%-75%quartile border(2.35;99.75).Six out of 80 patients(7.5%)presented with unsatisfactory results because of residual nerve root compression.The critical values for lateral recess depth and vertebral canal square that were associated with indirect decompression failure were 3 mm and 80 mm2 respectively.CONCLUSION Indirect decompression employing anterior reconstruction is achieved by the increase in disc height along the posterior boarder and reduction of the slipped vertebrae in patients with degenerative spondylolisthesis.Vertebral canal square below 80 mm2 and lateral recess depth less than 3 mm are associated with indirect decompression failures that require direct microsurgical decompression.

Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review

Intra-abdominal hypertension(IAH)and abdominal compartment syndrome(ACS)play a pivotal role in the pathophysiology of severe acute pancreatitis(SAP)and contribute to new-onset and persistent organ failure.The optimal management of ACS involves a multi-disciplinary approach,from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure(IAP).A targeted literature search from January 1,2000,to November 30,2022,revealed 20 studies and data was analyzed on the type and country of the study,patient demographics,IAP,type and timing of surgical procedure performed,post-operative wound management,and outcomes of patients with ACS.There was no randomized controlled trial published on the topic.Decom-pressive laparotomy is effective in rapidly reducing IAP(standardized mean difference=2.68,95%confidence interval:1.19-1.47,P<0.001;4 studies).The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but,potentially lethal ACS.Disease-specific patient selection and the role of less-invasive decompressive measures,like subcutaneous linea alba fasciotomy or component separation techniques,is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS.This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP.However,there is a lack of high-quality evidence on patient selection,timing,and modality of surgical decompression.Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.

Timing of biliary decompression for acute cholangitis

Severe acute cholangitis(AC)exacerbates the risk of death because of the rapid progression of the disease.The optimal timing of biliary decompression(BD)as a necessary intervention in patients with severe AC is controversial.A recently report titled“Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity”in the World Journal of Gastroenterology that the optimal time of endoscopic retrograde cholangiopancreatography for treating patients with severe AC is≤48 but not≤24 h,providing clinical evidence for selecting the optimal time for implementation of BD.Here,we discuss the controversy over the optimal timing of BD for AC based on guidelines and clinical evidence,and consider that more high-level clinical researches are urgent needed to benefit the management of patients with different severity of AC.

Minimally Invasive 360 Degrees Decompression for Ligamentous, Bony and Discogenic Lumbar Canal Stenosis

Background: For decades, traditional open surgical techniques were used to treat lumbar disc herniation and lumbar canal stenosis (LCS). However, seeking for better outcomes for patients and avoiding extensive bony loss with its sequences had raised minimally invasive technique for treating these disorders as an alternative surgery. Methods: This is a retrospective study in which 54 patients of LCS were operated upon via unilateral minimally invasive technique to decompress the canal in a 360 degrees fashion through laminotomy, deroofing of opposite laminar side, sublaminar ligamintectomy, bilateral foraminotomies and discectomy. We used VAS scores and ODI to assess clinical outcomes with a period of one year follow-up. Results: Our results demonstrated that minimally invasive techniques for treating these disorders are effective procedures. Minimally invasive 360 degrees decompression for treating LCS had better outcomes regarding postoperative back pain, smaller incisions, less bony loss and early ambulation. Conclusion: Minimally invasive techniques for treating lumbar canal stenosis of different causes could be considered a better option instead of traditional full laminectomy with better outcomes as regards respecting the anatomical layers such as posterior spinal integrity and musculature, postoperative pain, accompanied with less blood loss, shorter hospital stays, and shorter recovery periods.

Security Assurance for One-stage Resection of Left Colon Cancer with Acute Obstruction—Thorough and Prompt Enteral Decompression without Contamination

Objective: Thorough, prompt enteral decompression technique without contamination was de- veloped to ensure safety for emergent colon resection and primary anastomosis. Methods: After isolating the mesentery, the “to be resected colon segment” was cut at its lower end, then the proximal cut end was put into a plastic bag which was adhered to one side of the operating table. After releasing the clamp, the content could ?ow into this bag. The operator could squeeze the bowel with two hands by turns, from proximal to farness, and from small bowel to large bowel, until the entire bowel content was fully discharged. Then the upper end of this “to be resected colon segment” was cut, and was removed together with the plastic bag. Results: 31 cases of left colon cancer with acute obstruction were decompressed with this technique. They all recovered smoothly, without anastomosis ?stula. Another 6 cases of hepatic seg- mentectomy with incidental colonectomy were decompressed with this technique and had the same results. This technique was also used in di?erent kinds of acute small intestinal obstruction and gained satisfactory results. Conclusion: This technique could be considered as the preferable choice for intraoperative enteral decompression.

Early removing gastrointestinal decompression and early oral feeding improve patients' rehabilitation after colorectostomy

AIM： To evaluate the feasibility, safety, and tolerance of early removing gastrointestinal decompression and early oral feeding in the patients undergoing surgery for colorectal carcinoma. METHODS： Three hundred and sixteen patients submitted to operations associated with colorectostorny from January 2004 to September 2005 were randomized to two groups： In experimental group （n = 161）, the nasogastric tube was removed after the operation from 12 to 24 hours and was promised immediately oral feeding; In control group （n = 155）, the nasogastric tube was maintained until the passage of flatus per rectum. Variables assessed included the time to first passage of flatus, the time to first passage of stool, the time elapsed postoperative stay, and postoperative complications such as anastornotic leakage, acute dilation of stomach, wound infection and dehiscense, fever, pulmonary infection and pharyngolaryngitis. RESULTS： The median and average days to the first passage of flatus （3.0±0.9 vs 3.6±1.2, P〈0.001）, the first passage of stool （4.1± 1.1 vs 4.8±1.4 P〈0.001） and the length of postoperative stay （8.4±3.4 vs 9.6±5.0, P〈0.05） were shorter in the experimental group than in the control group. The postoperative complications such as anastomotic leakage （1.24% vs 2.58%）, acute dilation of stomach （1.86% vs 0.06%） and wound complications （2.48% vs 1.94%） were similar in the groups, but fever （3.73% vs 9.68%, P〈0.05）, pulmonary infection （0.62% vs 4.52%, P〈0.05） and pharyngolaryngitis （3.11% vs 23.23%, P〈0.001） were much more in the control group than in the experimental group. CONCLUSION： The present study shows that applicationof gastrointestinal decompression after colorectostomy can not effectively reduce postoperative complications. On the contrary, it may increase the incidence rate of fever, pharyngolaryngitis and pulmonary infection. These strategies of early removing gastrointestinal decompression and early oral feeding in the patients undergoing colorectostomy are feasible and safe and associated with reduced postoperative discomfort and can accelerate the return of bowel function and improve rehabilitation.

Effect of recombinant human bone morphogenetic protein 2/polylactide-co-glycolic acid (rhBMP-2/PLGA) with core decompression on repair of rabbit femoral head necrosis

Objective:To observe the effect of recombinant human bone morphogenetic protein 2/polylactide-co-glycolic acid(rhBMP-2/PLGA) with core decompression on repair of rabbit femoral head necrosis.Methods:Bilateral femoral head necrosis models of rabbit were established by steroid injection.A total of 48 rabbits(96 femoral head necrosis) were randomly divided into 4groups:Group A,control group with12 rabbits,24 femoral head necrosis;Group B,treated with rhBMP-2/PLCA implantation after core depression,with 12 rabbits,24 femoral head necrosis;Group C,treated with rhBMP-2 implantation after core depression,with 12 rabbits,24 femoral head necrosis;Croup D treated with core depression group without implantation,with 12 rabbits,24 femoral head necrosis.All animals were sacrificed after 12 weeks.The ability of repairing bone defect was evaluated by X-ray radiograph.Bone mineral density analysis of the defect regions were used to evaluate the level of ossification.The morphologic change and bone formation was assessed by HE staining.The angiogenesis was evaluated by VEGF immunohistochemistry.Results:The osteogenetic ability and quality of femoral head necrosis in group B were better than those of other groups after 12 weeks by X-ray radiograph and morphologic investigation.And the angiogenesis in group B was better than other groups.Group C had similar osteogenetic quality of femoral head necrosis and angiogenesis with group D.Conclusions:The treatment of rhBMP-2/PLCA implantation after core depression can promote the repair of rabbit femoral head necrosis.It is a promising and efficient synthetic bone material to treat the femoral head necrosis.

The effect of intravenous high-dose glucocorticoids and orbital decompression surgery on sight-threatening thyroid-associated ophthalmopathy

AIM: To report the effects of intravenous high-dose glucocorticoids(iv GC) and orbital decompression(OD) surgery for treatment of sight-threatening thyroid-associated ophthalmopathy(TAO).METHODS: A retrospective review of medical records from patients with sight-threatening TAO [definite or highly suspected dysthyroid optic neuropathy(DON)] treated with iv GC(60 cases) and OD(25 cases) was conducted at the Zhongshan Ophthalmic Center between January 2001 and January 2009. Patients were initially treated with iv GC(iv GC group). If no significant improvement in visual function was obtained, they then received OD surgery(OD group). The pre-versus post-treatment efficacies of either iv GC or OD in these patients were assessed using several indices, including visual acuity, intraocular pressure, ocular alignment, ocular motility, and exophthalmos. RESULTS: Nighty-one eyes had definite DON while 79 were considered to have highly suspected DON. In the iv GC group, 51 individuals(85.0%) eventually demonstrated normal vision, while 10 patients(16.7%) demonstrated a reduction in deviation(P<0.01), and 35 cases(58.3%) showed slight improvements in ocular motility(P<0.01). In OD group, visual acuity improved in 24 cases(96.0%, P<0.01) and all patients showed varying reductions of exophthalmos(mean: 4.35±1.13 mm, P<0.01). Eight cases(32.0%) experienced an 8-15 PD reduction of deviation and ocular motility improved in 12 cases(48.0%), while 3 patients(12.0%) developed new-onset strabismus with diplopia post-surgically(P<0.01). Patients were followed up at an average of 1.55±1.07 y. CONCLUSION: Both iv GC and OD show good therapeutic efficacy in the treatment of sight-threatening TAO. Thepresence of extremely poor eyesight(≥0.5 log MAR) was corrected in some patients with iv GC alone, thus sparing these patients from subsequent OD surgery. In patients who were refractory to steroids, subsequent OD surgery often provided satisfactory outcomes, however, new-onset strabismus with diplopia was observed in 12.0% of these cases.

Lumbopelvic Fixation and Sacral Decompression for U-shaped Sacral Fractures： Surgical Management and Early Outcome

U-shaped sacral fractures are rare and often difficult to diagnose primarily due to the difficulty in obtaining adequate imaging and the severe associated injuries. These fractures are highly unstable and frequently cause neurological deficits. The majority of surgeons have limited experience in management of U-shaped sacral fractures. No standard treatment protocol for U-shaped sacral fractures has been available till now. This study aimed to examine the management of U-shaped sacral fractures and the early outcomes. Clinical data of 15 consecutive patients with U-shaped sacral fracture who were admitted to our trauma center between 2009 and 2014 were retrospectively analyzed. Demographics, fracture classification, mechanism of injury and operative treatment and deformity angle were assessed. All the patients were treated with lumbopelvic fixation or （and） sacral decompression. EQ-5d score was applied to evaluate the patients＇ quality of life. Of the 15 consecutive patients with U-shaped sacral fracture, the mean age was 28.8 years （range： 15-55 years） at the time of injury. There were 6 females and 9 males. The mean follow- up time was 22.7 months （range： 9-47 months） and mean full weight-bearing time was 9.9 weeks （range： 8-14 weeks）. Ten patients received lumbopelvic fixation and sacral decompression, one lombosacral fixation, and 4 merely sacral decompression due to delayed diagnosis or surgery. The post-operation deformity angle （mean 27.87°, and range： 8°-90°） of the sacrum was smaller than that pre-operation （mean 35.67; range： 15-90） with no significance difference noted. At the latest follow-up, all patients obtained neurological recovery with different extents. Visual analogue score （VAS） was reduced from preoperative 7.07 （range： 5-9） to postoperetive 1.93 （range： 1-3）. All patients could walk without any aid after treatment. Eight patients were able to care for themselves and undertook some daily activities. Five patients had returned to work full time. In conclusion, lumbopelvic fixation is an effective method for stabilization of U-shaped sacral fractures with fewer complications developed. Effective reduction and firm fixation are the prerequisite of early mobilization and neurological recovery. Sacral decompression effectively promotes neurological recovery even in patients with old U-shaped sacral fractures.

Decompression of the small bowel by endoscopic long-tube placement

AIM:To investigate and compare the decompression effect on small bowel obstruction of a long tube inserted using either endoscopic or fluoroscopic placement.METHODS:Seventy-eight patients with small bowel obstruction requiring decompression were enrolled in the study and divided into two groups.Intubation of a long tube was guided by fluoroscopy in one group and by endoscopy in the other.The duration of the procedure and the success rate for each group were evaluated.RESULTS:A statistically significant difference in the mean duration of the procedure was found between the fluoroscopic group(32.6±14.6 min)and the endoscopic group(16.5±7.8 min)among the cases classified as successful(P<0.05).The success rate was significantly different between the groups:88.6%in the fluoroscopic group and 100%in the endoscopic group(P <0.05).CONCLUSION:For patients with adhesive small bowel obstruction,long-tube decompression is recommended and long-tube insertion by endoscopy was superior to fluoroscopic placement.

Profile of hepatocyte apoptosis and bile lakes before and after bile duct decompression in severe obstructive jaundice patients

BACKGROUND:Excessive hepatocyte apoptosis and bile lakes in severe obstructive jaundice might impair liver functions.Although decompression of the bile duct has been reported to improve liver functions in animal studies,the mechanism of obstruction differs from that in humans.This study aimed to determine the profiles of hepatocyte apoptosis and bile lakes following bile duct decompression in patients with severe obstructive jaundice in the clinical setting.METHODS:We conducted a 'before and after study' on severe obstructive jaundice patients as a model of inhibition of the excessive process by bile duct decompression.Specimens of liver biopsies were taken before and after decompression of the bile duct and then stained by terminal deoxynucleotide transferase-mediated dUTP nick end-labeling(TUNEL) to identify hepatocyte apoptosis and by hematoxilin-eosin(HE) to identify bile lakes.All measurements were independently done by 2 observers.RESULTS:Twenty-one severe obstructive jaundice patients were included.In all patients,excessive hepatocyte apoptosis and bile lakes were apparent.After decompression,the hepatocyte apoptosis index decreased from 53.1(SD 105) to 11.7(SD 13.6)(P<0.05),and the bile lakes from 23.6(SD 14.8) to 10.9(SD 6.9)(P<0.05).CONCLUSION:Bile duct decompression improves hepatocyte apoptosis and bile lakes in cases of severe obstructive jaundice,similar to the findings in animal studies.

Prognostic factors of trans-ethmosphenoid optic canal decompression for indirect traumatic optic neuropathy

AIM： To investigate a possible correlation between visual acuity（VA） prognosis and the presence at baseline of various orbital and ocular signs in patients affected by indirect traumatic optic neuropathy（ITON）. METHODS： From July 1 st, 2012 to July 1 st, 2015, 224 adults diagnosed with ITON who underwent endoscopic transethmosphenoid optic canal decompression（ETOCD） were reviewed. Visual outcome before and after treatment were taken into comparison. RESULTS： Accompanied older in age, longer time to medical treatment and existence of optic canal fracture（OCF） were the independent predictors for poor postoperative VA and lower improvement degree of visual acuity（IDVA）, while worse preoperative VA was predictive factor for poor postoperative VA only. Mean value of IDVA in patients with OCF was 0.19±0.30. Mean value of IDVA in patients without OCF was 0.29±0.35. IDVA in cases without OCF was significant higher than those with OCF（t=2.272, P〈0.05）. CONCLUSION： Patients suffered from ITON without OCF before ETOCD have better surgical outcome than those with OCF. Older in age, longer time to medical treatment and existence of OCF are independent factors for poor VA prognosis and lower IDVA. Preoperative VA is independent factor for VA prognosis only.

Efficacy and Safety of Low Molecular Weight Heparin Prophylaxis for Venous Thromboembolism Following Lumbar Decompression Surgery

Objective To evaluate the efficacy and safety of low molecular weight heparin (LMWH) prophylaxis for venous thromboembolism (VTE) after lumbar decompression surgery. Methods Patients at high or the highest risk of VTE who underwent lumbar spine surgery in Peking Union Medical College Hospital from January 2004 to April 2011 were included in the present study. All the patients received a half dose of LMWH 6 hours after surgery followed by a full dose LMWH once per day until discharge. We recorded incidences of deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding complications, and medication side effects. Results Seventy-eight consecutive patients were eligible and enrolled in this study. The mean hospital stat was 8.5±4.5 days. No symptomatic DVT, PE, or major bleeding events were observed. One patient developed wound ecchymosis, another developed wound bleeding, four had mild hepatic aminotransferase level elevation, and one developed a suspicious allergic reaction. Conclusion LMWH may be applied as an effective and safe prophylaxis for VTE in high-risk patients undergoing lumbar decompression surgery.

Orbital decompression surgery for the treatment of Graves＇ ophthalmopathy：comparison of different techniques and long-term results

AIM： To evaluate the long-term results of different orbital decompression techniques performed in patients with Graves＇ ophthalmopathy（GO）.METHODS： Totally 170 cases with GO underwent orbital decompression between 1994 and 2014. Patients were divided into 4 groups as medial-inferior, mediallateral（balanced）, medial-lateral-inferior, and lateral only according to the applied surgical technique. Surgical indications, regression degrees on Hertel exophthalmometer, new-onset diplopia in the primary gaze and new-onset gaze-evoked diplopia after surgery and visual acuity in cases with dysthyroid optic neuropathy（DON） were compared between different surgical techniques.RESULTS： The study included 248 eyes of 149 patients. The mean age for surgery was 42.3±13.2 y. DON was the surgical indication in 36.6% of cases, and three-wall decompression was the most preferred technique in these cases. All types of surgery significantly decrease the Hertel values（P〈0.005）. Balanced medial-lateral, and only lateral wall decompression caused the lowest rate of postoperative new-onset diplopia in primary gaze. The improvement of visual acuity in patients with DON did not significantly differ between the groups（P=0.181）. CONCLUSION： The study show that orbital decompression surgery has safe and effective long term results for functional and cosmetic rehabilitation of GO. It significantly reduces Hertel measurements in disfiguring proptosis and improves visual functions especially in DON cases.

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.