Surgical outcome following a decompressive craniectomy for acute epidural hematoma patients presenting with associated massive brain swelling.
ABSTRACT Acute epidural hematomas (AEDH) are generally managed with rapid surgical hematoma evacuation and bleeding control. However, the surgical outcome of patients with serious brain edema is poor. This study reviewed the clinical outcome for AEDH patients and evaluated the efficacy of the DC, especially in patients with associated massive brain swelling. Eighty consecutive patients surgically treated with AEDH were retrospectively assessed. The patients were divided into two groups: (a) hematoma evacuation (HE: 46 cases) and (b) HE+ an external decompression (ED: 34 cases). The medical charts, operative findings, radiological findings, and operative notes were reviewed. In the poor outcome group, there were 18 patients (72%), with a GCS score of less than 8 (severe injury), and 22 patients (88%) who showed pupil abnormalities. Many more patients showed a midline shift, basal cistern effacement, and brain contusion in comparison to the favorable outcome group. In the favorable outcome group, almost all of the patients (98%) showed less than 12 mm of a midline shift. The influential factors may be age, GCS, pupil abnormalities, size, midline shift, basal cistern effacement, coincidence of contusion and swelling. We conclude that an A DC may be effective to manage the AEDH patients with cerebral contusion or massive brain swelling.
- SourceAvailable from: Athanasios Zisakis[Show abstract] [Hide abstract]
ABSTRACT: The development of emergency medical services and especially neurosurgical emergencies during recent decades has necessitated the development of novel tools. Although the gadgets that the neurosurgeon uses today in emergencies give him important help in diagnosis and treatment, we still need new technology, which has rapidly developed. This review presents the latest diagnostic tools, which offer precious help in everyday emergency neurosurgery practice. New ultrasound devices make the diagnosis of haematomas easier. In stroke, the introduction of noninvasive new gadgets aims to provide better treatment to the patient. Finally, the entire development of computed tomography and progress in radiology have resulted in innovative CT scans and angiographic devices that advance the diagnosis, treatment, and outcome of the patent. The pressure on physicians to be quick and effective and to avoid any misjudgement of the patient has been transferred to the technology, with the emphasis on developing new systems that will provide our patients with a better outcome and quality of life.Emergency medicine international. 01/2013; 2013:568960.
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ABSTRACT: Decompressive craniectomy (DC) is the surgical management removing part of the skull vault over a swollen brain used to treat elevated intracranial pressure that is unresponsive to maximal medical therapy. The commonest indication for DC is traumatic brain injury (TBI) or middle cerebral artery (MCA) infarction, though DC has been reported to have been used for treatment of aneurysmal subarachnoid haemorrhage and venous infarction. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies are retrospective, the recent publication of several randomised prospective studies prompts a re-evaluation of the use of DC. We review the literature concerning the pathophysiology, indication, surgical techniques and timing, complications and long-term effects of DC (including reversal with cranioplasty), in order to rationalise its use. We conclude that at the time of this review, though we cannot support the routine use of DC in TBI or MCA stroke, there is evidence that early and aggressive use of DC in TBI patients with intracranial haematomas or younger malignant MCA stroke patients may improve outcome. Though the results of the DECRA trial suggest that primary DC may worsen outcome, the decision to perform DC after diffuse TBI is still individualised. We await the results of the RESCUEicp trial to ascertain whether an evidence-based protocol for its use can be agreed in the future.Trauma 01/2012; 14(1):16-38.
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ABSTRACT: Posttraumatic massive cerebral infarction (MCI) is a fatal complication of concurrent epidural haematoma (EDH) and brain herniation that commonly requires an aggressive decompressive craniectomy. The risk factors and surgical indications of MCI have not been fully elucidated. In this retrospective study, posttraumatic MCI was diagnosed in 32 of 176 patients. The performance of a decompressive craniectomy simultaneously with the initial haematoma-evacuation surgery improved their functional outcomes compared with delayed surgery [on the 6-month Extended Glasgow Outcome Scale, 5.6±1.5 vs. 3.4±0.6, P <0.001]. Significantly increased risks for MCI were observed in patients with an EDH at a trans-temporal location (adjusted odds ratio [OR] 16.48, P =0.003), an EDH larger than 100 mL in volume (OR 7.04, P =0.001), pre-operative shock for longer than 30 minutes (OR 13.78, P =0.002), bilateral mydriasis (OR 7.08, P =0.004), pre-operative brain herniation for longer than 90 minutes (OR 6.41, P <0.001), and a Glasgow Coma Score of 3-5 points (OR 2.86, P <0.053). Multivariate logistic regression analysis revealed no significant association between posttraumatic MCI and age, gender, midline shift, Rotterdam CT score, intra-operative hypotension, or serum concentrations of sodium or glucose. The incidence of posttraumatic MCI increased from 16.4% in those having any two of the six risk factors to 47.7% in those having any three or more of the six risk factors ( P <0.001). The patients with concurrent EDH and brain herniation exhibited an increased risk for posttraumatic MCI with the accumulation of several critical clinical factors. Early decompressive craniectomy based on accurate risk estimation is recommended in efforts to improve the patient functional outcomes.Journal of neurotrauma 04/2014; · 4.25 Impact Factor