Surgical outcome following a decompressive craniectomy for acute epidural hematoma patients presenting with associated massive brain swelling
Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan. Acta neurochirurgica. Supplement
01/2010; 106(106):261-4. DOI: 10.1007/978-3-211-98811-4_49
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.
Available from: Andrew A. Tarnaris
- " haematoma evacuation ( n ¼ 46 ) or haematoma evacuation and DC ( n ¼ 34 ) . They concluded that DC helps to reduce the morbidity and mortality by controlling the ICP for AEDH patients in critical condition . However , further investigations are required to clarify the usefulness of DC for treating long - term higher cortical function after AEDH ( Otani et al . , 2009 ) ."
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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.
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ABSTRACT: Background: Acute subdural hematoma is frequently associated with primary brain injury consisting of cerebral contusion and/or cerebral edema. Subdural hematoma evacuation addresses mass effect caused by the hematoma but does not address the underlying associated primary brain injury. Objective: To review the clinical outcome of a series of severe head injured patients (GCS ≤8) with acute subdural hematoma who underwent surgical evacuation of the hematoma along with a decompressive craniectomy, determining prognostic factors related to a favorable outcome. Methods: This retrospective study identified 37 patients with acute sudural hematoma and an admission GCS score ≤8, who underwent treatment by surgical evacuation of the hematoma as well as a decompressive craniectomy. The patient's hospital records, radiological findings and operative records were reviewed. The data was analyzed to determine factors associated with prognosis. Results: Thirty (81.1%) were males and 7 (18.9%) were females. Ages ranged from 14-65 years. There were 11 (29.7%) patients with signs of herniation. The mean time elapsed from head trauma to surgery was 4.8 hours. The mean thickness of the ASDH was 10.1mm, while the mean midline shift was 11.4 mm. In 9 (24.3%) cases there was an associated brain injury. The mortality rate was 13.5% (5 patients). Conclusion: Prognostic factors affecting outcome were admission GCS score, signs of herniation, patient comorbidities and midline shift in preoperative CT.
Available from: Athanasios Zisakis
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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.
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