Decompressive Craniectomy For Decompressive Craniectomy For Refractory Intracranial Hypertension: Refractory Intracranial Hypertension:

Rationale, Indications and Rationale, Indications and complications.complications.

Khaled Abdeen M.D.*, Hisham Khaled Abdeen M.D.*, Hisham Aboul-Enein M.D*, Yasser Orz M.D*, Aboul-Enein M.D*, Yasser Orz M.D*,

Shahira A El-Metainy M.D**. Shahira A El-Metainy M.D**.*Department of Neurosurgery – Alexandria University*Department of Neurosurgery – Alexandria University

** Department of Anesthesiology – Alexandria University** Department of Anesthesiology – Alexandria University

Malignant brain edema is a state of severe, Malignant brain edema is a state of severe, progressive and diffuse cerebral edema that progressive and diffuse cerebral edema that causes rapid clinical deterioration which does causes rapid clinical deterioration which does not respond to aggressive treatment .not respond to aggressive treatment .

Clinically, malignant brain oedema is Clinically, malignant brain oedema is manifested by herniation syndrome in the form manifested by herniation syndrome in the form of rapid deterioration of consciousness and of rapid deterioration of consciousness and pupillary changes . pupillary changes .

Radiologically , there are compression of the Radiologically , there are compression of the ventricles, poor grey white matter differentiation , ventricles, poor grey white matter differentiation , obliteration of the basal cisterns , and loss of obliteration of the basal cisterns , and loss of normal gyral pattern .normal gyral pattern .

The American Association of The American Association of Neurological SurgeonsNeurological Surgeons

has recommended decompressive craniectomy for has recommended decompressive craniectomy for patients with traumatic brain injury (TBI) and refractory patients with traumatic brain injury (TBI) and refractory IH if some or all of the following criteria were met: IH if some or all of the following criteria were met:

1) Diffuse cerebral swelling on cranial CT imaging. 1) Diffuse cerebral swelling on cranial CT imaging. 2) Within 48 hours of injury .2) Within 48 hours of injury . 3) No episodes of sustained ICP > 40 mmHg before 3) No episodes of sustained ICP > 40 mmHg before

surgery.surgery. 4) GCS >3 at some point subsequent to injury. 4) GCS >3 at some point subsequent to injury. 5) Secondary clinical deterioration.5) Secondary clinical deterioration. 6) Evolving cerebral herniation syndrome.6) Evolving cerebral herniation syndrome. 7) pupillary abnormalities but respond to mannitol . 7) pupillary abnormalities but respond to mannitol .

Malignant” MCA infarctionMalignant” MCA infarction is defined as an infarction of at least two thirds is defined as an infarction of at least two thirds

MCA territory upward . These patients present MCA territory upward . These patients present clinically with severe hemispheric stroke clinically with severe hemispheric stroke syndrome and progressive deterioration of syndrome and progressive deterioration of consciousness within the first 2 days. Thereafter, consciousness within the first 2 days. Thereafter, symptoms of transtentorial herniation occur symptoms of transtentorial herniation occur within 2–4 days of stroke onset. These patients’ within 2–4 days of stroke onset. These patients’ prognosis is poor and mortality is as high as prognosis is poor and mortality is as high as 80% . So therapy of malignant MCA infarction 80% . So therapy of malignant MCA infarction should be more aggressive . should be more aggressive .

Malignant Middle Cerebral Artery Malignant Middle Cerebral Artery Infarction SyndromeInfarction Syndrome

Large hemispheric infarction involving Large hemispheric infarction involving >50% of MCA territory associated with a >50% of MCA territory associated with a massive cerebral oedema and brain-stem massive cerebral oedema and brain-stem herniationherniation

Caused by complete/ near complete Caused by complete/ near complete occlusion of either internal carotid artery occlusion of either internal carotid artery (ICA trunk) or proximal middle cerebral (ICA trunk) or proximal middle cerebral artery artery

MMCAISMMCAIS

Dense pyramidal signs (initial)Dense pyramidal signs (initial) Neurological deterioration < 24-72 hrNeurological deterioration < 24-72 hr1 1 due to due to

elevated ICP leading to brain stem herniationelevated ICP leading to brain stem herniation Very high mortality despite maximal medical Very high mortality despite maximal medical

treatmenttreatment 70% (37/ 53 ) died in NICU (33/37 died within first 70% (37/ 53 ) died in NICU (33/37 died within first

5 days)5 days)22

78% (35/45) died within 1 week78% (35/45) died within 1 week11

1. NG L et al. Stroke 19702. Berrouschot J et al. ICM 1998

Decompressive craniectomy [DC] has Decompressive craniectomy [DC] has been used as a final option in the been used as a final option in the management of refractory intracranial management of refractory intracranial hypertension . It is a method of giving hypertension . It is a method of giving room to the swelling brain , can be life room to the swelling brain , can be life saving procedure because it decreases saving procedure because it decreases compression of brain stem structures and compression of brain stem structures and minimizes herniation . minimizes herniation .

Reduce ICP . Reduce ICP . Improve blood flow . Improve blood flow . Reduce damage to surrounding brain Reduce damage to surrounding brain

tissue . tissue . reduce secondary brain injury . reduce secondary brain injury .

Aims of Decompressive Aims of Decompressive CraniectomyCraniectomy

Early DCEarly DC

Early DC reduces brain edema formation by more than 50% and prevents secondary brain damage when performed early enough (i.e., during the first 3 h after trauma).

(Zweckberger K, et al.; 2006)

Does decompressive craniectomy improve Does decompressive craniectomy improve outcomes?outcomes?

Survival (mortality) Survival (mortality) Functional outcomes .Functional outcomes . Can we predict malignant brain Can we predict malignant brain

oedema? oedema? Timing: when to operate? Timing: when to operate?

Before and after…Before and after…

Large (10 × 15 cm) frontotemporoparietal craniectomy with the

lower margin from the middle cranial fossa. In the event of massive cerebral swelling, extensive duraplasty

with internal decompression is performed.

Decompressive Hemicraniectomy Decompressive Hemicraniectomy (DH)(DH)

11stst described by Kocher in 1901 for the treatment of TBI described by Kocher in 1901 for the treatment of TBI 11stst reported by Rengachary S et al. reported by Rengachary S et al.1 1 for the treatement for the treatement

of MMCAIS in 1981of MMCAIS in 1981 Removal of an ipsilateral bone flap ≥ 12 cm in Removal of an ipsilateral bone flap ≥ 12 cm in

diameter and including parts of the frontal, parietal, diameter and including parts of the frontal, parietal, temporal and occipital squama plus Duraplastytemporal and occipital squama plus Duraplasty

To relieve ICPTo relieve ICP Inadequate craniectomy size is associated with Inadequate craniectomy size is associated with

parencymal haemorrhage ± infarction and increased parencymal haemorrhage ± infarction and increased mortalitymortality22

1. Rengachary S et al Neurosurgery 1981: vol 8/3, 321-3282. Wagner S et al. Journal of Neurosurgery, May 2001, vol./is. 94/5(693-6)

Results Results Group (A) trauma patients:Group (A) trauma patients: In the current study, using the inclusion criteria ; 65 In the current study, using the inclusion criteria ; 65

patients had severe head injuries. The mean GCS of patients had severe head injuries. The mean GCS of patients was 5.83± 1.76 with a range of 4-9 (9 cases patients was 5.83± 1.76 with a range of 4-9 (9 cases were moderate head injury with GCS 9 while the rest were moderate head injury with GCS 9 while the rest were severe head injury with GCS 8 or less).In our were severe head injury with GCS 8 or less).In our study, 25 cases were managed within the first 12 hours study, 25 cases were managed within the first 12 hours of admission with a range from 2-8 hours. The time of admission with a range from 2-8 hours. The time interval from admission to initial management in hours interval from admission to initial management in hours for the studied cases ranged between 2 to 8 hours with for the studied cases ranged between 2 to 8 hours with mean of 3.27 ± 0.98. According to GOS , the outcome mean of 3.27 ± 0.98. According to GOS , the outcome was favorable in 54% , unfavorable in 38.4% , and death was favorable in 54% , unfavorable in 38.4% , and death in 7.6% . in 7.6% .

Results Results Group (B) post-ischemic:Group (B) post-ischemic: This group included 15 patients with malignant MCA infarction , one of This group included 15 patients with malignant MCA infarction , one of

them with carotid artery dissection causing hemispheric infarction . All them with carotid artery dissection causing hemispheric infarction . All underwent ipsilateral frontotemporal decompressive craniectomy . Large underwent ipsilateral frontotemporal decompressive craniectomy . Large parenchymal hyperdensity more than 50% and within 48 hours of stroke parenchymal hyperdensity more than 50% and within 48 hours of stroke onset . The outcome was favorable in 53.4% , unfavorable in 26.6% and onset . The outcome was favorable in 53.4% , unfavorable in 26.6% and death in 20% . death in 20% .

Group (C) post-intra-axial temporal lobe tumorGroup (C) post-intra-axial temporal lobe tumor:: This group included only 4 patients who underwent elective craniectomy This group included only 4 patients who underwent elective craniectomy

for excision of temporal intra-axial lesion (two patients with glioblastoma for excision of temporal intra-axial lesion (two patients with glioblastoma multiformi and two patients with oligodendroglioma) where in the first multiformi and two patients with oligodendroglioma) where in the first post-operative 24 hours the patients showed marked deterioration post-operative 24 hours the patients showed marked deterioration together with signs of lateralization and an immediate CT scan was together with signs of lateralization and an immediate CT scan was done which showed no residual lesion , no hematoma, yet extensive done which showed no residual lesion , no hematoma, yet extensive temporal lobe edema with subfalcine herniation for more than 2 cms. temporal lobe edema with subfalcine herniation for more than 2 cms. These cases add a new indication for decompressive craniotomy as a These cases add a new indication for decompressive craniotomy as a lie saving procedure when all other conservative maneuvers fail. The lie saving procedure when all other conservative maneuvers fail. The outcome was favorable in 75% and unfavorable in 25% . outcome was favorable in 75% and unfavorable in 25% .

Results Results Group (D) spontaneous intra-cerebral hematoma:Group (D) spontaneous intra-cerebral hematoma: This group included 6 cases admitted to the ICU This group included 6 cases admitted to the ICU

suffering from spontaneous intra-cerebral hematoma in suffering from spontaneous intra-cerebral hematoma in the temporal lobe which caused disturbance in the level the temporal lobe which caused disturbance in the level of conscious. All patients where operated upon for of conscious. All patients where operated upon for primary evacuation of the hematoma and simultaneously primary evacuation of the hematoma and simultaneously for decompressive craniectomy to avoid the effect of for decompressive craniectomy to avoid the effect of post-operative vasogenic edema and subsequent post-operative vasogenic edema and subsequent subfalcine shiftsubfalcine shift. . The outcome was favorable in 50 % , The outcome was favorable in 50 % , unfavorable in 33% and death in 17% . unfavorable in 33% and death in 17% .

The total outcome for all groups was favorable outcome The total outcome for all groups was favorable outcome in 54.4 % [49 patients] . unfavorable in 35.6 % [ 32 in 54.4 % [49 patients] . unfavorable in 35.6 % [ 32 patients ] , death in 10 % [9 patients ] patients ] , death in 10 % [9 patients ]

Literature SearchLiterature Search

Ovid Medline, Embase, Cochrane & finally Ovid Medline, Embase, Cochrane & finally handsearchhandsearch

keywords “stroke, middle cerebral artery keywords “stroke, middle cerebral artery infarction, brain oedema, decompressive infarction, brain oedema, decompressive hemicraniectomy and decompressive hemicraniectomy and decompressive surgery” from January surgery” from January 1998 to July 20091998 to July 2009

Medline – 165, Embase 465, Cochrane 17Medline – 165, Embase 465, Cochrane 17 3 RCTs, one meta-analysis, 3 SR, 50 3 RCTs, one meta-analysis, 3 SR, 50

observational studiesobservational studies

Scoring systemScoring system

NIHSSNIHSS National Institute Health Stroke ScaleNational Institute Health Stroke Scale Motor / sensory / speech / visionMotor / sensory / speech / vision 11 parts, scores -4011 parts, scores -40 >25 severe stroke>25 severe stroke

Barthel Index (BI)Barthel Index (BI) Assess disability in regards to activity of daily Assess disability in regards to activity of daily

livingliving Total score 0-100Total score 0-100 Dependency - Score < 60 Dependency - Score < 60

Scoring systemScoring system Modified Rankins ScoreModified Rankins Score

0 No symptoms at all1 No significant disability despite symptoms;

able to carry out all usual duties and activities

2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance

3 Moderate disability; requiring some help, but able to walk without assistance

4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance

5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention

6 Dead

Scoring systemScoring system Glasgow Outcome ScoreGlasgow Outcome Score1 Dead2 Persistent vegetative state

Patient exhibits no obvious cortical function.

3 Severe Disability(Conscious but disabled). Patient depends upon others for daily support due to mental or physical disability or both

4 Moderate Disability(Disabled but independent). Patient is independent as far as daily life is concerned. The disabilities found include varying degrees of dysphasia, hemiparesis, or ataxia, as well as intellectual and memory deficits and personality changes.

5 Good RecoveryResumption of normal activities even though there may be minor neurological or psychological deficits.

Case seriesCase series

30 case series (4 prospective)30 case series (4 prospective) Early mortality : mean 23% (range 7% to 60%) [18 Early mortality : mean 23% (range 7% to 60%) [18

studies]studies] Long term Long term mortality, ≥6 months to 3.4 yr : mean mortality, ≥6 months to 3.4 yr : mean

29.68% (15.7% to 49%)29.68% (15.7% to 49%) [19 studies] [19 studies] Barthel Index - mean 45 to 80 [9 studies]Barthel Index - mean 45 to 80 [9 studies] mRS – no/ mild in 20%, moderate/severe in 50% (9 mRS – no/ mild in 20%, moderate/severe in 50% (9

studies)studies) GOS – similar to mRSGOS – similar to mRS

Complications Complications

Complications Complications % % -Subdural hygroma Subdural hygroma -Hydrocephalus Hydrocephalus -CSF leak CSF leak -Wound infectionWound infection-Intraventricular hemorrhage Intraventricular hemorrhage -Contralateral small EDH Contralateral small EDH

6.66.64.44.410105.55.51.11.11.11.1

Comparative StudiesComparative Studies

Schwab et al – 63 pts, Early (<24 hr, b/4 Schwab et al – 63 pts, Early (<24 hr, b/4 MLS) vs. Late (>24 h), early mortality was MLS) vs. Late (>24 h), early mortality was 16%16%vs. 34.4% and BI 68.8 vs. 62vs. 34.4% and BI 68.8 vs. 62

Cho et al – 52 pts, (<6h vs. > 6 h vs. Cho et al – 52 pts, (<6h vs. > 6 h vs. Medical), early mortality (Medical), early mortality (7.8% 7.8% vs. 36.7% vs. 36.7% vs. 80%), better BI (70)and GOS (4)vs. 80%), better BI (70)and GOS (4)

6 studies compared DH with medical Rx. 6 studies compared DH with medical Rx. Early mortality was Early mortality was 4.8%4.8% - 21% in DH - 21% in DH whereas 42-83% in Medical groupswhereas 42-83% in Medical groups

Different outcomes in non-Different outcomes in non-randomised studiesrandomised studies

AgeAge Timing of surgery – before or after signs Timing of surgery – before or after signs

of brain herniationof brain herniation Additional vascular territory involvementAdditional vascular territory involvement

Can we predict brain oedema?Can we predict brain oedema?

Kasner S et al, 2001Kasner S et al, 2001 Hypertension, heart failure, ↑ WBCHypertension, heart failure, ↑ WBC CT - > 50% hypodensity and additional CT - > 50% hypodensity and additional

vascular involvementvascular involvement Hofmeijer J et al 2008Hofmeijer J et al 2008

Infarct size > 66%Infarct size > 66% additional vascular involvementadditional vascular involvement

Thormalla G et al 2003Thormalla G et al 2003 Quantitative analysis of early DWI & PWI Quantitative analysis of early DWI & PWI

can predict MMCAIcan predict MMCAI

Systematic ReviewsSystematic Reviews

Cochrane (Morley N et al, 2002) – no RCT Cochrane (Morley N et al, 2002) – no RCT evidence to support DH (reviewed non-evidence to support DH (reviewed non-randomised studies from 1971-2001)randomised studies from 1971-2001)

Hofmeijer J et al (CCM 2003; 31/2: 617-Hofmeijer J et al (CCM 2003; 31/2: 617-25) - 2 large non-randomised studies 25) - 2 large non-randomised studies showed promising results in terms of showed promising results in terms of reduction in mortality and functional reduction in mortality and functional outcome outcome

Juttler E et al (DESTINY) 2007, Juttler E et al (DESTINY) 2007, Germany (RCT)Germany (RCT)

Age 18 to 60 years with Age 18 to 60 years with clinical signs of MCA territory clinical signs of MCA territory infarctioninfarction

Severity - NIHSS >18 for (D) Severity - NIHSS >18 for (D) and ≥ 20 for (ND) lesions, and ≥ 20 for (ND) lesions,

CT - ≥ 2/3 of MCA territory, CT - ≥ 2/3 of MCA territory, Concious level - score ≥ 1 on Concious level - score ≥ 1 on

item 1a of NIHSSitem 1a of NIHSS Timing - Timing - onset >12 hr and < onset >12 hr and <

36hr36hr, possibility to start , possibility to start within 6 hr after within 6 hr after randomizationrandomization

Surgery (n=17) vs. medical Surgery (n=17) vs. medical (n=15)(n=15)

Mean age: 43.2±9.7 vs Mean age: 43.2±9.7 vs 46.1±8.446.1±8.4

Dominant side 53% vs. 73%Dominant side 53% vs. 73% Median NIHSS 21 vs.24Median NIHSS 21 vs.24 Time to surgery 24.4±6.9 hTime to surgery 24.4±6.9 h 30 day survial : 88% vs. 30 day survial : 88% vs.

47%47% mRS 0-3: 47% vs. 27% mRS 0-3: 47% vs. 27%

(NS)(NS)

Vahedi et al 2007 (DECIMAL), Vahedi et al 2007 (DECIMAL), FranceFrance

Onset within 24 hr Onset within 24 hr of of malignant MCA infarct malignant MCA infarct defined by – 3 criteria: defined by – 3 criteria:

NIHSS ≥ 16 (including NIHSS ≥ 16 (including score ≥ 1 on item 1a), score ≥ 1 on item 1a),

CT ischaemic signs > CT ischaemic signs > 50% of MCA territory, 50% of MCA territory,

DWI infarct volume > DWI infarct volume > 145 cm145 cm33

Surgery (n=20) vs. Surgery (n=20) vs. medical (n=18)medical (n=18)

Mean interval to Mean interval to surgery20.5 ± 8.3 (7-43) surgery20.5 ± 8.3 (7-43) hrhr

Mean age 43.5 ± 9.7 vs. Mean age 43.5 ± 9.7 vs. 43.3 ± 7.1 yr43.3 ± 7.1 yr

28 day mortality: (25%) 28 day mortality: (25%) vs. (77.7%), p<0.0001vs. (77.7%), p<0.0001

mRS ≤ 3 at 12 months: mRS ≤ 3 at 12 months: 50% vs. 22.2% (NS)50% vs. 22.2% (NS)

mRS ≤ 4 at 12 months: mRS ≤ 4 at 12 months: 75% vs. 2.2% (p 0.0029)75% vs. 2.2% (p 0.0029)

Hofmeijer et al 2009 [HAMLET] – Hofmeijer et al 2009 [HAMLET] – NetherlandNetherland

Age 18 to 60 years with Age 18 to 60 years with clinical signs of MCA territory clinical signs of MCA territory infactioninfaction

Severity - NIHSS >16 for Severity - NIHSS >16 for (ND) and ≥ 21 for (D) lesions, (ND) and ≥ 21 for (D) lesions,

CT - ≥ 2/3 of MCA territory + CT - ≥ 2/3 of MCA territory + formation of space occupying formation of space occupying oedema oedema

Concious level - GCS ≤ 13 Concious level - GCS ≤ 13 for (R) or ≤ 9 for (L)for (R) or ≤ 9 for (L)

Timing - Timing - onset < 96hronset < 96hr, , possibility to start within 3 hr possibility to start within 3 hr after randomizationafter randomization

64 (DH vs. Medical)64 (DH vs. Medical) Age 50 vs. 47 yrAge 50 vs. 47 yr Mean interval of Mean interval of

randomisation – 31 randomisation – 31 hrhr

Mortality 21 vs. 59% Mortality 21 vs. 59% (ARR 38%, p 0.002)(ARR 38%, p 0.002)

mRS 4-6 - no diffmRS 4-6 - no diff

Pooled analysis of 3 RCTsPooled analysis of 3 RCTs

At 12 month

Surgery Medical ARR

mRS > 3 35/58 – 60.3%

39/51 – 76%

16.3% (- 0.1- 33.1)

mRS > 4 19/58 – 32.7%

38/51 – 74.5%

41.9% (25.2 to 58.6)

Death 12/58 – 20.6%

36/51 – 70.5%

49.9% (33.9 to 65.9)109 patients included (DESTINY+DECIMAL+ HAMLET)

Inclusion – within 45 hr (DH < 48 hr)NNT To prevent mRS > 3 at one year is 6To prevent mRS > 4 at one year is 2To prevent death at one year is 2

Summary of EvidenceSummary of Evidence

Decompressive Hemicraniectomy if Decompressive Hemicraniectomy if performed early (< 48 hr) improve survival performed early (< 48 hr) improve survival and functional outcome in patients (< 60 yr) and functional outcome in patients (< 60 yr) with malignant MCA infarction [RCT with malignant MCA infarction [RCT confirms the results of observational study)confirms the results of observational study)

Level of evidence 1Level of evidence 1++, Grade B, Grade B Recommended by National Clinical Recommended by National Clinical

Guideline for Stroke, 4.6.1.k, 3Guideline for Stroke, 4.6.1.k, 3rdrd edition July edition July 20082008

FutureFuture Quality of life by SF36 and SIS, and Quality of life by SF36 and SIS, and

Aphasia by Aachen aphasia test at 2-3 Aphasia by Aachen aphasia test at 2-3 year from DESTINY trial are still awaitedyear from DESTINY trial are still awaited

4 Ongoing trials4 Ongoing trials HeaDDFIRSTHeaDDFIRST HeMMIHeMMI DEMITURDEMITUR DESTINY 2DESTINY 2

Economic AssessmentEconomic Assessment ? DH + Therapeutic Hypothermia? DH + Therapeutic Hypothermia

ConclusionConclusion Malignant MCA syndrome should be Malignant MCA syndrome should be

consideredconsidered For ICU oncall - If indicated, mechanical For ICU oncall - If indicated, mechanical

ventilation should be offered in appropriate ventilation should be offered in appropriate patients (age < 60 y, no significant patients (age < 60 y, no significant comorbidity)comorbidity)

Decompressive surgery is aggressive but Decompressive surgery is aggressive but life saving and should be discussed with life saving and should be discussed with patient/ familypatient/ family

Need s a hospital guideline agreed by all Need s a hospital guideline agreed by all parties involvedparties involved

1. Japanese guidelines for the management of severe head injury (1st ed., 2000; 2nd ed. 2006)

“ DC may be done after the evacuation of intracranial hematoma such as acute subdural hematoma and so on (level III evidence).” 2. Japanese guidelines for the management of stroke (2004)

① “DC in cerebellar infarction with brain stem compression is recommended as level III evidence.”

② “DC in hemispheric infarction involved in MCA

territory is recommended as level IIa and III evidence.”

Operative Indications for DC

based on the guidelines in Japan

Early DC should be performed before the onset

of brain herniation to achieve satisfactory outcome

in patients with large infarction (Mori K, et al., 2004)

Early DC Delayed DC

Operative timing for DC

Surgical Technique for DC (4)・ The autologous bone flap is sealed in a sterilized vinyl bag and stored in a deep freezer at -70℃.・ Cranioplasty is performed 2 to 3 months after DC. On the morning of cranioplasty, the bone flap is allowed to remain at room temperature and gently rinsed in sterile saline containing antibiotics.

Autoclaving the bone flap has shown to denature bone protein and impair vascularization and resorption and therefore is not routinely performed.

Hydrocephalus with shunt valve adjusted at

200 mmH2O

After bed-up 30°

Complications of DC“sinking skin flap syndrome” and

paradoxical transtentorial herniation

Sinking skin flap syndrome Midline shift & herniation

After bed rest

Surgical Technique for DC (5) Recently, a variety of custom-made alloimplants, (including polymerized polymethylmethacrylate (PMM), titanium mesh, ceramics and hydroxyapatite) are used as a bone graft material, if the autologous bone flap is out of use.

Custom-made polymerized PMMCustom-made titanium mesh

CT scans obtained before and after DCCerebral infarction

SAH with vasospasm

Acute subduralhematoma

with internal decompression

Intracerebralhematoma

Preope

Postope

SummarySummary

DC improves ICP and brain tissue DC improves ICP and brain tissue oxygenationoxygenation

DC likely to be more effective in young DC likely to be more effective in young and when done earlyand when done early

Lack of Class I evidence at present Lack of Class I evidence at present Two big RCT’s on the wayTwo big RCT’s on the way

Study design Study design

We retrospectively reviewed a series of 90 We retrospectively reviewed a series of 90 patients who were operated upon for patients who were operated upon for Decompressive craniotomy with augmented Decompressive craniotomy with augmented duroplasty over a period of 3 year starting duroplasty over a period of 3 year starting from June 2005 to June 2009. All patients from June 2005 to June 2009. All patients were admitted to the neurosurgery were admitted to the neurosurgery department, Alexandria University suffering department, Alexandria University suffering from severe intracranial hypertension that from severe intracranial hypertension that was refractory to the all conventional anti-was refractory to the all conventional anti-edema measures done at the intensive care edema measures done at the intensive care unit.unit.

classificationclassification Group (A) : resulting from traumatic brain injury . Group (A) : resulting from traumatic brain injury . Group (B) : ischemic resulting from middle Group (B) : ischemic resulting from middle

cerebral artery occlusion causing malignant cerebral artery occlusion causing malignant infarction . infarction .

Group (C) : postoperative after excision of an Group (C) : postoperative after excision of an intra-axial temporal lobe tumor . intra-axial temporal lobe tumor .

Group (D) : suffering from spontaneous Group (D) : suffering from spontaneous intracerebral haematoma with surrounding intracerebral haematoma with surrounding vasogenic edema..vasogenic edema..

Results Results The study included 90 patients 57 of them were males The study included 90 patients 57 of them were males

while 33 were females, with a mean age of 47 years while 33 were females, with a mean age of 47 years (range, 18-66 years), underwent DC. Mean preoperative (range, 18-66 years), underwent DC. Mean preoperative GCS score was 7/15 (range, 3-8/15),GCS score was 7/15 (range, 3-8/15),

Unilateral dilated un-reactive pupil was seen in 18 cases Unilateral dilated un-reactive pupil was seen in 18 cases and bilateral variants in 6 cases. All patients received a and bilateral variants in 6 cases. All patients received a wide DC with duroplasty. Median preoperative time was wide DC with duroplasty. Median preoperative time was 8 hours from the time of trauma. The patients’ outcome 8 hours from the time of trauma. The patients’ outcome was evaluated by using the GOS. Furthermore, the was evaluated by using the GOS. Furthermore, the results were analyzed toward the time of surgical results were analyzed toward the time of surgical intervention (early or late), the patient’s age, and the intervention (early or late), the patient’s age, and the preoperative GCS using a multivariate analysis.preoperative GCS using a multivariate analysis.

ConclusionsConclusions

The encouraging results of our study as The encouraging results of our study as well as those of recent published reports well as those of recent published reports emphasize the importance of this emphasize the importance of this procedure in changing and improving the procedure in changing and improving the Glasgow coma score of the patients. It Glasgow coma score of the patients. It was observed that the early the surgical was observed that the early the surgical intervention was the better the outcome of intervention was the better the outcome of patients. Decompressive craniotomy patients. Decompressive craniotomy showed minor complications in unilateral showed minor complications in unilateral temporal lobe edema.temporal lobe edema.

ConclusionsConclusions

Decompressive craniectomy (DC) is an effective treatment, able to reduce mortality

improve neurological outcome in patients with massive brain swelling.

However, there is still a lack of randomized trials showing the effects of DC.

ii) ) Do you do bifrontal craniectomy or bifrontoDo you do bifrontal craniectomy or bifronto--temporal temporal craniectomy craniectomy

We perform decompressive craniectomy (DC) according We perform decompressive craniectomy (DC) according with the morphology of the brain edema.Bifrontotemporal with the morphology of the brain edema.Bifrontotemporal

  ii) do you divide the sagittal sinus anteriorly? You you ii) do you divide the sagittal sinus anteriorly? You you divide the falx? how do you divide the falx? YES , it gives divide the falx? how do you divide the falx? YES , it gives adequated decomptression of the frontal lobes bur avoid adequated decomptression of the frontal lobes bur avoid venous injury as it leads to hemorrhagic lesion .venous injury as it leads to hemorrhagic lesion .

  iii) do you open the frontal sinus and remove the iii) do you open the frontal sinus and remove the posterior wall of the frontal sinus?posterior wall of the frontal sinus?

If the anatomy of frontal sinus is wide, YES. And we If the anatomy of frontal sinus is wide, YES. And we taponade the nasal ostium with temporal muscletaponade the nasal ostium with temporal muscle

iviv) ) do you leave the bone over the sagittal sinus intact? do you leave the bone over the sagittal sinus intact? NO . i remove all the bone NO . i remove all the bone

A special consideration is taken with the borders of the A special consideration is taken with the borders of the craniectomy, that must be drilled to become angled craniectomy, that must be drilled to become angled (app.45º ), to impede a cutting pressure over the draining (app.45º ), to impede a cutting pressure over the draining veins.And when we go to the media fossa, we reach the veins.And when we go to the media fossa, we reach the skull base.skull base.

  v) do you monitor ICP in patients who had craniectomy? v) do you monitor ICP in patients who had craniectomy? if so do you use a parenchymal probe or subdural if so do you use a parenchymal probe or subdural catéter. YES. i suse parenchymal sensor ..catéter. YES. i suse parenchymal sensor ..

  vi) do you do duroplasty-YES. With artificial dura vi) do you do duroplasty-YES. With artificial dura   vii) do you leave a silastic sheet between the brain and vii) do you leave a silastic sheet between the brain and

the scalp/temporalis muscle.NO.the scalp/temporalis muscle.NO.

ii) ) Do you do bifrontal craniectomy or bifrontoDo you do bifrontal craniectomy or bifronto--temporal temporal craniectomycraniectomy

ii) do you divide the sagittal sinus anteriorly? You you ii) do you divide the sagittal sinus anteriorly? You you divide the falx? how do you divide the falx?divide the falx? how do you divide the falx?

iii) do you open the frontal sinus and remove the iii) do you open the frontal sinus and remove the posterior wall of the frontal sinus?posterior wall of the frontal sinus?

iv) do you leave the bone over the sagittal sinus intact?iv) do you leave the bone over the sagittal sinus intact?

vv) ) do you monitor ICP in patients who had do you monitor ICP in patients who had craniectomy? if so do you use a craniectomy? if so do you use a parenchymal probe or subdural catheterparenchymal probe or subdural catheter

vi) do you do duroplastyvi) do you do duroplasty

vii) do you leave a sialastic sheet between vii) do you leave a sialastic sheet between the brain and the scalp/temporalis musclethe brain and the scalp/temporalis muscle

Comparison of the effect of decompressive Comparison of the effect of decompressive craniectomy on different neurosurgical craniectomy on different neurosurgical diseasesdiseases

However, there are no reports in the literature that However, there are no reports in the literature that compare the effect of decompressive craniectomy on compare the effect of decompressive craniectomy on different neurosurgical diseases. different neurosurgical diseases.

Therefore, the authors performed decompressive Therefore, the authors performed decompressive craniectomy with dural expansions in severe traumatic craniectomy with dural expansions in severe traumatic bran injury (TBI), massive intracerebral haemorrhage bran injury (TBI), massive intracerebral haemorrhage (ICH) and major infarction (MI) patients following the (ICH) and major infarction (MI) patients following the same indications for the surgery. The patient outcomes in same indications for the surgery. The patient outcomes in terms of mortality andterms of mortality and

Glasgow Outcome Scale (GOS) as well as the ventricular Glasgow Outcome Scale (GOS) as well as the ventricular pressure changes during the decompressive craniectomy pressure changes during the decompressive craniectomy were compared between the different disease groupswere compared between the different disease groups..

Indications for surgeryIndications for surgery

The indications for decompressive craniectomy The indications for decompressive craniectomy with dural expansion werewith dural expansion were

(1) the appearance of definite unilateral or (1) the appearance of definite unilateral or bilateral brain swelling on the CT scan e.g. bilateral brain swelling on the CT scan e.g. midline shift of more than 6 mm and/or midline shift of more than 6 mm and/or obliteration of the cisternal structures on the CT obliteration of the cisternal structures on the CT scan and/or ascan and/or a

(2) patients with an initial Glasgow Coma Scale (2) patients with an initial Glasgow Coma Scale (GCS) score of less than 8 or worsening of the (GCS) score of less than 8 or worsening of the neurological status (GCS score less than 8). neurological status (GCS score less than 8).

Patients with primary fatal brainstem failure, as Patients with primary fatal brainstem failure, as indicated by a GCS score of 3 and had no spontaneous indicated by a GCS score of 3 and had no spontaneous respiration did not undergo surgical intervention. Therespiration did not undergo surgical intervention. The

differential indication for either a hemicraniectomy or differential indication for either a hemicraniectomy or bilateral decompression where decided. Unilateral bilateral decompression where decided. Unilateral oedema/swelling and opening ventricular pressure less oedema/swelling and opening ventricular pressure less than 25 mmHg were treated by hemicraniectomy over than 25 mmHg were treated by hemicraniectomy over the swollen hemisphere, whereas bilateral diffuse the swollen hemisphere, whereas bilateral diffuse oedema/swelling or opening ventricular pressure more oedema/swelling or opening ventricular pressure more than 25 mmHg were treated by bilateralthan 25 mmHg were treated by bilateral

decompressiondecompression

. If the neurological status was were . If the neurological status was were better than our surgical indications, other better than our surgical indications, other medical treatments such as intravenous or medical treatments such as intravenous or intraarterial thrombolysis were intraarterial thrombolysis were administered before considering administered before considering decompression surgery.decompression surgery.

bilateral decompression was performed using large bicoronal bilateral decompression was performed using large bicoronal skin flaps. The skin flaps were placed just behind the parietal skin flaps. The skin flaps were placed just behind the parietal eminence, extending inferiorly to the zygoma on both sides eminence, extending inferiorly to the zygoma on both sides and curving anteriorly towards the midline. This was reflected and curving anteriorly towards the midline. This was reflected subperiosteally to the level of the supraorbital ridges. subperiosteally to the level of the supraorbital ridges.

The reference points used for the bone flaps were at the The reference points used for the bone flaps were at the pterion of frontal bone, the parietal eminence and in the pterion of frontal bone, the parietal eminence and in the temporal squamous areas. temporal squamous areas.

A frontal median segment of the bone, measuring about 3 to A frontal median segment of the bone, measuring about 3 to 4 cm in width along the sagittal sinus, was saved to avoid 4 cm in width along the sagittal sinus, was saved to avoid damage to the sagittal sinus and to serve as a framework for damage to the sagittal sinus and to serve as a framework for later cranioplasty. Additional bone was removed at the later cranioplasty. Additional bone was removed at the temporal region to the floor of the middle fossa .temporal region to the floor of the middle fossa .

Ten or fifteen minutes after completion of Ten or fifteen minutes after completion of the craniectomy, the ventricular pressure the craniectomy, the ventricular pressure became stabilised. The dura was then became stabilised. The dura was then opened with a large cruciated or curved Z-opened with a large cruciated or curved Z-shaped incision, in the areas involving the shaped incision, in the areas involving the frontal, temporal and parietal lobes. When frontal, temporal and parietal lobes. When the dura was opened, the underlying brain the dura was opened, the underlying brain orhaematoma typically herniated orhaematoma typically herniated outwards.. outwards..

In MI patients, cortical resection was not performed. In MI patients, cortical resection was not performed. In TBI patients, the epidural or subdural haematoma In TBI patients, the epidural or subdural haematoma was removed but haematoma mixed with contused was removed but haematoma mixed with contused brain parenchyma was not evacuated. In all brain parenchyma was not evacuated. In all patients, artificial dura patients, artificial dura was placed was placed underneath the underneath the incised dura, and secured with several sutures to incised dura, and secured with several sutures to allow the brain to herniated outward in a more allow the brain to herniated outward in a more controlled manner, and to prevent cortical adhesion. controlled manner, and to prevent cortical adhesion. After insertion of an ICP sensor at the posterior After insertion of an ICP sensor at the posterior temporal bone margin for epidural ICP monitoring, temporal bone margin for epidural ICP monitoring, the temporalis muscle and skin flap were then the temporalis muscle and skin flap were then reapproximated with suturesreapproximated with sutures

Thin large gelfoam (less than 5 mm Thin large gelfoam (less than 5 mm thickness and 4×5 cm size) pieces were thickness and 4×5 cm size) pieces were placed between the dura and muscle layer placed between the dura and muscle layer for postoperative bleeding control and for postoperative bleeding control and prevention of adherence between the dura prevention of adherence between the dura and temporalis muscle. This gel-foam layer and temporalis muscle. This gel-foam layer facilitated the dissection plane for the facilitated the dissection plane for the cranioplasty to be performed later.cranioplasty to be performed later.

If the ventricular pressure exceeded 30 If the ventricular pressure exceeded 30 mmHg more than 2 h, regardless of mmHg more than 2 h, regardless of previous mentioned medical therapy, mild previous mentioned medical therapy, mild hypothermia (rectal temperature, 32–34°C) hypothermia (rectal temperature, 32–34°C) a cold blanket and/or barbiturate coma a cold blanket and/or barbiturate coma therapy were initiated.therapy were initiated.

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The bone flap was usually reimplanted 1–3 The bone flap was usually reimplanted 1–3 monthsmonths

after the craniectomy, having been stored after the craniectomy, having been stored under sterile conditions at −70°C (Fig. 3). under sterile conditions at −70°C (Fig. 3). A ventriculo-peritoneal shunt was A ventriculo-peritoneal shunt was performed if the diagnosis of performed if the diagnosis of hydrocephalus was confirmedhydrocephalus was confirmed

Neurological outcomeNeurological outcome The pre-operative clinical condition according to GCS wasThe pre-operative clinical condition according to GCS was similar in all study groups. The clinical outcomes weresimilar in all study groups. The clinical outcomes were evaluated at 6 months after the decompressive surgery byevaluated at 6 months after the decompressive surgery by other neurosurgeons who had no information about theother neurosurgeons who had no information about the patients. Mortality was 21.4% in TBI, 25% in ICH andpatients. Mortality was 21.4% in TBI, 25% in ICH and 60.9% in the MI group. A favourable outcome of GOS 4–560.9% in the MI group. A favourable outcome of GOS 4–5 (moderate disability or better) was observed in 16 patients(moderate disability or better) was observed in 16 patients with TBI, 12 with ICH and seven in the MI group. A poorwith TBI, 12 with ICH and seven in the MI group. A poor outcome was a GOS of 1–3 (death, vegetative state, oroutcome was a GOS of 1–3 (death, vegetative state, or severe disability) and was observed in 12 patients with TBI,severe disability) and was observed in 12 patients with TBI, 12 with ICH and 16 with MI groups12 with ICH and 16 with MI groups

Decompressive craniectomy with dura expansion Decompressive craniectomy with dura expansion involves removing a defined portion of the skull with involves removing a defined portion of the skull with loose closure of the dura and skin layers. The loose closure of the dura and skin layers. The surgery is intended to increase the volume of the surgery is intended to increase the volume of the space available for expansion of oedematous brain space available for expansion of oedematous brain tissue and thereby increase compliance which will tissue and thereby increase compliance which will result in a shift to the right of the pressure-volume result in a shift to the right of the pressure-volume curve . This results in effective lowering of the curve . This results in effective lowering of the increased ICP, improvement in cerebral oxygenation increased ICP, improvement in cerebral oxygenation and prevention of secondary brain damage.and prevention of secondary brain damage.

Early reports of craniectomy, performed as a Early reports of craniectomy, performed as a salvagesalvage

procedure for the relief of increased ICP after TBI, procedure for the relief of increased ICP after TBI, were not promising [9, 27]. According to the were not promising [9, 27]. According to the Traumatic Coma Data Bank (TCDB) study, Traumatic Coma Data Bank (TCDB) study, patients with a GCS score of 8 or less on patients with a GCS score of 8 or less on admission have an overall mortality of 33%, with admission have an overall mortality of 33%, with 14% in the vegetative state, and only 7% 14% in the vegetative state, and only 7% achieving a good outcome [10, 11, 16, 37].achieving a good outcome [10, 11, 16, 37].

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Recent studies have reported an improved outcome usingRecent studies have reported an improved outcome using decompressive craniectomy after the development of decompressive craniectomy after the development of

refractory intracranial hypertension. One to two thirds of refractory intracranial hypertension. One to two thirds of the surviving patients have been reported to have a the surviving patients have been reported to have a favourable outcome and the mortality has been reported favourable outcome and the mortality has been reported as less than 20% .as less than 20% .

In our study, decompressive craniectomy was performed In our study, decompressive craniectomy was performed as the first treatment, if the patients had our specific as the first treatment, if the patients had our specific criteria indicating surgery. The mortality was 21.4% and criteria indicating surgery. The mortality was 21.4% and favourable outcome was 57.1% in the TBI patientsfavourable outcome was 57.1% in the TBI patients