Craniectomy size for subdural haematomas and the impact on brain shift and outcomes

Acta Neurochirurgica (2020) 162:2019–2027

Midline shift in trauma relates to the severity of head injury. Large craniectomies are thought to help resolve brain shift but can be associated with higher rates of morbidity. This study explores the relationship between craniectomy size and subtemporal decompression for acute subdural haematomas with the resolution of brain compression and outcomes. No systematic study correlating these measures has been reported.

Method A retrospective study of all adult cases of acute subdural haematomas that presented to a Major Trauma Centre and underwent a primary decompressive craniectomy between June 2008 and August 2013. Data collection included patient demographics and presentation, imaging findings and outcomes. All imaging metrics were measured by two independent trained assessors. Compression was measured as midline shift, brainstem shift and cisternal effacement.

Results Thirty-six patients with mean age of 36.1 ± 12.5 (range 16–62) were included, with a median follow-up of 23.5 months (range 2.2–109.6). The median craniectomy size was 88.7 cm2 and the median subtemporal decompression was 15.0 mm. There was significant post-operative resolution of shift as measured by midline shift, brainstem shift and cisternal effacement score (all p < .00001). There was no mortality, and the majority of patients made a good recovery with 82.8% having a Modified Rankin Score of 2 or less. There was no association between craniectomy size or subtemporal decompression and any markers of brain shift or outcome (all R2 < 0.05).

Conclusions This study suggests that there is no clear relationship between craniectomy size or extent of subtemporal decompression and resolution of brain shift or outcome. Further studies are needed to assess the relative efficacy of large craniectomies and the role of subtemporal decompression.

Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations

Neurosurgery 87:427–434, 2020

When the fourth edition of the Brain Trauma Foundation’s Guidelines for theManagement of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released.

The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of “living guidelines,” whereby topics are updated more frequently, and between new editions, when important new evidence is published.

The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice.

This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline canbe found at: https://braintrauma.org/guidelines/guidelines-for-themanagement- of-severe-tbi-4th-ed#/.

Biomechanics of a novel reversibly expandable dynamic craniotomy bone flap fixation plate

J Neurosurg 132:560–567, 2020

Biomechanical evaluation of a novel expandable cranial fixation plate was assessed in cadavers. The dynamic craniotomy procedure uses low-profile reversibly expandable plates that allow cranial decompression by providing for intracranial volume expansion without removal of the bone flap. The plates allow reversible outward movement of the bone flap upon an increase in intracranial pressure (ICP) and also retract the bone flap and prevent it from sinking inside the cranium once the ICP normalizes.

METHODS A comparative evaluation of the extent of ICP control with an increase in intracranial volume between various bone flap fixation techniques was undertaken along with testing of the expandable plate compliance. Static compression tests of the plates were performed to assess bone flap fixation and prevention of sinking. Quasi-static shear tension testing of the plates was undertaken to test the tolerance of the plates for expansion. Fatigue shear tension evaluation of the plates was undertaken to assess tolerance for repetitive expansion and contraction.

RESULTS The dynamic craniotomy provided superior control of ICP with an increase in intracranial volume compared to the hinged craniotomy and standard craniotomy techniques (p < 0.001). Static compression results revealed that the plates withstood bone flap sinkage with a mean peak load of 643.3 ± 26.1 N and a mean inward bone flap displacement of 1.92 ± 0.09 mm. Static shear tension results indicated that the plates could withstand a peak expansion of 71.6 mm. Dynamic shear tension testing of the plates with repetitive 15-mm outward expansion and retraction for a total of up to 500 cycles revealed no cracking and no failure points.

CONCLUSIONS The reversibly expandable plates provide for a low-profile bone flap fixation with rigid restriction of bone flap sinking and also enable cranial decompression with a high tolerance for repetitive expansion and contraction.

Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation

Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation

Neurosurg Rev (2014) 37:653–659

Additional space-occupying intracerebral hematoma (ICH) in patients suffering from subarachnoid hemorrhage (SAH) is a known predictor for poor outcome. Emergent clot evacuation might be mandatory. However, data concerning the influence of ICH location on outcome is scarce. Therefore, we analyzed the influence of ICH location on clinical course and outcome in patients with SAH and additional ICH.

One hundred seventy-four patients were treated with aneurysmal SAH and additional ICH between September 1999 and May 2012. Information including patient characteristics, treatment, and radiological findings were prospectively entered into a database. Patients were stratified according to ICH location and neurological outcome. Neurological outcome was assessed according to modified Rankin Scale (mRS).

ICH location was temporal (58.6 %), frontal (28.7 %), and perisylvian ICH (12.6%); 63.8% presented in poor admission status and favorable outcome was achieved in 35.6 %. In the multivariate analysis, favorable outcome was associated with young age, ICH <50 ml, and good admission status. The location of ICH was not associated with outcome. The current data confirms that a significant number of patients with ICH after aneurysm rupture achieve favorable outcome. Prognostic factor for favorable outcome are “age,” “size of the hematoma,” and “admission status.” The location of the ICH seems not to be associated with outcome.