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Lin MJ. Intractable subdural effusion after decompressive craniectomy for traumatic brain injury: A case report. World J Clin Cases 2025; 13:103350. [DOI: 10.12998/wjcc.v13.i17.103350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Revised: 12/25/2024] [Accepted: 01/23/2025] [Indexed: 02/18/2025] Open
Abstract
BACKGROUND Traumatic subdural effusion is a common complication of traumatic brain injury, especially after decompressive craniectomy (DC). For neurosurgeons, early diagnosis and timely treatment are particularly important, which can help improve patient prognosis and enhance quality of life.
CASE SUMMARY A 47 year old male underwent DC for traumatic brain herniation. After surgery, he developed stubborn subdural effusion (SDE) on the contralateral side and underwent multiple subdural drilling and drainage surgeries, but only temporarily improved the patient’s symptoms. After the final cranioplasty, the contralateral SDE completely disappeared. The patient did not experience any new contralateral neurological dysfunction, and the Glasgow prognostic score was 11 points (E4V1M6).
CONCLUSION For neurosurgeons, accurate assessment of the condition is necessary when treating patients with stubborn SDE after DC surgery, and timely cranioplasty can be performed to avoid multiple surgeries. This is a safe and effective surgical method for treating traumatic subdural effusion.
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Affiliation(s)
- Ming-Jian Lin
- Department of Neurosurgery, Gaozhou People’s Hospital, Maoming 525200, Guangdong Province, China
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Lepine HL, Semione G, Povoa RG, de Oliveira Almeida G, Abraham D, Figueiredo EG. Decompressive Craniectomy with or Without Dural Closure: Systematic Review and Meta-analysis. Neurocrit Care 2025; 42:635-643. [PMID: 39112817 DOI: 10.1007/s12028-024-02081-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 07/16/2024] [Indexed: 03/29/2025]
Abstract
Decompressive craniectomy is used to alleviate intracranial pressure in cases of traumatic brain injury and stroke by removing part of the skull to allow brain expansion. Traditionally, this procedure is followed by a watertight dural suture, although evidence supporting this method is not strong. This meta-analysis examines the feasibility of the open-dura (OD) approach versus the traditional closed-dura (CD) technique with watertight suturing. A systematic review and comparative meta-analysis were conducted on OD and CD dural closure techniques. Medline, Embase, and Cochrane were searched for relevant trials. The primary end point was the rate of complications, with specific analyses for infection and cerebrospinal fluid (CSF) leaks. Mortality, poor neurological outcomes, and operation duration were also assessed. Odds ratios with 95% confidence intervals (CIs) were calculated using a random-effects model. Following a comprehensive search, 930 studies were screened, from which four studies and a total of 368 patients were ultimately selected. The primary outcome analysis showed a reduced likelihood of complications in the OD group when compared with the CD group (368 patients, odds ratio 0.54 [95% CI 0.32-0.90]; I2 = 17%; p < 0.05). Specific analysis of infections and CSF leaks did not show statistically significant results, as well as the evaluation of the mortality rates and poor neurological outcome differences between groups. Assessment of operation duration, however, demonstrated a significant difference between techniques, with a mean reduction of 52.50 min favoring the OD approach (mean difference - 52.50 [95% CI - 92.13 to - 12.87]; I2 = 96%). This study supports the viability of decompressive craniectomy without the conventional time-spending watertight duraplasty closure, exhibiting no differences in the rate of infections or CSF leaks. Furthermore, this approach has been associated with improved rates of complications and faster surgery, which are important aspects of this technique, particularly in its potential to reduce both costs and procedure length.
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Affiliation(s)
- Henrique L Lepine
- Faculty of Medicine of the University of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gabriel Semione
- University of West of Santa Catarina, Joaçaba, Santa Catarina, Brazil
| | - Raphael G Povoa
- Faculty of Medicine of the University of São Paulo, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - David Abraham
- Federal University of Amazonas, Manaus, Amazonas, Brazil
| | - Eberval G Figueiredo
- Division of Neurosurgery, University of São Paulo, Street Dr. Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, SP, 05403-010, Brazil.
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Wu B, Zhang J, Chen J, Sun X, Tan D. Establishment of a model to predict mortality after decompression craniotomy for traumatic brain injury. Brain Behav 2024; 14:e3492. [PMID: 38641890 PMCID: PMC11031634 DOI: 10.1002/brb3.3492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 02/24/2024] [Accepted: 04/03/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND The mortality rate of patients with traumatic brain injury (TBI) is still high even while undergoing decompressive craniectomy (DC), and the expensive treatment costs bring huge economic burden to the families of patients. OBJECTIVE The aim of this study was to identify preoperative indicators that influence patient outcomes and to develop a risk model for predicting patient mortality by a retrospective analysis of TBI patients undergoing DC. METHODS A total of 288 TBI patients treated with DC, admitted to the First Affiliated Hospital of Shantou University Medical School from August 2015 to April 2021, were used for univariate and multivariate logistic regression analysis to determine the risk factors for death after DC in TBI patients. We also built a risk model for the identified risk factors and conducted internal verification and model evaluation. RESULTS Univariate and multivariate logistic regression analysis identified four risk factors: Glasgow Coma Scale, age, activated partial thrombin time, and mean CT value of the superior sagittal sinus. These risk factors can be obtained before DC. In addition, we also developed a 3-month mortality risk model and conducted a bootstrap 1000 resampling internal validation, with C-indices of 0.852 and 0.845, respectively. CONCLUSIONS We developed a risk model that has clinical significance for the early identification of patients who will still die after DC. Interestingly, we also identified a new early risk factor for TBI patients after DC, that is, preoperative mean CT value of the superior sagittal sinus (p < .05).
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Affiliation(s)
- Birui Wu
- Department of NeurosurgeryGuangdong Sanjiu Brain HospitalGuangzhouGuangdongChina
| | - Juntao Zhang
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Junchen Chen
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Xibo Sun
- Department of NeurosurgeryGuangdong Sanjiu Brain HospitalGuangzhouGuangdongChina
| | - Dianhui Tan
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeShantouGuangdongChina
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Liu C, Liu X, Wei Z, Chang Z, Bai Y, Zeng P, Cao Q, Tie C, Lei Z, Sun P, Liang H, Sun Q, Zhang X. Amorphous Albumin Gadolinium-Based Nanoparticles for Ultrahigh-Resolution Magnetic Resonance Angiography. ACS APPLIED MATERIALS & INTERFACES 2024; 16:9702-9712. [PMID: 38363797 PMCID: PMC10911108 DOI: 10.1021/acsami.3c16391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/24/2024] [Accepted: 01/31/2024] [Indexed: 02/18/2024]
Abstract
Magnetic resonance angiography (MRA) contrast agents are extensively utilized in clinical practice due to their capability of improving the image resolution and sensitivity. However, the clinically approved MRA contrast agents have the disadvantages of a limited acquisition time window and high dose administration for effective imaging. Herein, albumin-coated gadolinium-based nanoparticles (BSA-Gd) were meticulously developed for in vivo ultrahigh-resolution MRA. Compared to Gd-DTPA, BSA-Gd exhibits a significantly higher longitudinal relaxivity (r1 = 76.7 mM-1 s-1), nearly 16-fold greater than that of Gd-DTPA, and an extended blood circulation time (t1/2 = 40 min), enabling a dramatically enhanced high-resolution imaging of microvessels (sub-200 μm) and low dose imaging (about 1/16 that of Gd-DTPA). Furthermore, the clinically significant fine vessels were successfully mapped in large mammals, including a circle of Willis, kidney and liver vascular branches, tumor vessels, and differentiated arteries from veins using dynamic contrast-enhanced MRA BSA-Gd, and have superior imaging capability and biocompatibility, and their clinical applications hold substantial promise.
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Affiliation(s)
- Chenchen Liu
- Department
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Institute
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Guangdong
Provincial Key Laboratory of Biomedical Optical Imaging Technology
& Center for Biomedical Optics and Molecular Imaging, Shenzhen Institute of Advanced Technology, Chinese
Academy of Science, Shenzhen 518055, China
| | - Xiaoming Liu
- Department
of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Zhihao Wei
- Department
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Institute
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zong Chang
- Guangdong
Provincial Key Laboratory of Biomedical Optical Imaging Technology
& Center for Biomedical Optics and Molecular Imaging, Shenzhen Institute of Advanced Technology, Chinese
Academy of Science, Shenzhen 518055, China
| | - Yaowei Bai
- Department
of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Pei Zeng
- Department
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Institute
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Qi Cao
- Department
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Institute
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Changjun Tie
- Paul
C. Lauterbur
Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Ziqiao Lei
- Department
of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Peng Sun
- Clinical
& Technical Support, Philips Healthcare, Beijing 100600, China
| | - Huageng Liang
- Department
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Institute
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Qinchao Sun
- Guangdong
Provincial Key Laboratory of Biomedical Optical Imaging Technology
& Center for Biomedical Optics and Molecular Imaging, Shenzhen Institute of Advanced Technology, Chinese
Academy of Science, Shenzhen 518055, China
| | - Xiaoping Zhang
- Department
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Institute
of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Truckenmueller P, Früh A, Wolf S, Faust K, Hecht N, Onken J, Ahlborn R, Vajkoczy P, Zdunczyk A. Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy. J Neurosurg 2023; 139:554-562. [PMID: 36681955 DOI: 10.3171/2022.10.jns221589] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/07/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC. METHODS The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema. RESULTS A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21). CONCLUSIONS In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.
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Affiliation(s)
| | - Anton Früh
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Stefan Wolf
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Katharina Faust
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Nils Hecht
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Julia Onken
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Robert Ahlborn
- 2Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Germany
| | - Peter Vajkoczy
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Anna Zdunczyk
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
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The risk factors associated with traumatic subdural effusion for patients with traumatic brain injury who did not undergo decompressive craniectomy. Acta Neurol Belg 2022:10.1007/s13760-022-02099-5. [DOI: 10.1007/s13760-022-02099-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/12/2022] [Indexed: 11/01/2022]
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Lee SG, Whang K, Cho SM, Jang YG, Kim J, Choi J. Factors Associated With Subdural Hygroma Following Mild Traumatic Brain Injury. Korean J Neurotrauma 2022; 18:230-237. [PMCID: PMC9634298 DOI: 10.13004/kjnt.2022.18.e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/19/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Subdural hygroma (SDG) is a complication of traumatic brain injury (TBI). In particular, the outcome and outpatient treatment period may vary depending on the occurrence of SDG. However, the pathogenesis of SDG has not been fully elucidated. Therefore, this study aimed to identify the risk factors associated with the occurrence of SDG after mild TBI. Methods We retrospectively analyzed 250 patients with mild TBI admitted to a single institution between January 2021 and December 2021. The SDG occurrence and control groups were analyzed according to the risk factors of SDG, such as age, history, initial computed tomography (CT) findings, and initial laboratory findings. Results The overall occurrence rate of SDG was 31.6% (n=79). A statistically significant association was found between preoperative diagnoses and the occurrence of SDG, such as subarachnoid hemorrhage (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.26–4.39) and basal skull fracture (OR, 0.32; 95% CI, 0.12–0.83). Additionally, age ≥70 years (OR, 3.20; 95% CI, 1.74–5.87) and the use of tranexamic acid (OR, 2.12; 95% CI, 1.05–4.54) were statistically significant factors. The prognostic evaluation of patients using the Glasgow Outcome Scale (GOS) did not show any statistical differences between patients with and without SDG. Conclusion SDG was not associated with the prognosis of patients assessed using the GOS. However, depending on the occurrence of SDG, differences in patient symptoms may occur after mild TBI. Therefore, the early evaluation of patients with mild TBI and determination of the probability of developing SDG are important.
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Affiliation(s)
- Sang-Geun Lee
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Min Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeon Gyu Jang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongwook Choi
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Wei L, Chang B, Geng Z, Chen M, Cao Y, Yao L, Ma C. Nomogram for predicting traumatic subdural effusion after mild traumatic brain injury. Front Neurol 2022; 13:947976. [PMID: 36119698 PMCID: PMC9475217 DOI: 10.3389/fneur.2022.947976] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTraumatic subdural effusion (TSE) is a common complication of traumatic brain injury (TBI). This study aimed to determine the risk factors associated with subdural effusion and to propose a nomogram to predict the risk of TSE in patients with mild TBI.MethodsWe retrospectively analyzed 120 patients with mild TBI between January 2015 and December 2020 at the Third People's Hospital of Hefei. The risk factors of TSE were selected using univariate and multivariable logistic regression analysis. A nomogram was developed to predict the incidence of TSE. Receiver operating characteristics and calibration plots were used to evaluate the discrimination and fitting performance.ResultsOf the 120 patients, 32 developed subdural effusion after mild TBI. Univariate analysis showed that gender, age, history of hypertension, traumatic subarachnoid hemorrhage, subdural hematoma, basilar skull fracture, and cerebral contusion were varied significantly between groups (p < 0.05). Logistic multivariate regression analysis showed that the gender, age, history of hypertension, and basilar skull fracture were independent risk factors for TSE. Based on these results, a nomogram model was developed. The C-index of the nomogram was 0.78 (95% CI: 0.70–0.87). The nomogram had an area under the receiver operating characteristic curve of 0.78 (95% CI: 0.70–0.87). The calibration plot demonstrated the goodness of fit between the nomogram predictions and actual observations.ConclusionGender, age, history of hypertension, and basilar skull fracture can be used in a nomogram to predict subdural effusion after mild TBI.
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Affiliation(s)
- Lichao Wei
- Department of Neurosurgery, The Third People's Hospital of Hefei, Anhui Medical University Hefei Third Clinical College, Hefei, China
| | - Bowen Chang
- Department of Neurology, The School of Mental Health and Psychological Sciences, The First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Zhi Geng
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China Hefei, Hefei, China
- *Correspondence: Zhi Geng
| | - Ming Chen
- Department of Neurosurgery, School of Medicine, XinHua Hospital, Shanghai Jiaotong University, Shanghai, China
- Ming Chen
| | - Yongsheng Cao
- Department of Neurosurgery, The Third People's Hospital of Hefei, Anhui Medical University Hefei Third Clinical College, Hefei, China
| | - Liang Yao
- Department of Neurosurgery, The Third People's Hospital of Hefei, Anhui Medical University Hefei Third Clinical College, Hefei, China
| | - Chao Ma
- Department of Neurosurgery, The Third People's Hospital of Hefei, Anhui Medical University Hefei Third Clinical College, Hefei, China
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Effects of Cranioplasty on Contralateral Subdural Effusion After Decompressive Craniectomy: A Literature Review. World Neurosurg 2022; 165:147-153. [PMID: 35779748 DOI: 10.1016/j.wneu.2022.06.117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Contralateral subdural effusion(CSE) after decompressive craniectomy (CSEDC) is occasionally observed. Cranioplasty is routinely performed for reconstruction and has recently been associated with improving contralateral subdural effusion . OBJECTIVE To systematically review all available literature and evaluate the effectiveness of cranioplasty for CSE. METHODS A PubMed, Web of Science, and Google Scholar search was conducted for preferred reporting items following the guidelines of systematic review and meta-analysis, including studies reporting patients who underwent cranioplasty because of CSEDC. RESULTS The search yielded eight articles. A total of 56 patients ranging in age from 21 to 71 years, developed CSEDC. Of them, 32 patients underwent cranioplasty. Eighteen cases with symptomatic CSE underwent cranioplasty alone, two cases received Ommaya drainage later because of a a recurrence of CDC, and one case underwent a ventriculoperitoneal shunt because the CSE did not resolve completely and the ventricle was dilated again. The symptoms of 14 cases lessened without recurrence after simultaneous cranioplasty and drainage or a shunt. The total success rate(CSE disappeared without recurrence) was 90.6% for patients who underwent cranioplasty; however, the total incidence of hydrocephalus was 40.1%. CONCLUSIONS This review suggests that cranioplasty is effective for the treatment of CSEDC, particularly intractable cases, but early cranioplasty may be more effective. In addition, hydrocephalus is fairly common after cranioplasty and requires further treatment.
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Deng H, Goldschmidt E, Nwachuku E, Yue JK, Angriman F, Wei Z, Agarwal N, Puccio AM, Okonkwo DO. Hydrocephalus and Cerebrospinal Fluid Analysis Following Severe Traumatic Brain Injury: Evaluation of a Prospective Cohort. Neurol Int 2021; 13:527-534. [PMID: 34698266 PMCID: PMC8544497 DOI: 10.3390/neurolint13040052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
The development of hydrocephalus after severe traumatic brain injury (TBI) is an under-recognized healthcare phenomenon and can increase morbidity. The current study aims to characterize post-traumatic hydrocephalus (PTH) in a large cohort. Patients were prospectively enrolled age 16-80 years old with Glasgow Coma Scale (GCS) score ≤8. Demographics, GCS, Injury Severity Score (ISS), surgery, and cerebrospinal fluid (CSF) were analyzed. Outcomes were shunt failure and Glasgow Outcome Scale (GOS) at 6 and 12-months. Statistical significance was assessed at p < 0.05. In 402 patients, mean age was 38.0 ± 16.7 years and 315 (78.4%) were male. Forty (10.0%) patients developed PTH, with predominant injuries being subdural hemorrhage (36.4%) and diffuse axonal injury (36.4%). Decompressive hemicraniectomy (DHC) was associated with hydrocephalus (OR 3.62, 95% CI (1.62-8.07), p < 0.01). Eighteen (4.5%) patients had shunt failure and proximal obstruction was most common. Differences in baseline CSF cell count were associated with increased shunt failure. PTH was not associated with worse outcomes at 6 (p = 0.55) or 12 (p = 0.47) months. Hydrocephalus is a frequent sequela in 10.0% of patients, particularly after DHC. Shunt placement and revision procedures are common after severe TBI, within the first 4 months of injury and necessitates early recognition by the clinician.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94143, USA;
| | - Enyinna Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - John K. Yue
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON M4N 3M5, Canada; (J.K.Y.); (F.A.)
| | - Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON M4N 3M5, Canada; (J.K.Y.); (F.A.)
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.N.); (Z.W.); (N.A.); (A.M.P.); (D.O.O.)
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Ling H, Yang L, Huang Z, Zhang B, Dou Z, Wu J, Jin T, Sun C, Zheng J. Contralateral subdural effusion after decompressive craniectomy: What is the optimal treatment? Clin Neurol Neurosurg 2021; 210:106950. [PMID: 34583274 DOI: 10.1016/j.clineuro.2021.106950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Contralateral subdural effusion after decompressive craniectomy (CSEDC) is rare, and the optimal treatment is not determined. We present 11 cases of CSEDC and give an overview of the English literature pertaining to this disease. METHODS We searched the database at our institution and performed a search of English literature in PubMed and Google Scholar. Keywords used were as follows (single word or combination): "subdural hygroma"; "subdural effusion"; "decompressive craniectomy". Only patients with CSEDC and contained adequate clinical information pertinent to the analysis were included. RESULTS 11 cases of CSEDC were recorded at our institution. They comprised ten men and one woman with an average age of 41.9 years. All the 8 symptomatic patients underwent surgery and the CSEDC resolved gradually. 68 cases of CSEDC were found in the literature. Including ours, a total of 79 patients were analyzed. Conservative treatment was effective in the asymptomatic patients. 41.7% of the symptomatic CSEDC underwent burr hole drainage and successfully drained the CSEDC. However, 76% of them received subsequent surgery to manage the reaccumulation of CSEDC. 25% of the symptomatic patients underwent cranioplasty, while 13.3% of them received Ommaya drainage later because of CSEDC recurrence. 18.3% of the symptomatic patients underwent cranioplasty plus subduroperitoneal shunting, and all CSEDC resolved completely. CONCLUSIONS Burr hole drainage appears to be only a temporary measure. Early cranioplasty should be performed for patients with CSEDC. CSF shunting procedures may be required for patients in whom CSEDC have not been solved or hydrocephalus manifest after cranioplasty.
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Affiliation(s)
- Hui Ling
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
| | - Lijun Yang
- Department of Neurosurgery, JiangShan People's Hospital, 9 Daohang Road, Jiangshan, Zhejiang 324100, China.
| | - Zhaoxu Huang
- Department of Echocardiography, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
| | - Buyi Zhang
- Department of Pathology, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
| | - Zhangqi Dou
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
| | - Jiawei Wu
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
| | - Taian Jin
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
| | - Chongran Sun
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
| | - Jian Zheng
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang 310009, China.
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12
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Guo H, Zhou X, Li X, Yang S, Wang Y. Scenario for the use of effusion-peritoneal shunt necessary against subdural effusion secondary to decompressive craniectomy. Clin Neurol Neurosurg 2021; 203:106598. [PMID: 33730617 DOI: 10.1016/j.clineuro.2021.106598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study aimed to summarize the surgical strategies for subdural effusion secondary to decompressive craniectomy (SESDC) and discuss the applicable scenarios of effusion-peritoneal shunt (EP shunt). METHODS A total of 53 consecutive patients with SESDC were screened out of 7569 cases. The SESDC was divided into five types, and the treatment methods of each type were analyzed and compared. According to the implementation strategy of cranioplasty (CP), patients were divided into CP-first and delayed-CP groups. The differences in surgical methods were compared between the two groups. RESULTS All patients with SESDC in this cohort had undergone cranioplasty. Subcutaneous puncture and aspiration (SPAA) proved ineffective. Only 2/30 patients in the CP-first group used EP shunt, while 6/19 patients in the delayed-CP group used EP shunt; the difference was statistically significant (P = 0.03). A significant difference was found in the use of EP shunt among type 1, type 2, and type 5 SESDC (χ2 = 6.778, P = 0.034). CONCLUSIONS CP combined with other treatments could cure most SESDC. EP shunt should be used preferentially in some specific scenarios in which CP cannot be performed first, rather than as a backup measure that can only be used when other preceding treatments fail.
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Affiliation(s)
- Hongbin Guo
- Department of Neurosurgery, Xia Sha Campus of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Xuehui Zhou
- Department of Neurosurgery, Xia Sha Campus of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Xinwei Li
- Department of Neurosurgery, Xia Sha Campus of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Shuxu Yang
- Department of Neurosurgery, Xia Sha Campus of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Yirong Wang
- Department of Neurosurgery, Xia Sha Campus of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China.
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Motoyama Y, Kogeichi Y, Matsuoka R, Takamura Y, Takeshima Y, Matsuda R, Tamura K, Nishimura F, Yamada S, Nakagawa I, Saito K, Park YS, Sugie K, Fukushima H, Nakase H. External Brain Tamponade Paradoxically Induced by Cerebrospinal Fluid Hypovolemia After Decompressive Craniectomy: A Retrospective Cohort Study. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okaa023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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DiRisio AC, Stopa BM, Pompeu YA, Vasudeva V, Khawaja AM, Izzy S, Gormley WB. Extra-Axial Fluid Collections After Decompressive Craniectomy: Management, Outcomes, and Treatment Algorithm. World Neurosurg 2021; 149:e188-e196. [PMID: 33639283 DOI: 10.1016/j.wneu.2021.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Extra-axial fluid collections (EACs) frequently develop after decompressive craniectomy. Management of EACs remains poorly understood, and information on how to predict their clinical course is inadequate. We aimed to better characterize EACs, understand predictors of their resolution, and delineate the best treatment paradigm for patients. METHODS We reviewed patients who developed EACs after undergoing decompressive craniectomy for treatment of refractory intracranial pressure elevations. We excluded patients who had an ischemic stroke, as EACs in these patients have a different clinical course. We performed univariate analysis and multiple linear regression to find variables associated with earlier resolution of EACs and stratified our analyses by EAC phenotype (complicated vs. uncomplicated). We conducted a systematic review to compare our findings with the literature. RESULTS Of 96 included patients, 73% were male, and median age was 42.5 years. EACs resolved after a median of 60 days. Complicated EACs were common (62.5%) and required multiple drainage methods before cranioplasty. These were not associated with a protracted course or increased risk of death (P > 0.05). Early bone flap restoration with simultaneous drainage was independently associated with earlier resolution of EACs (β = 0.56, P < 0.001). Systematic review confirmed lack of standardized direction with respect to EAC management. CONCLUSIONS Our analyses reveal 2 clinically relevant phenotypes of EAC: complicated and uncomplicated. Our proposed treatment algorithm involves replacing the bone flap as soon as it is safe to do so and draining refractory EACs aggressively. Further studies to assess long-term clinical outcomes of EACs are warranted.
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Affiliation(s)
- Aislyn C DiRisio
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Brittany M Stopa
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Yuri A Pompeu
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Viren Vasudeva
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Ayaz M Khawaja
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Saef Izzy
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA
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15
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Iaccarino C, Kolias A, Adelson PD, Rubiano AM, Viaroli E, Buki A, Cinalli G, Fountas K, Khan T, Signoretti S, Waran V, Adeleye AO, Amorim R, Bertuccio A, Cama A, Chesnut RM, De Bonis P, Estraneo A, Figaji A, Florian SI, Formisano R, Frassanito P, Gatos C, Germanò A, Giussani C, Hossain I, Kasprzak P, La Porta F, Lindner D, Maas AIR, Paiva W, Palma P, Park KB, Peretta P, Pompucci A, Posti J, Sengupta SK, Sinha A, Sinha V, Stefini R, Talamonti G, Tasiou A, Zona G, Zucchelli M, Hutchinson PJ, Servadei F. Consensus statement from the international consensus meeting on post-traumatic cranioplasty. Acta Neurochir (Wien) 2021; 163:423-440. [PMID: 33354733 PMCID: PMC7815592 DOI: 10.1007/s00701-020-04663-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/28/2020] [Indexed: 12/26/2022]
Abstract
Background Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach. Methods The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP. Results The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations. Conclusions This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.
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Svedung Wettervik T, Lenell S, Enblad P, Lewén A. Decompressive Craniectomy in Traumatic Brain Injury-Craniectomy-Related and Cranioplasty-Related Complications in a Single Center. World Neurosurg 2021; 148:e508-e517. [PMID: 33444838 DOI: 10.1016/j.wneu.2021.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) relieves intracranial hypertension after severe traumatic brain injury (TBI), but it has been associated with poor clinical outcome in 2 recent randomized controlled trials. In this study, we investigated the incidence and explanatory variables for DC-related and cranioplasty (CP)-related complications after TBI. METHODS In this retrospective study, we identified 61 patients with TBI who were treated with DC in the neurointensive care unit, Uppsala University Hospital, Sweden, between 2008 and 2018. Demography, admission status, radiology, and clinical outcome were analyzed. RESULTS Eleven patients (18%) were reoperated because of postoperative hemorrhage after DC. Six (10%) developed postoperative infection during neurointensive care. Twenty-eight (46%) developed subdural hygromas and 10 (16%) received a permanent cerebrospinal fluid shunt. Sixteen patients (26%) died before CP. Median time to CP was 7 months (range, 2-19 months) and 32 (71%) were operated on with autologous bone and 13 (29%) with synthetic material primarily. In 9 patients with autologous bone (29%), the CP had to be replaced because of bone resorption/infection, whereas this did not occur after synthetic material (P = 0.04). However, all 4 postoperative hemorrhages after CP occurred when synthetic material was used (P = 0.005). CONCLUSIONS DC and CP surgery have a high risk for complications, leading to additional neurosurgery in about one third of cases. Synthetic CP materials may decrease the risk of reoperation, but special care with hemostasis is required because of increased risk of postoperative hemorrhage. Future trials need to address these topics to further improve the outcome for these patients.
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Affiliation(s)
| | - Samuel Lenell
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Wang H, Chen F, Wen L, Zhu Y, Chen Z, Yang X. Cranioplasty as the treatment for contralateral subdural effusion secondary to decompressive craniectomy: a case report and review of the relevant literature. J Int Med Res 2020; 48:300060520966890. [PMID: 33203286 PMCID: PMC7683921 DOI: 10.1177/0300060520966890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Subdural effusion (SDE) is a common complication secondary to decompressive craniectomy (DC). This current case report describes a patient with contralateral SDE with a typical clinical course. Initially, he made a good recovery following a head trauma that caused a loss of consciousness and was treated with decompressive craniectomy. However, he only achieved temporary relief after each percutaneous fluid aspiration from an Ommaya reservoir implanted into the cavity of the SDE. He was eventually transferred to the authors’ hospital where he underwent cranioplasty, which finally lead to the reduction and disappearance of his contralateral SDE. Unexpectedly, his clinical condition deteriorated again 2 weeks after the cranioplasty with symptoms of an uncontrolled bladder. A subsequent CT scan found the apparent expansion of the whole cerebral ventricular system, indicating symptomatic communicating hydrocephalus. He then underwent a ventriculoperitoneal shunt procedure, which resulted in a favourable outcome and he was discharged 2 weeks later. A review of the current literature identified only 14 cases of contralateral SDE that were cured by cranioplasty alone. The mechanism of contralateral SDE has been widely discussed. Although the exact mechanism of contralateral SDE and why cranioplasty is effective remain unclear, cranioplasty could be an alternative treatment option for contralateral SDE.
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Affiliation(s)
- Hao Wang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Fumei Chen
- Department of Emergency and Trauma Centre, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Liang Wen
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yuanrun Zhu
- Department of Emergency and Trauma Centre, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zuobing Chen
- Department of Rehabilitation, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xiaofeng Yang
- Department of Emergency and Trauma Centre, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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Simultaneous cranioplasty and ventriculoperitoneal shunt placement in patients with traumatic brain injury undergoing unilateral decompressive craniectomy. J Clin Neurosci 2020; 79:45-50. [PMID: 33070916 DOI: 10.1016/j.jocn.2020.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/20/2020] [Accepted: 07/06/2020] [Indexed: 11/23/2022]
Abstract
Hydrocephalus is a common complication after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI). However, the strategy of managing TBI patients with a cranial defect and hydrocephalus remains controversial. Placement of a ventriculoperitoneal shunt (VPS) in patients with a cranial defect and hydrocephalus may aggravate sinking skin flap overlying the cranial defect and result in syndrome of sinking skin flap (SSSF) that causes neurological deterioration. A retrospective analysis of 49 TBI patients who developed hydrocephalus after unilateral DC was undertaken to investigate the safety of simultaneous cranioplasty and VPS placement, and the incidence of SSSF after VPS placement. Among these patients, 17 patients underwent simultaneous cranioplasty and VPS placement, and 32 patients underwent staged cranioplasty and VPS placement. The overall complication rate was 9.3% (3/32) in staged group and 29.4% (5/17) in simultaneous group, respectively. There was no statistically significance between two study groups regarding overall complication (p = 0.11) and reoperation rate (p = 0.47). Two patients with severe brain bulging in staged group developed SSSF after placement of a nonprogrammable VPS. Our study showed that simultaneous cranioplasty and VPS placement may be safe in TBI patients with a cranial defect and hydrocephalus. However, due to the contradictory results about the safety of simultaneous cranioplasty and VPS placement in the literatures, neurosurgeons should carefully consider whether patients are suitable for such treatment. In patients planning to undergo VPS placement first, a programmable shunt may be a better choice for the possibility of SSSF after shunt placement.
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Jeong TS, Yee GT, Lim TG, Kim WK, Yoo CJ. Efficacy and safety of decompressive craniectomy with non-suture duraplasty in patients with traumatic brain injury. PLoS One 2020; 15:e0232561. [PMID: 33031373 PMCID: PMC7544056 DOI: 10.1371/journal.pone.0232561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/23/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Decompressive craniectomy is an important surgical treatment for patients with severe traumatic brain injury (TBI). Several reports have been published on the efficacy of non-watertight sutures in duraplasty performed in decompressive craniectomy. This study sought to determine the safety and feasibility of the non-suture dural closure technique in decompressive craniectomy. METHODS A total of 106 patients were enrolled at a single trauma center between January 2017 and December 2018. We retrospectively collected data and classified the patients into non-suture and suture duraplasty craniectomy groups. We compared the characteristics of patients and their intra/postoperative findings such as operative time, blood loss, imaging findings, complications, and Glasgow Outcome Scale scores. RESULTS There were 37 and 69 patients in the non-suture and suture duraplasty groups, respectively. There were no significant differences between the two groups concerning general characteristics. The operative time was significantly lower in the non-suture duraplasty group than in the suture duraplasty group (150 min vs. 205 min; p = 0.002). Furthermore, blood loss was significantly less severe in the non-suture duraplasty group than in the suture duraplasty group (1000 mL vs. 1500 mL; p = 0.028). There were no other significant differences. CONCLUSION Non-suture duraplasty involved shorter operative times and less severe blood losses than suture duraplasty. Other complications and prognoses were similar across groups. Therefore, the non-suture duraplasty in decompressive craniectomy is a safe and feasible surgical technique.
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Affiliation(s)
- Tae Seok Jeong
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Gi Taek Yee
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea
- * E-mail:
| | - Tae Gyu Lim
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Woo Kyung Kim
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Chan Jong Yoo
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea
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Endoscopic-assisted surgery for skull defects with subdural effusion. Wideochir Inne Tech Maloinwazyjne 2020; 16:219-226. [PMID: 33786137 PMCID: PMC7991952 DOI: 10.5114/wiitm.2020.99350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/03/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Subdural effusion is a common complication that occurs after decompressive craniectomy. According to the endoscopy results, the formation mechanism of subdural effusion after decompressive craniectomy was discussed. Aim The morphological structure of subdural effusion in skull defects was observed with endoscopy, and endoscopic-assisted surgery was performed for subdural effusion. Material and methods From January 2018 to March 2020, 19 cases of skull repair and treatment of subdural effusion were performed. The external wall of the capsule was kept intact during the operation, subdural effusion and surgical procedure of the subdural effusion under an endoscope could be observed, and the results of endoscopic observation were described and recorded. A hemostasis gauze was placed between the two layers of the subdural effusion cavity. Another 13 cases of skull defects with subdural effusion treated without endoscopy during the same time period were enrolled in the study as the control group. The postoperative disappearance of effusion and the incidence of postoperative complications were compared between the two groups. Results Analysis with an endoscope revealed that all cases of subdural effusion in skull defects presented capsules. The main structures included the outer wall, boundary, inner wall, and fistula. The outer wall was made up of new tissue that had formed after removing the bone flap under the skin flap by artificial peeling under the condition of keeping the whole cavity. The inner wall consisted of thickened arachnoid, dura, and artificial dura. It presented with neovascularization networks, which showed a tendency to form new membrane structures through mutual adhesion and fusion. The inner and outer wall of the skull had fused to form the boundary of the cavity. Cerebrospinal fluid fistulas were detected in 31.6% of the internal walls. Subdural effusion was effectively treated in both the experimental group and the control group. Compared with the control group, complications in the experimental group were significantly reduced. Conclusions The effusion cavity can be divided into three types based on its structural characteristics: fistula type, membrane type, and closed type. In this study, the formation mechanism of skull defects combined with subdural effusion was explored. This represents a new method for treating subdural effusion in which hemostasis gauze is placed between the two layers of the effusion cavity and cerebrospinal fluid fistula under an endoscope, which can effectively reduce the incidence of postoperative complications.
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Factors involved in the development of subdural hygroma after decompressive craniectomy for traumatic brain injury. A systematic review and meta-analysis. J Clin Neurosci 2020; 78:273-276. [PMID: 32402617 DOI: 10.1016/j.jocn.2020.05.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/04/2020] [Indexed: 11/23/2022]
Abstract
Subdural hygroma (SDG) represents a common complication following decompressive craniectomy (DC). To our knowledge we present the first meta-analysis investigating the role of clinical and technical factors in the development of SDG after DC for traumatic brain injury. We further investigated the impact of SDG on the final prognosis of patients. The systematic review of the literature was done according to the PRISMA guidelines. Two different online medical databases (PubMed/Medline and Scopus) were screened. Four articles were included in this meta-analysis. Data regarding age, sex, trauma dynamic, Glasgow Coma Scale (GCS), pupil reactivity and CT scan findings on admission were collected for meta-analysis in order to evaluate the possible role in the SDG formation. Moreover we studied the possible impact of SDG on the outcome by evaluating the rate of patients dead at final follow-up and the Glasgow Outcome Scale (GOS) at final follow-up. Among the factors available for meta-analysis only the basal cistern involvement on CT scan was associated with the development of a SDG after DC (p < 0.001). Moreover, patients without SDG had a statistically significant better outcome compared with patients who developed SDG after DC in terms of GOS (p < 0.001). The rate of patients dead at follow-up was lower in the group of patients without SDH (8.25%) compared with patients who developed SDG (11.51%). SDG after DC is a serious complication affecting the prognosis of patients. Further studies are needed to define the role of some adjustable technical aspect of DC in preventing such a complication.
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Hanko M, Soršák J, Snopko P, Opšenák R, Zeleňák K, Kolarovszki B. Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a 5-year experience. Eur J Trauma Emerg Surg 2020; 47:1635-1647. [PMID: 32307561 DOI: 10.1007/s00068-020-01367-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Decompressive craniectomy is an effective measure to reduce a pathologically elevated intracranial pressure. Patients' survival and life quality following this surgery have been a subject of several studies and significantly differ according to the primary diagnosis. Since this operation is often associated with a wide spectrum of possibly serious complications, we aimed to describe their incidence and possible associated risk factors. METHODS We evaluated 118 patients who underwent decompressive craniectomy at our clinic during years 2013-2017. The indications included traumatic brain injuries, ischaemic or haemorrhagic strokes and postoperative complications of planned neurosurgical procedures. Subsequently, we assessed the incidence of early postoperative complications (occurring during the first 3 postoperative weeks). The results were statistically analysed with relation to a wide selection of possible risk factors. RESULTS At least one early surgical postoperative complication occurred in 87 (73.73%) patients, the most frequent being a development of an extraaxial fluid collection in 41 (34.75%) patients. We were able to identify risk factors linked with extraaxial fluid collections, subcutaneous and extradural haematomas, postoperative seizures and meningitis. An overall need for reoperation was 13.56%. Neither the duration of the surgery nor the qualification of the operating surgeon had any effect on the complications' occurrence. CONCLUSIONS Decompressive craniectomy is associated with numerous early postoperative complications with a various degree of severity. Most cases of complications can, however, be managed in a conservative way. The risk factors linked with postoperative complications should be taken into account during the indication process in each individual patient.
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Affiliation(s)
- Martin Hanko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Jakub Soršák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Pavol Snopko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - René Opšenák
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Branislav Kolarovszki
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic.
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Assad S, O' Connell K, Nolte J, Rana A, Singh D. Bilateral refractory subdural hygromas following intrathecal methotrexate injections for B-Cell Acute Lymphocytic Leukemia. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2019.100608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Goldschmidt E, Deng H, Puccio AM, Okonkwo DO. Post-traumatic hydrocephalus following decompressive hemicraniectomy: Incidence and risk factors in a prospective cohort of severe TBI patients. J Clin Neurosci 2020; 73:85-88. [PMID: 31987632 DOI: 10.1016/j.jocn.2020.01.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 01/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND In severe traumatic brain injury (TBI) patients undergoing decompressive hemicraniectomy (DHC), the rate of post-traumatic hydrocephalus (PTH) is high at 12-36%. Early diagnosis and shunt placement can improve outcomes. Herein, we examined the incidence of and predictors of PTH after craniectomy. METHODS A retrospective analysis of prospectively collected database of severe TBI patients at a single U.S. Level 1 trauma center from May 2000 to July 2014 was performed. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), bleeding pattern and time-to-cranioplasty were analyzed. Glasgow Outcome Scale (GOS) scores at 6 and 12-months were studied. Statistical significance was assessed at p < 0.05. RESULTS A total of 402 patients were enrolled and 105 patients had DHC. Twenty-two (21.0%) of 105 required ventriculoperitoneal shunt (VPS), compared to 18 (6%) of 297 patients without DHC. There was increased odds ratio for shunting after DHC at 3.62 (95%CI:1.62-8.07; p < 0.01). Mean age at time of DHC was 43.8 ± 17.7 years old, and 81.9% were male. Subdural hematoma (SDH) was most common at 57.1%. Median time from admission to cranioplasty was 63 days. Patients who experienced PTH after DHC were younger (35.5 ± 17.7 versus 46.0 ± 17.7 years, p < 0.01) and had higher ISS scores (35 versus 26, p = 0.04) compared to patients without shunt after DHC. CONCLUSIONS After severe TBI requiring hemicraniectomy, shunt-dependent hydrocephalus was 21%. Younger patients and higher ISS score were associated with PTH. Shunt-dependent patients achieved similar 6- and 12-month outcomes as those without PTH. Early diagnosis and shunt placement can enhance long-term neurological recovery.
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Affiliation(s)
- Ezequiel Goldschmidt
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213-2582, USA.
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213-2582, USA.
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213-2582, USA; Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213-2582, USA.
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213-2582, USA; Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213-2582, USA.
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Su TM, Lan CM, Lee TH, Hsu SW, Tsai NW, Lu CH. Risk factors for the development of posttraumatic hydrocephalus after unilateral decompressive craniectomy in patients with traumatic brain injury. J Clin Neurosci 2019; 63:62-67. [DOI: 10.1016/j.jocn.2019.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 01/29/2019] [Accepted: 02/20/2019] [Indexed: 11/30/2022]
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Kim BO, Kim JY, Whang K, Cho SM, Oh JW, Koo YM, Hu C, Pyen JS, Choi JW. The Risk Factors of Subdural Hygroma after Decompressive Craniectomy. Korean J Neurotrauma 2018; 14:93-98. [PMID: 30402425 PMCID: PMC6218352 DOI: 10.13004/kjnt.2018.14.2.93] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/13/2018] [Accepted: 10/15/2018] [Indexed: 11/25/2022] Open
Abstract
Objective Subdural effusion, also known as subdural hygroma (SDG), is a secondary complication that can occur after decompressive craniectomy (DC). However, the pathogenesis of SDG is not fully understood. It is unclear whether SDG occurrence is related to preoperative patient status or surgical technique. The purpose of this study is to identify risk factors for SDG after DC. Methods Fifty-nine patients who underwent DC from January 2016 to December 2016 at the same institution were analyzed. We retrospectively reviewed the clinical and radiological features of the patients. We divided the patients into two groups based on the occurrence of SDG after DC. The risk factors for SDG were analyzed. Results The overall SDG rate after DC was 39% (23 patients). A statistically significant association was observed between preoperative diagnosis, e.g., subdural hemorrhage (SDH; odds ratio [OR], 4.99; 95% confidence interval [CI], 1.36–18.34) or subarachnoid hemorrhage (SAH; OR, 4.18; 95% CI, 1.07–16.32), and the occurrence of SDG after DC. Traumatic brain injury (OR, 4.91; 95% CI, 1.35–17.91) and preoperative cortical opening (OR, 4.77; 95% CI, 1.39–16.32) were important risk factors for SDG. Several surgical techniques did not show a statistically significant association with SDG. The occurrence of SDG after DC was related to the length of hospital stay (p=0.012), but not to prognosis. Conclusion After DC, SDG is not related to patients' prognosis but to the length of hospital stay. Therefore, it is necessary to study the occurrence of postoperative SDG by confirming the presence of preoperative SDH, SAH, and cortical opening.
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Affiliation(s)
- Byeong Oh Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong Yeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Min Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji-Woong Oh
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Youn Moo Koo
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Chul Hu
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jin Soo Pyen
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong Wook Choi
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Kelly ML, Shammassian B, Roach MJ, Thomas C, Wagner AK. Craniectomy and Craniotomy in Traumatic Brain Injury: A Propensity-Matched Analysis of Long-Term Functional and Quality of Life Outcomes. World Neurosurg 2018; 118:e974-e981. [PMID: 30048790 DOI: 10.1016/j.wneu.2018.07.124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the comprehensive long-term functional and quality of life outcomes after craniectomy (CE) and craniotomy (CO) in individuals with traumatic brain injury (TBI). METHODS Information on all individuals with TBI who had undergone CE or CO were extracted from the TBI Model Systems database from 2002 to 2012. A 1:1 propensity matching with replacement technique was used to balance the baseline characteristics across groups. The matched sample was analyzed for outcomes during hospitalization, acute rehabilitation, and ≤2 years of follow-up. RESULTS We identified 1470 individuals who had undergone CE or CO. Individuals undergoing CE compared with CO demonstrated a longer length of stay in the hospital (median, 22 vs. 18 days; P < 0.0001) and acute rehabilitation (median 26 vs. 21 days; P < 0.0001). Individuals with CE had required rehospitalization more often by the 1-year follow-up point (39% vs. 25%; P < 0.0001) for reasons other than cranioplasty, including seizures (12% vs. 8%; P < 0.0001), neurologic events (i.e., hydrocephalus; 9% vs. 4%; P < 0.0001), and infections (10% vs 6%; P < 0.0001). Individuals with CE had significantly greater impairment using the Glasgow Outcome Scale-Extended, required more supervision, and were less likely to be employed at 1 and 2 years after TBI. No difference was observed in the satisfaction with life scale scores at 2 years. The Kaplan-Meier mortality estimates at 1 and 2 years showed no differences between the 2 groups (hazard ratio, 0.57; P = 0.4). CONCLUSION In a matched cohort, individuals undergoing CE compared with CO after TBI had a longer length of stay, decreased functional status, and more rehospitalizations. The survival at 2 years and the satisfaction with life scale scores were similar.
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Affiliation(s)
- Michael L Kelly
- Department of Neurosurgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA.
| | - Berje Shammassian
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Mary Jo Roach
- Center for Healthcare Research and Policy, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Charles Thomas
- Center for Healthcare Research and Policy, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Amy K Wagner
- Department of Physical Medicine and Rehabilitation, Neuroscience, Safar Center for Resuscitation Research, Center for Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Vedantam A, Yamal JM, Hwang H, Robertson CS, Gopinath SP. Factors associated with shunt-dependent hydrocephalus after decompressive craniectomy for traumatic brain injury. J Neurosurg 2018; 128:1547-1552. [PMID: 28621627 DOI: 10.3171/2017.1.jns162721] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posttraumatic hydrocephalus (PTH) affects 11.9%-36% of patients undergoing decompressive craniectomy (DC) and is an important cause of morbidity after traumatic brain injury (TBI). Early diagnosis and treatment of PTH can prevent further neurological compromise in patients who are recovering from TBI. There is limited data on predictors of shunting for PTH after DC for TBI. METHODS Prospectively collected data from the erythropoietin severe TBI randomized controlled trial were studied. Demographic, clinical, and imaging data were analyzed for enrolled patients who underwent a DC. All head CT scans during admission were reviewed and assessed for PTH by the Gudeman criteria or the modified Frontal Horn Index ≥ 33%. The presence of subdural hygromas was categorized as unilateral/bilateral hemispheric or interhemispheric. Using L1-regularized logistic regression to select variables, a multiple logistic regression model was created with ventriculoperitoneal shunting as the binary outcome. Statistical significance was set at p < 0.05. RESULTS A total of 60 patients who underwent DC were studied. Fifteen patients (25%) underwent placement of a ventriculoperitoneal shunt for PTH. The majority of patients underwent unilateral decompressive hemicraniectomy (n = 46, 77%). Seven patients (12%) underwent bifrontal DC. Unilateral and bilateral hemispheric hygromas were noted in 31 (52%) and 7 (11%) patients, respectively. Interhemispheric hygromas were observed in 19 patients (32%). The mean duration from injury to first CT scan showing hemispheric subdural hygroma and interhemispheric hygroma was 7.9 ± 6.5 days and 14.9 ± 11.7 days, respectively. The median duration from injury to shunt placement was 43.7 days. Multivariate analysis showed that the presence of interhemispheric hygroma (OR 63.6, p = 0.001) and younger age (OR 0.78, p = 0.009) were significantly associated with the need for a shunt after DC. CONCLUSIONS The presence of interhemispheric subdural hygromas and younger age were associated with shunt-dependent hydrocephalus after DC in patients with severe TBI.
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Affiliation(s)
- Aditya Vedantam
- 1Department of Neurosurgery, Baylor College of Medicine; and
| | - Jose-Miguel Yamal
- 2Department of Biostatistics, University of Texas School of Public Health, Houston, Texas
| | - Hyunsoo Hwang
- 2Department of Biostatistics, University of Texas School of Public Health, Houston, Texas
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Gupta A, Sattur MG, Aoun RJN, Krishna C, Bolton PB, Chong BW, Demaerschalk BM, Lyons MK, McClendon J, Patel N, Sen A, Swanson K, Zimmerman RS, Bendok BR. Hemicraniectomy for Ischemic and Hemorrhagic Stroke: Facts and Controversies. Neurosurg Clin N Am 2018; 28:349-360. [PMID: 28600010 DOI: 10.1016/j.nec.2017.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Malignant large artery stroke is associated with high mortality of 70% to 80% with best medical management. Decompressive craniectomy (DC) is a highly effective tool in reducing mortality. Convincing evidence has accumulated from several randomized trials, in addition to multiple retrospective studies, that demonstrate not only survival benefit but also improved functional outcome with DC in appropriately selected patients. This article explores in detail the evidence for DC, nuances regarding patient selection, and applicability of DC for supratentorial intracerebral hemorrhage and posterior fossa ischemic and hemorrhagic stroke.
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Affiliation(s)
- Aman Gupta
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Precision Neuro-theraputics Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Mithun G Sattur
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Precision Neuro-theraputics Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Rami James N Aoun
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Precision Neuro-theraputics Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Chandan Krishna
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Patrick B Bolton
- Department of Anesthesia & Periop Med, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Brian W Chong
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Department of Radiology, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Bart M Demaerschalk
- Department of Neurology, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Mark K Lyons
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Jamal McClendon
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Naresh Patel
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Kristin Swanson
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Precision Neuro-theraputics Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Richard S Zimmerman
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Precision Neuro-theraputics Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Department of Radiology, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Department of Otolaryngology, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
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Mortazavi MM, Quadri SA, Khan MA, Gustin A, Suriya SS, Hassanzadeh T, Fahimdanesh KM, Adl FH, Fard SA, Taqi MA, Armstrong I, Martin BA, Tubbs RS. Subarachnoid Trabeculae: A Comprehensive Review of Their Embryology, Histology, Morphology, and Surgical Significance. World Neurosurg 2017; 111:279-290. [PMID: 29269062 DOI: 10.1016/j.wneu.2017.12.041] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/06/2017] [Accepted: 12/08/2017] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Brain is suspended in cerebrospinal fluid (CSF)-filled subarachnoid space by subarachnoid trabeculae (SAT), which are collagen-reinforced columns stretching between the arachnoid and pia maters. Much neuroanatomic research has been focused on the subarachnoid cisterns and arachnoid matter but reported data on the SAT are limited. This study provides a comprehensive review of subarachnoid trabeculae, including their embryology, histology, morphologic variations, and surgical significance. METHODS A literature search was conducted with no date restrictions in PubMed, Medline, EMBASE, Wiley Online Library, Cochrane, and Research Gate. Terms for the search included but were not limited to subarachnoid trabeculae, subarachnoid trabecular membrane, arachnoid mater, subarachnoid trabeculae embryology, subarachnoid trabeculae histology, and morphology. Articles with a high likelihood of bias, any study published in nonpopular journals (not indexed in PubMed or MEDLINE), and studies with conflicting data were excluded. RESULTS A total of 1113 articles were retrieved. Of these, 110 articles including 19 book chapters, 58 original articles, 31 review articles, and 2 case reports met our inclusion criteria. CONCLUSIONS SAT provide mechanical support to neurovascular structures through cell-to-cell interconnections and specific junctions between the pia and arachnoid maters. They vary widely in appearance and configuration among different parts of the brain. The complex network of SAT is inhomogeneous and mainly located in the vicinity of blood vessels. Microsurgical procedures should be performed with great care, and sharp rather than blunt trabecular dissection is recommended because of the close relationship to neurovascular structures. The significance of SAT for cerebrospinal fluid flow and hydrocephalus is to be determined.
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Affiliation(s)
- Martin M Mortazavi
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA.
| | - Syed A Quadri
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Muhammad A Khan
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Aaron Gustin
- Advocate BroMenn Medical Center, Normal, Illinois, USA
| | - Sajid S Suriya
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | | | | | - Farzad H Adl
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Salman A Fard
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - M Asif Taqi
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Ian Armstrong
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Bryn A Martin
- National Skull Base Center, Thousand Oaks, California, USA; University of Idaho, Moscow, Idaho, USA
| | - R Shane Tubbs
- National Skull Base Center, Thousand Oaks, California, USA; Seattle Science Foundation, Seattle, Washington, USA
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Subdural effusion protects the aging brain from harmful ventriculomegaly. Med Hypotheses 2017; 108:108-114. [PMID: 29055382 DOI: 10.1016/j.mehy.2017.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/17/2017] [Accepted: 08/06/2017] [Indexed: 11/21/2022]
Abstract
The human brain loses its volume and its function during aging. The solid part of the brain within the intracranial space, the brain parenchyma, decreases in volume with age; while the cerebrospinal fluid (CSF) volume increases. With progressive loss of brain parenchymal volume (BPV), CSF may shift from cerebral ventricles to the subdural space, forming subdural effusion (SDE), whose role in the brain aging process remains unclear. We hypothesize that damages associated with ventriculomegaly can be lessened after formation of SDE. As the BPV decreases, the enlarged ventricular surface area causes dysfunction of its lining ependymal cells, followed by damages to the periventricular tissue. The periventricular nerve fibers are stretched by the enlarged ventricles. We hypothesize that after the formation of SDE, ventriculomegaly can be stopped or even reversed. By allowing the atrophic brain to reside in a smaller fraction of the intracranial volume, damages associated with ventriculomegaly can be alleviated. If our hypothesis is correct, physicians should continue to maintain a conservative approach for uncomplicated SDE. For focal or global brain parenchymal loss caused by various pathologies, intracranial spacers can be employed to simulate the effect of SDE to protect the brain. For treatment of idiopathic normal pressure hydrocephalus, aggressive ventricular size reduction should be pursued. Finally, the protective effects of SDE have its limits. Extremely enlarged subdural volume can cause acute or chronic subdural hematoma, further damaging the brain.
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Huang KT, Bi WL, Abd-El-Barr M, Yan SC, Tafel IJ, Dunn IF, Gormley WB. The Neurocritical and Neurosurgical Care of Subdural Hematomas. Neurocrit Care 2017; 24:294-307. [PMID: 26399248 DOI: 10.1007/s12028-015-0194-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Subdural hematomas (SDHs), though frequently grouped together, can result from a variety of different etiologies, and therefore many different subtypes exist. Moreover, the high incidence of these lesions in the neurocritical care settings behooves practitioners to have a firm grasp on their diagnosis and management. We present here a review of SDHs, with an emphasis on how different subtypes of SDHs differ from one another and with discussion of their medical and surgical management in the neurocritical care setting. In this paper, we discuss considerations for acute, subacute, and chronic SDHs and how presentation and management may change in both the elderly and pediatric populations. We discuss SDHs that arise in the setting of anticoagulation, those that arise in the setting of active cerebrospinal fluid diversion, and those that are recurrent and recalcitrant to initial surgical evacuation. Management steps reviewed include detailed discussion of initial assessment, anticoagulation reversal, seizure prophylaxis, blood pressure management, and indications for intracranial pressure monitoring. Direct surgical management options are reviewed, including open craniotomy, twist-drill, and burr-hole drainage and the usage of subdural drainage systems. SDHs are a common finding in the neurocritical care setting and have a diverse set of presentations. With a better understanding of the fundamental differences between subtypes of SDHs, critical care practitioners can better tailor their management of both the patient's intracranial and multi-systemic pathologies.
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Affiliation(s)
- Kevin T Huang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Sandra C Yan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Ian J Tafel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Ian F Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA.
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Malcolm JG, Miller BA, Grossberg JA, Pradilla G, Ahmad FU. Early urgent cranioplasty for symptomatic hygroma: Report of two cases. J Clin Neurosci 2016; 34:273-275. [PMID: 27523587 DOI: 10.1016/j.jocn.2016.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/01/2016] [Indexed: 10/21/2022]
Abstract
Following craniectomy, hygromas are relatively common. While many cases resolve spontaneously, some patients develop neurologic deficits. Management of symptomatic hygromas often involves shunting or drainage. We present two patients who three weeks after decompressive hemicraniectomy developed declining neurologic status secondary to enlarging hygroma. Failing conservative management, both were treated with urgent cranioplasty and returned to neurologic baseline. Early cranioplasty may be safe and effective for symptomatic collections.
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Affiliation(s)
- James G Malcolm
- Department of Neurological Surgery, Emory University, Atlanta, GA, United States
| | - Brandon A Miller
- Department of Neurological Surgery, Emory University, Atlanta, GA, United States
| | - Jonathan A Grossberg
- Department of Neurological Surgery, Emory University, Atlanta, GA, United States
| | - Gustavo Pradilla
- Department of Neurological Surgery, Emory University, Atlanta, GA, United States
| | - Faiz U Ahmad
- Department of Neurological Surgery, Emory University, Atlanta, GA, United States.
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35
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Feng Y, Wang Y. Coexistent of paradoxical herniation and subdural hygroma: a case report. Chin Neurosurg J 2015. [DOI: 10.1186/s41016-015-0012-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Avecillas-Chasin JM. Subdural effusion in decompressive craniectomy. Acta Neurochir (Wien) 2015; 157:2121-3. [PMID: 26264071 DOI: 10.1007/s00701-015-2537-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 07/30/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Josué M Avecillas-Chasin
- Department of Neurosurgery, Institute of Neurosciences, Instituto de Investigación Sanitaria San Calos, Hospital Clínico San Carlos, Prof. Martín Lagos s/n, 28040, Madrid, Spain.
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Ki HJ, Lee HJ, Lee HJ, Yi JS, Yang JH, Lee IW. The Risk Factors for Hydrocephalus and Subdural Hygroma after Decompressive Craniectomy in Head Injured Patients. J Korean Neurosurg Soc 2015; 58:254-61. [PMID: 26539270 PMCID: PMC4630358 DOI: 10.3340/jkns.2015.58.3.254] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 08/08/2015] [Accepted: 08/10/2015] [Indexed: 12/03/2022] Open
Abstract
Objective The present study aims to investigate 1) the risk factors for hydrocephalus and subdural hygroma (SDG) occurring after decompressive craniectomy (DC), and 2) the association between the type of SDG and hydrocephalus. Methods We retrospectively reviewed the clinical and radiological features of 92 patients who underwent DC procedures after severe head injuries. The risk factors for developing post-traumatic hydrocephalus (PTH) and SDG were analyzed. Types of SDGs were classified according to location and their relationship with hydrocephalus was investigated. Results Ultimately, 26.09% (24/92) of these patients developed PTH. In the univariate analyses, hydrocephalus was statically associated with large bone flap diameter, large craniectomy area, bilateral craniectomy, intraventricular hemorrhage, contralateral or interhemisheric SDGs, and delayed cranioplasty. However, in the multivariate analysis, only large craniectomy area (adjusted OR=4.66; p=0.0239) and contralateral SDG (adjusted OR=6.62; p=0.0105) were significant independent risk factors for developing hydrocephalus after DC. The incidence of overall SDGs after DC was 55.43% (51/92). Subgroup analysis results were separated by SDG types. Statistically significant associations between hydrocephalus were found in multivariate analysis in the contralateral (adjusted OR=5.58; p=0.0074) and interhemispheric (adjusted OR=17.63; p=0.0113) types. Conclusion For patients who are subjected to DC following severe head trauma, hydrocephalus is associated with a large craniectomy area and contralateral SDG. For SDGs after DC that occur on the interhemispherical or controlateral side of the craniectomy, careful follow-up monitoring for the potential progression into hydrocephalus is needed.
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Affiliation(s)
- Hee Jong Ki
- Department of Neurosurgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Hyung-Jin Lee
- Department of Neurosurgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Hong-Jae Lee
- Department of Neurosurgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Jin-Seok Yi
- Department of Neurosurgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Ji-Ho Yang
- Department of Neurosurgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Il-Woo Lee
- Department of Neurosurgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
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Alotaibi NM, Witiw CD, Germans MR, Macdonald RL. Spontaneous subdural fluid collection following aneurysmal subarachnoid hemorrhage: subdural hygroma or external hydrocephalus? Neurocrit Care 2015; 21:312-5. [PMID: 25030709 DOI: 10.1007/s12028-014-0017-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Subdural fluid collections (hygromas and effusions) in adults are usually seen following head trauma or overdrainage of cerebrospinal fluid (CSF) after CSF diversion procedures. We report an unusual case of subdural fluid collection that developed spontaneously 5 days after an aneurysmal subarachnoid hemorrhage (SAH). This patient neither had permanent CSF diversion procedure nor history of significant head trauma during her clinical course. METHODS This study is a Case report of the patient suffering from an SAH. RESULTS A 71-year-old woman suffered an SAH from a ruptured right-sided posterior communicating artery aneurysm. Computed tomography (CT) demonstrated diffuse SAH and signs of early hydrocephalus that did not require treatment. The aneurysm was treated with endovascular coil occlusion without any complications. Throughout her hospital course, she remained alert without neurological deficits. A large subdural fluid collection was discovered incidentally during a routine CT scan of the brain 5 days after the SAH. The patient remained asymptomatic; therefore, the collection was treated conservatively. It resolved spontaneously at five days after the initial diagnosis. CONCLUSION Subdural fluid collections following SAH can occur as a result of head trauma, external hydrocephalus, or as a treatment complication of CSF shunting and craniotomies. It is critical to differentiate simple hygromas from external hydrocephalus since their response to CSF diversion is entirely different.
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Affiliation(s)
- Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Krishnan P, Roy Chowdhury S. Recurrent, symptomatic, late-onset, contralateral subdural effusion following decompressive craniectomy treated by cranial strapping. Br J Neurosurg 2015; 29:730-2. [PMID: 26037938 DOI: 10.3109/02688697.2015.1039485] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Subdural effusions following decompressive craniotomy for trauma are usually benign, ipsilateral to the craniotomy and resolve spontaneously. Far less common and more dangerous are contralateral subdural effusions causing external cerebral herniation. We report a case of recurrent contralateral effusion and highlight the management dilemmas. Arachnoid tear is probably the cause of these collections. Contralateral subdural effusions should be suspected in patients who have delayed neurological deterioration after an initial improvement particularly in the setting of increased "flap bulge" though they may also be found in patients who remain moribund after initial surgery. There are no clear-cut guidelines on their management due to their rarity. A variety of options like subduro-peritoneal shunt and drainage with simultaneous cranioplasty may be tried. In situations where resources or patient compliance is an issue, tapping the effusion followed by cranial strapping may be tried as was done in our case.
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Affiliation(s)
- Prasad Krishnan
- a Department of Neurosurgery , National Neurosciences Centre , Kolkata , West Bengal , India
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Yuan Q, Wu X, Yu J, Sun Y, Li Z, Du Z, Wu X, Zhou L, Hu J. Subdural hygroma following decompressive craniectomy or non-decompressive craniectomy in patients with traumatic brain injury: Clinical features and risk factors. Brain Inj 2015; 29:971-80. [DOI: 10.3109/02699052.2015.1004760] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Salunke P, Garg R, Kapoor A, Chhabra R, Mukherjee KK. Symptomatic contralateral subdural hygromas after decompressive craniectomy: plausible causes and management protocols. J Neurosurg 2015; 122:602-9. [DOI: 10.3171/2014.10.jns14780] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Contralateral subdural hygromas are occasionally observed after decompressive craniectomies (DCs). Some of these hygromas are symptomatic, and the etiology and management of these symptomatic contralateral subdural collections (CLDCs) present surgical challenges. The authors share their experience with managing symptomatic CLSDCs after a DC.
METHODS
During a 10-month period, 306 patients underwent a DC. Of these patients, 266 had a head injury, 25 a middle cerebral artery infarction (that is, a thrombotic stroke), and 15 an infarction due to a vasospasm (resulting from an aneurysmal subarachnoid hemorrhage [SAH]). Seventeen patients (15 with a head injury and 2 with an SAH) developed a CLSDC, and 7 of these patients showed overt symptoms of the fluid collection. These patients were treated with a trial intervention consisting of bur hole drainage followed by cranioplasty. If required, a ventriculo- or thecoperitoneal shunt was inserted at a later time.
RESULTS
Seven patients developed a symptomatic CLSDC after a DC, 6 of whom had a head injury and 1 had an SAH. The average length of time between the DC and CLSDC formation was 24 days. Fluid drainage via a bur hole was attempted in the first 5 patients. However, symptoms in these patients improved only temporarily. All 7 patients (including the 5 in whom the bur hole drainage had failed and 2 directly after the DC) underwent a cranioplasty, and the CLSDC resolved in all of these patients. The average time it took for the CLSDC to resolve after the cranioplasty was 34 days. Three patients developed hydrocephalus after the cranioplasty, requiring a diversion procedure, and 1 patient contracted meningitis and died.
CONCLUSIONS
Arachnoid tears and blockage of arachnoid villi appear to be the underlying causes of a CLSDC. The absence of sufficient fluid pressure required for CSF absorption after a DC further aggravates such fluid collections. Underlying hydrocephalus may appear as subdural collections in some patients after the DC. Bur hole drainage appears to be only a temporary measure and leads to recurrence of a CLSDC. Therefore, cranioplasty is the definitive treatment for such collections and, if performed early, may even avert CLSDC formation. A temporary ventriculostomy or an external lumbar drainage may be added to aid the cranioplasty and may be removed postoperatively. Ventriculoperitoneal or thecoperitoneal shunting may be required for patients in whom a hydrocephalus manifests after cranioplasty and underlies the CLSDC.
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Harreld JH, Mohammed N, Goldsberry G, Li X, Li Y, Boop F, Patay Z. Postoperative intraspinal subdural collections after pediatric posterior fossa tumor resection: incidence, imaging, and clinical features. AJNR Am J Neuroradiol 2015; 36:993-9. [PMID: 25614472 DOI: 10.3174/ajnr.a4221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 11/01/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Postoperative intraspinal subdural collections in children after posterior fossa tumor resection may temporarily hinder metastasis detection by MR imaging or CSF analysis, potentially impacting therapy. We investigated the incidence, imaging and clinical features, predisposing factors, and time course of these collections after posterior fossa tumor resection. MATERIALS AND METHODS Retrospective review of postoperative spine MRI in 243 children (5.5 ± 4.6 years of age) from our clinical data base postresection of posterior fossa tumors from October 1994 to August 2010 yielded 37 (6.0 ± 4.8 years of age) subjects positive for postoperative intraspinal subdural collections. Their extent and signal properties were recorded for postoperative (37/37), preoperative (15/37), and follow-up spine (35/37) MRI. Risk factors were compared with age-matched internal controls (n = 37, 5.9 ± 4.5 years of age). Associations of histology, hydrocephalus and cerebellar tonsillar herniation, and postoperative intracranial subdural collections with postoperative intraspinal subdural collections were assessed by the Fisher exact test or χ(2) test. The association between preoperative tumor volume and postoperative intraspinal subdural collections was assessed by the Wilcoxon rank sum test. RESULTS The overall incidence of postoperative intraspinal subdural collections was 37/243 (15.2%), greatest ≤7 days postoperatively (36%); 97% were seen 0-41 days postoperatively (12.9 ± 11.0 days). They were T2 hyperintense and isointense to CSF on T1WI, homogeneously enhanced, and resolved on follow-up MR imaging (35/35). None were symptomatic. They were associated with intracranial subdural collections (P = .0011) and preoperative tonsillar herniation (P = .0228). CONCLUSIONS Postoperative intraspinal subdural collections are infrequent and clinically silent, resolve spontaneously, and have a distinctive appearance. Preoperative tonsillar herniation appears to be a predisposing factor. In this series, repeat MR imaging by 4 weeks documented improvement or resolution of these collections in 88%.
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Affiliation(s)
- J H Harreld
- From the Departments of Radiological Sciences (J.H.H., Z.P.)
| | - N Mohammed
- Department of Imaging Diagnostic (N.M.), Institute of Paediatric, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - G Goldsberry
- Department of Radiology (G.G.), McFarland Clinic, Ames, Iowa
| | - X Li
- Biostatistics (X.L., Y.L.)
| | - Y Li
- Biostatistics (X.L., Y.L.)
| | - F Boop
- Surgery (F.B.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Z Patay
- From the Departments of Radiological Sciences (J.H.H., Z.P.)
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Takeuchi S, Takasato Y, Masaoka H, Nagatani K, Otani N, Wada K, Mori K. Decompressive craniectomy for arteriovenous malformation-related intracerebral hemorrhage. J Clin Neurosci 2015; 22:483-7. [PMID: 25564272 DOI: 10.1016/j.jocn.2014.08.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/30/2014] [Indexed: 10/24/2022]
Abstract
Arteriovenous malformation (AVM)-related intracerebral hemorrhage (ICH) is the cause of approximately 2-3% of ICH and is an important factor in the significant morbidity and mortality in patients with AVM. Decompressive craniectomy (DC) is a surgical procedure to relieve malignant elevation of intracranial pressure. The use of DC to treat patients with AVM-ICH has been much less common. The present study describes our experience with DC for AVM-ICH and discusses the safety of this procedure. The present retrospective analysis compared 12 consecutive patients treated with DC for AVM-ICH with 23 patients treated with DC for hypertensive ICH. Nine patients were male and three were female, aged from 11 to 53 years (mean, 31.7 years). Hematoma volumes ranged from 50 to 106 ml (mean, 75.8 ml). The outcomes were good recovery in one patient, moderate disability in three, severe disability in seven, and vegetative state in one. Complications after DC included subdural hygroma in four patients, hydrocephalus in one, intracranial infection in two, and intracranial hemorrhage in one. No significant difference was found in the incidence of complications between DC for large AVM-ICH and DC for hypertensive ICH. In conclusion, the present study found no significant difference in the incidence of complications between DC for large AVM-ICH and DC for hypertensive ICH. Further investigations including a prospective randomized trial are needed to confirm the safety and efficacy of DC for the treatment of large AVM-ICH.
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Affiliation(s)
- Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan.
| | - Yoshio Takasato
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Hiroyuki Masaoka
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Kimihiro Nagatani
- Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Naoki Otani
- Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
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Lin MS, Chen TH, Kung WM, Chen ST. Simultaneous cranioplasty and subdural-peritoneal shunting for contralateral symptomatic subdural hygroma following decompressive craniectomy. ScientificWorldJournal 2015; 2015:518494. [PMID: 25879062 PMCID: PMC4386681 DOI: 10.1155/2015/518494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/27/2015] [Accepted: 02/28/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Contralateral subdural hygroma caused by decompressive craniectomy tends to combine with external cerebral herniation, causing neurological deficits. MATERIAL AND METHODS Nine patients who underwent one-stage, simultaneous cranioplasty and contralateral subdural-peritoneal shunting were included in this study. Clinical outcome was assessed by Glasgow Outcome Scale as well as Glasgow Coma Scale, muscle power scoring system, and complications. RESULTS Postoperative computed tomography scans demonstrated completely resolved subdural hygroma and reversed midline shifts, indicating excellent outcome. Among these 9 patients, 4 patients (44%) had improved GOS following the proposed surgery. Four out of 4 patients with lethargy became alert and orientated following surgical intervention. Muscle strength improved significantly 5 months after surgery in 7 out of 7 patients with weakness. Two out of 9 patients presented with drowsiness due to hydrocephalus at an average time of 65 days after surgery. Double gradient shunting is useful to eliminate the respective hydrocephalus and contralateral subdural hygroma. CONCLUSION The described surgical technique is effective in treating symptomatic contralateral subdural hygroma following decompressive craniectomy and is associated with an excellent structural and functional outcome. However, subdural-peritoneal shunting plus cranioplasty thoroughly resolves the subdural hygroma collection, which might deteriorate the cerebrospinal fluid circulation, leading to hydrocephalus.
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Affiliation(s)
- Muh-Shi Lin
- 1Department of Surgery, Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- 2Department of Neurosurgery, Taipei City Hospital, Zhong Xiao Branch, Taipei, Taiwan
- 3Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan, Taiwan
- *Muh-Shi Lin:
| | - Tzu-Hsuan Chen
- 4Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Woon-Man Kung
- 5Department of Exercise and Health Promotion, College of Education, Chinese Culture University, Taipei, Taiwan
- 6Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan
- 7Department of Neurosurgery, Lo-Hsu Foundation, Lotung Poh-Ai Hospital, Luodong, Yilan, Taiwan
| | - Shuo-Tsung Chen
- 8Department of Mathematics, Tunghai University, Taichung, Taiwan
- 9Sustainability Research Center, Tunghai University, Taichung 40704, Taiwan
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45
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Krishnan P, Mishra R, Jena M. Comment on dreaded complications of mistaken identity: Hygroma versus effusion following decompressive craniotomy. J Neurosci Rural Pract 2014; 5:S108-9. [PMID: 25540527 PMCID: PMC4271370 DOI: 10.4103/0976-3147.145246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Prasad Krishnan
- Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal, India
| | - Rohit Mishra
- Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal, India
| | - Manaranjan Jena
- Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal, India
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46
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Subdural effusion with ventriculomegaly after decompressive craniectomy for traumatic brain injury: A challenging entity. INDIAN JOURNAL OF NEUROTRAUMA 2014. [DOI: 10.1016/j.ijnt.2014.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Honeybul S, Ho KM. Decompressive craniectomy for severe traumatic brain injury: the relationship between surgical complications and the prediction of an unfavourable outcome. Injury 2014; 45:1332-9. [PMID: 24704150 DOI: 10.1016/j.injury.2014.03.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 02/20/2014] [Accepted: 03/12/2014] [Indexed: 02/02/2023]
Abstract
OBJECT To assess the impact that injury severity has on complications in patients who have had a decompressive craniectomy for severe traumatic brain injury (TBI). METHODS This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia from 2004 to 2012. All complications were recorded during this period. The clinical and radiological data of the patients on initial presentation were entered into a web-based model prognostic model, the CRASH (Corticosteroid Randomization After Significant Head injury) collaborators prediction model, to obtain the predicted risk of an unfavourable outcome which was used as a measure of injury severity. RESULTS Complications after decompressive craniectomy for severe TBI were common. The predicted risk of unfavourable outcome was strongly associated with the development of neurological complications such as herniation of the brain outside the skull bone defects (median predicted risk of unfavourable outcome for herniation 72% vs. 57% without herniation, p=0.001), subdural effusion (median predicted risk of unfavourable outcome 67% with an effusion vs. 57% for those without an effusion, p=0.03), hydrocephalus requiring ventriculo-peritoneal shunt (median predicted risk of unfavourable outcome 86% for those with hydrocephalus vs. 59% for those without hydrocephalus, p=0.001), but not infection (p=0.251) or resorption of bone flap (p=0.697) and seizures (0.987). We did not observe any associations between timing of cranioplasty and risk of infection or resorption of bone flap after cranioplasty. CONCLUSIONS Mechanical complications after decompressive craniectomy including herniation of the brain outside the skull bone defects, subdural effusion, and hydrocephalus requiring ventriculo-peritoneal shunt were more common in patients with a more severe form of TBI when quantified by the CRASH predicted risk of unfavourable outcome. The CRASH predicted risk of unfavourable outcome represents a useful baseline characteristic of patients in observational and interventional trials involving patients with severe TBI requiring decompressive craniectomy.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Western Australia, Australia.
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
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Early Pressure Dressing for the Prevention of Subdural Effusion Secondary to Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury. J Craniofac Surg 2014; 25:1836-9. [DOI: 10.1097/scs.0b013e3182a21056] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Rambarki O, Rajesh A. Dreaded complications of mistaken identity - Hygroma vs effusion following decompressive craniotomy. J Neurosci Rural Pract 2014; 5:305-7. [PMID: 25002783 PMCID: PMC4078628 DOI: 10.4103/0976-3147.133623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Omekareswar Rambarki
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India
| | - Alugolu Rajesh
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India
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Sharma P, Mishra A, Arora G, Tripathi M, Bal C, Kumar R. Post meningitis subdural hygroma: Anatomical and functional evaluation with (99m)Tc-ehylene cysteine dimer single photon emission tomography/computed tomography. Indian J Nucl Med 2013; 28:23-5. [PMID: 24019670 PMCID: PMC3764686 DOI: 10.4103/0972-3919.116806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Subdural hygroma is the collection of cerebrospinal fluid in the subdural space. Most often these resolve spontaneously. However, in cases with neurological complications surgical drainage may be needed. We here, present the case of an 8-year-old boy with post meningitis subdural hygroma. (99m)Tc-ehylene cysteine dimer ((99m)Tc-ECD) hybrid single photon emission tomography/computed tomography (SPECT/CT) carried out in this patient, demonstrated the subdural hygroma as well as the associated cerebral hypoperfusion. If (99m)Tc-ECD SPECT/CT is integrated into management of these patients, it can help in decision making with respect to conservative versus surgical management.
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Affiliation(s)
- Punit Sharma
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
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