Efficacy of the Decompressive Craniectomy for Acute Cerebral Infarction : Timing of Surgical Intervention and Clinical Prognostic Factors

Cho, Tae-Koo,Cheong, Jin-Hwan,Kim, Jae-Hoon,Bak, Koang-Hum,Kim, Choong-Hyun,Kim, Jae-Min The Korean Neurosurgical Society 2006 Journal of Korean neurosurgical society Vol.40 No.1

Objective : Acute cerebral infarction is often accompanied by transtentorial herniation which can be fatal. The aim of this study is to determine the timing of surgical intervention and prognostic factors in patients who present with acute cerebral infarction. Methods : We reviewed retrospectively 23 patients with acute cerebral infarction, who received decompressive craniectomy or conservative treatment from January 2002 to December 2004. We divided patients into two groups according to the treatment modalities [Group 1 : conservative treatment, Group 2 : decompressive craniectomy]. In all patients, the outcome was quantified with Glasgow Outcome Scale and Barthel Index. Results : Of the 23 patients, 11 underwent decompressive craniectomy. With decompressive craniectomy at the time of loss of pupillary light reflex, we were able to prevent death secondary to severe brain edema in all cases. Preoperative Glasgow Coma Scale and loss of pupillary light reflex were significant to the clinical outcome statistically. With conservative treatment, 9 of the 12 patients died secondary to transtentorial herniation. The clinical outcomes of remaining 3 patients were poor. Conclusion : This study confirms the value of life-saving procedure of decompressive craniectomy after acute cerebral infarction. We propose that the loss of pupillary light reflex should be considered one of the most important factors to determine the timing of the decompressive craniectomy.

Long-Term Incidence and Predicting Factors of Cranioplasty Infection after Decompressive Craniectomy

Im, Sang-Hyuk,Jang, Dong-Kyu,Han, Young-Min,Kim, Jong-Tae,Chung, Dong Sup,Park, Young Sup The Korean Neurosurgical Society 2012 Journal of Korean neurosurgical society Vol.52 No.4

Objective : The predictors of cranioplasty infection after decompressive craniectomy have not yet been fully characterized. The objective of the current study was to compare the long-term incidences of surgical site infection according to the graft material and cranioplasty timing after craniectomy, and to determine the associated factors of cranioplasty infection. Methods : A retrospective cohort study was conducted to assess graft infection in patients who underwent cranioplasty after decompressive craniectomy between 2001 and 2011 at a single-center. From a total of 197 eligible patients, 131 patients undergoing 134 cranioplasties were assessed for event-free survival according to graft material and cranioplasty timing after craniectomy. Kaplan-Meier survival analysis and Cox regression methods were employed, with cranioplasty infection identified as the primary outcome. Secondary outcomes were also evaluated, including autogenous bone resorption, epidural hematoma, subdural hematoma and brain contusion. Results : The median follow-up duration was 454 days (range 10 to 3900 days), during which 14 (10.7%) patients suffered cranioplasty infection. There was no significant difference between the two groups for event-free survival rate for cranioplasty infection with either a cryopreserved or artificial bone graft (p=0.074). Intergroup differences according to cranioplasty time after craniectomy were also not observed (p=0.083). Poor neurologic outcome at cranioplasty significantly affected the development of cranioplasty infection (hazard ratio 5.203, 95% CI 1.075 to 25.193, p=0.04). Conclusion : Neurologic status may influence cranioplasty infection after decompressive craniectomy. A further prospective study about predictors of cranioplasty infection including graft material and cranioplasty timing is necessary.

Therapeutic Hypothermia for Increased Intracranial Pressure after Decompressive Craniectomy: A Single Center Experience

임현택,안준형,김지희,오재근,송준호,장인복 대한신경손상학회 2016 Korean Journal of Neurotrauma Vol.12 No.2

Objective: Therapeutic hypothermia (TH) and decompressive craniectomy are neuroprotective interventions following severe brain swelling. The precise benefits, risks, and clinical outcomes in brain swelling after TH are still being investigated. We aimed to investigate the effects of TH in severe brain injury after decompressive craniectomy. Methods: We reviewed the cases of 24 patients who underwent decompressive craniectomy with intracranial pressure (ICP) monitor insertion in one medical center between January 2012 and May 2016. All patients had an ICP greater than 15 mmHg and a Glasgow Coma Scale score of less than 7 at the time of intervention. TH was induced in half of the patients (n=12) directly after surgery; the remaining 12 patients remained normothermic. The ICP, vital signs, complications, and functional outcomes were reviewed and compared between the patient groups. Results: The mean ICP in the TH group was significantly lower than in the normothermia group. Complications during the 3 days after surgery were not different between the groups, with the exception of hypokalemia in the TH group. Mortality in the intensive care unit (ICU) was higher in the normothermia group, but the functional outcomes 3 months after surgery were not different between the TH and normothermia groups. Conclusion: TH after decompressive craniectomy was effective for lowering ICP in patients with severe brain swelling. TH also reduced mortality in the ICU, but it had no benefit in functional outcomes.

악성 뇌경색증에 대한 감압 두개골 절제술

최승원 최신의학사 2003 最新醫學 Vol.46 No.11-12

Biomarkers of Physiological Disturbances for Predicting Mortality in Decompressive Craniectomy

정영하,김소현,최은희,황금 대한신경손상학회 2016 Korean Journal of Neurotrauma Vol.12 No.2

Objective: Of many critical care regimens, the management of physiological disturbances in serum is particularly drawing an attention in conjunction with patient outcome. The aim of this study was to assess the association of serum biochemical markers with mortality in head trauma patients with decompressive craniotomy. Methods: Ninety six patients with acute subdural hematoma underwent decompressive craniectomy between January 2014 and December 2015. The clinical data and laboratory variables of these patients were recorded and analyzed retrospectively. The pre-operative and post-operative day (POD) 0, day 1 and day 2 serum variables were measured. These were compared between the survivors and non-survivors. Results: The factors of a large amount of intra-operative blood loss, shorter length of intensive care unit stays, and the needs for mechanical ventilation were related with mortality in the patients with decompressive craniectomy. These clinical factors were associated with the physiological derangements of sera. The average difference in serum chloride concentration between the pre-operative and POD 2 measurements (p=0.0192) showed a statistical significance in distinguishing between survivors and non-survivors. The average differences in albumin (p=0.0011) and platelet count (p=0.0004) between the pre-operative and POD 0 measurements suggested to be strong predictors of mortality in decompressive craniectomy. Conclusion: Isolated values of physiological biomarkers are not sufficient enough to predict in-hospital mortality. This study emphasizes the importance of a combined prognostic model of the differences in the pre-operative and post-operative hyperchloremia, thrombocytopenia, and hypoalbuminemia to identify the risk of mortality in decompressive craniecomy.

Complications of Cranioplasty Following Decompressive Craniectomy: Risk Factors of Complications and Comparison Between Autogenous and Artificial Bones

Ho Hyun Nam,Hee Jong Ki,Hyung Jin Lee,Sang Kyu Park 대한신경손상학회 2022 Korean Journal of Neurotrauma Vol.18 No.2

Objectives: Craniectomy is widely performed to lower the intracranial pressure in various conditions, such as traumatic brain injury, stroke, or brain swelling. Several complications can occur after craniectomy and cranioplasty, which significantly affect the prognosis of the patients after surgery. We studied the complications of craniectomy and cranioplasty and the factors affecting prognosis after the operation. Methods: Patients who underwent cranioplasty after craniectomy at Daejeon St. Mary’s Hospital from 2015 to 2021 were included. We retrospectively reviewed their medical records and images. All patients were classified according to their sex, age, clinical grade, and diagnosis. Complications after craniectomy and cranioplasty were investigated for 1 year after surgery. The complications included postoperative hemorrhage, infection, hydrocephalus, and bone resorption. Results: This study included 104 patients. Complications after decompressive craniectomy were significantly frequent in patients with hypertension history (p=0.03). In contrast, complications of cranioplasty were significantly frequent in patients with history of diabetes mellitus, hepatic failure, or trauma (p=0.03, p<0.01, and p=0.01, respectively). Artificial bones were used more frequently than autologous bones in patients with trauma (p=0.03); however, there was no difference in the incidence of complications between them (p=0.64). Conclusion: Hypertension is a significant risk factor for decompressive craniectomy complications, especially rebleeding. Diabetes, hepatic failure, and trauma are significant risk factors for cranioplasty complications. There was no statistical difference in the incidence of complications between the use of autologous and artificial bones.

외상성 뇌부종 환자에서 감압적 두개절제술의 임상적 의의

신형식,김태홍,황용순,박상근 인제대학교 백병원 2002 仁濟醫學 Vol.23 No.2

Objectives: Mortality and morbidity rates of malignant posttraumatic brain swelling remain high depite advances in treatment of increased intracranial pressure. If conventional therapy fails in patients suffering from intracranial hypertension, there is only small number of second-tier option left including decompressive craniectomy. The role of decompressive craniectomy in posttraumatic brain swelling remains controversial. We assessed the efficacy and indications of decompressive craniectomy. Methods: The authors performed decompressive bifrontotemporal craniectomy and dural expansion in 24 patients with malignant posttraumatic brain swelling between January 1997 and March 2000. Epidural pressure monotoring was performed in all patients. The clnical data and surgical outcomes were reviewed retrospectively. Results: The favorable outcome(GOS score 4-5) was 58%(14 of 24 patients), whereas the mortality rate was 29%(7 of 24 patients). Three patients(12%) remained in severely disabled state. Increased rate of favorable outcome was seen in the patients who had 8 or more of GCS score at admission and exhibited B wave in ICP monitoring and who showed steady state or slow deterioration in clinical course. Conclusion: If conservative therapy fails, decompressive bifrontotemporal craniectomy should be considered in the management of malignant posttraumatic brain swelling before irreversible ischemic brain damage occurs.

급성뇌경색증에 동반된 악성 뇌부종 환자에 있어서 뇌경막확장성형술을 통한 두개골 감압술의 효용성

손성호,김수영,정영균,조봉수,박혁,이동열,Son, Sung Ho,Kim, Soo Young,Jeong, Young Gyun,Cho, Bong Soo,Park, Hyuck,Rhee, Dong Youl 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.9

Objectives : There is continuing controversy about the benefits of decompressive craniectomy in massive cerebral edema following space occupying hemispheric cerebral infarction. The aims of this study are to determine the effectiveness and to confirm the life-saving nature of decompressive craniectomy with dural augmentation for massive cerebral infarction. Patients and Methods : We present twelve patients with medically uncontrollable hemispheric cerebral infarction. All were treated with extensive craniectomy and duroplasty without resection of necrotic tissue. We evaluated various characteristics(size of hemispheric infarction, Glasgow Coma Scale, volume of low density and midline shift in CT) at three different periods(preoperative, immediate postoperative and 3-4weeks after operation) and evaluated effectiveness of hemicraniectomy for massive cerebral edema after large hemispheric infarction. Results : All patients have survived from surgery. Nine patients with nondominant hemispheric infarction showed significant functional recovery with minimal assistance, and remaining two patients with dominant hemispheric infarction and one patient with nondominant hemispheric infarction have functionally dependent. The volume of low density and midline shift in CT were significantly reduced after decompressive craniectomy. Conclusions : Our results indicate that decompressive craniectomy with dural augmentation without resection of necrotic tissue for massive cerebral hemispheric infarction not only reduce the mortality and infarction size but also significantly improve the outcome, especially for nondominant hemispheric infarction.

중증 외상성 뇌부종 환자에서 양측 전두-측두부 감압적 개두술의 의의

신형식,김진용,김태홍,황용순,김상진,박상근,Shin, Hyung Shik,Kim, Jin Yong,Kim, Tae Hong,Hwang, Yong Soon,Kim, Sang Jin,Park, Sang Keun 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.9

Objective : The treatment of malignant posttraumatic brain swelling remains a frustrating endeavor for neurosurgeon. Mortality and morbidity rates remain high depite advances in medical treatment of increased intracranial pressure. If conventional therapy fails in patients suffering from intracranial hypertension, there is only small number of second-tier option left including decompressive craniectomy. The role of decompressive craniectomy in posttraumatic brain swelling remains controversial. We assessed the efficacy and indications of decompressive craniectomy. Methods : The authors performed decompressive bifrontotemporal craniectomy in 22 patients with malignant posttraumatic brain swelling. Epidural pressure monotoring was performed in all patients. The clnical data and surgical outcomes were reviewed retrospectively. Result : The favorable outcome(GOS score 4-5) was 59%(13 of 22 patients), whereas the mortality rate was 32% (7 of 22 patients). Two patients(9%) remained in severely disabled state. Increased rate of favorable outcome was seen in the patients who had 8 or more of GCS score at admission and exhibited B wave in ICP monitoring and who showed steady state or slow deterioration in clinical course. Conclusion : If conservative therapy fails, decompressive bifrontotemporal craniectomy should be considered in the management of malignant posttraumatic brain swelling before irreversible ischemic brain damage occur.

Decompressive Surgery in Patients with Poor-grade Aneurysmal Subarachnoid Hemorrhage: Clipping with Simultaneous Decompression Versus Coil Embolization Followed by Decompression

황의성,신희섭,이승환,고준석 대한뇌혈관외과학회 2014 Journal of Cerebrovascular and Endovascular Neuros Vol.16 No.3

Objective : In addition to obliterating the aneurysm using clipping or coiling,decompressive surgery for control of rising intracranial pressure (ICP)is thought to be crucial to prevention of adverse outcomes in patientswith poor grade aneurysmal subarachnoid hemorrhage (aSAH). We evaluatedthe clinical characteristics of patients with poor-grade aSAH, andcompared outcomes of aneurysmal clipping with simultaneous decompressivesurgery to those of coil embolization followed by decompression. Materials and Methods : In 591 patients with aSAH, 70 patients with H-Hgrade IV and V underwent decompressive surgery including craniectomy,lobectomy, and hematoma removal. We divided the patients into twogroups according to clipping vs. coil embolization (clip group vs. coilgroup), and analyzed outcomes and mortality. Results : Aneurysmal clipping was performed in 40 patients and coil embolizationwas performed in 30 patients. No significant differences in demographicswere observed between the two groups. Middle cerebral arteryand posterior circulation aneurysms were more frequent in the clip group. Among 70 patients, mortality occurred in 29 patients (41.4%) and 61 patients(87.1%) had a poor score on the Glasgow outcome scale (scores I-III). Nosignificant difference in mortality was observed between the two groups,but a favorable outcome was more frequent in the coil group (p < 0.05). Conclusion : In this study, despite aggressive surgical and endovascularmanagement for elevated ICP, there were high rates of adverse outcomesand mortality in poor-grade aSAH. Despite poor outcomes overall, earlycoil embolization followed by decompression surgery could lead to morefavorable outcomes in patients with poor-grade aSAH.