Evaluation of Pupil Diameter and Midline Shift in Patients Undergoing Decompressive Craniectomy

Sinking skin flap syndrome is rare phenomenon that occurs in patients with large craniectomies. Alteration in normal anatomy and pathophysiology can result in wide variety of symptoms including altered mental status, hemodynamic instability, and dysautonomias. Management is largely conservative. We here present a case of a patient with large craniectomy who was admitted to our hospital with pneumonia. Later on, he developed worsening mental status and CT head revealed sinking skin flap with significant midline shift. This is a very rare case of neurological deterioration after craniectomies, commonly known as sinking skin flap syndrome. To our knowledge, only few cases have been reported so far.

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Massive Temporalis Muscle Swelling after Decompressive Craniectomy: Case Report

Eastern Green Neurosurgery ◽

10.3126/egn.v2i3.31465 ◽

2020 ◽

Vol 2 (3) ◽

pp. 32-34

Author(s):

Dinesh Kumar Thapa ◽

Pankaj Raj Nepal ◽

Robin Bhattarai ◽

Jagat Narayan Rajbanshi ◽

Navin Kumar Yadav

Keyword(s):

Case Report ◽

Decompressive Craniectomy ◽

Surgical Procedure ◽

Mass Effect ◽

Brain Herniation ◽

Midline Shift ◽

Brain Swelling ◽

Temporalis Muscle ◽

Significant Mass Effect ◽

Significant Mass

Background: Decompressive Craniectomy is a surgical procedure in neurosurgery to handle brain swelling subsequent to trauma, vascular insult, or tumor. There are different techniques and measurements of decompressive craniectomy performed worldwide. We follow the regular trauma flap involving fronto-temporo-parietal craniectomy. There have been many complications seen in these procedures, like brain herniation, malignant swelling, hydrocephalus, infection, etc. But we have encountered quite rare complications of decompressive craniectomy which had massive swelling of the temporalis muscle leading to significant mass effect and midline shift.

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Acute paradoxical brain herniation after decompressive craniectomy for severe traumatic brain injury: A case report

Surgical Neurology International ◽

10.25259/sni-235-2019 ◽

2019 ◽

Vol 10 ◽

pp. 79

Author(s):

Ryo Hiruta ◽

Shinya Jinguji ◽

Taku Sato ◽

Yuta Murakami ◽

Mudathir Bakhit ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Decompressive Craniectomy ◽

Severe Traumatic Brain Injury ◽

Skin Flap ◽

Temporal Lobectomy ◽

Acute Subdural Hematoma ◽

Brain Herniation ◽

Midline Shift ◽

The Right

Background: Sinking skin flap syndrome or paradoxical brain herniation is an uncommon neurosurgical complication, which usually occurs in the chronic phase after decompressive craniectomy. We report a unique case presenting with these complications immediately after decompressive craniectomy for severe traumatic brain injury. Case Description: A 65-year-old man had a right acute subdural hematoma (SDH), contusion of the right temporal lobe, and diffuse traumatic subarachnoid hemorrhage with midline shift to the left side. He underwent an emergency evacuation of the right SDH with a right decompressive frontotemporal craniectomy. Immediately after the operation, his neurological and computed tomography (CT) findings had improved. However, within 1 h after the surgery, his neurological signs deteriorated. An additional follow-up CT showed a marked midline shift to the left, i.e., paradoxical brain herniation, and his skin flap overlying the decompressive site was markedly sunken. We immediately performed an urgent cranioplasty with the right temporal lobectomy. He responded well to the procedure. We suspected that a cerebrospinal fluid leak had caused this phenomenon. Conclusion: Decompressive craniectomy for severe traumatic brain injury can lead to sinking skin flap syndrome and/or paradoxical brain herniation even in the acute phase. We believe that immediate cranioplasty allows the reversal of such neurosurgical complications.

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Association Between Preoperative Midline Shift Growing Rate and Outcomes of Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction

Current Neurovascular Research ◽

10.2174/1567202617666200207125552 ◽

2020 ◽

Vol 17 (2) ◽

pp. 131-139

Author(s):

Ruozhen Yuan ◽

Simiao Wu ◽

Yajun Cheng ◽

Kaili Ye ◽

Zilong Hao ◽

...

Keyword(s):

Computed Tomography ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Decompressive Craniectomy ◽

Mass Effect ◽

Midline Shift ◽

Middle Cerebral Artery Infarction ◽

West China Hospital ◽

Computed Tomography Scans ◽

Adequate Decompression

Background: Whether preoperative midline shift and its growing rate are associated with outcomes of decompressive craniectomy in patients with malignant middle cerebral artery infarction is unknown. Methods: We retrospectively included patients: 1) who underwent decompressive craniectomy for malignant middle cerebral artery infarction in West China Hospital from August 2010 to December 2, 2018) who had at least two brain computed tomography scans before decompressive craniectomy. Midline shift was measured on the first and last preoperative computed tomography scans. Midline shift growing rate was calculated by dividing Δmidline shift value using Δ time. The primary outcome was inadequate decompression of the mass effect. Secondary outcomes were 3 month death and unfavorable outcomes. Results: Sixty-one patients (mean age 53.7 years, 57.4% (35/61) male) were included. Median time from onset to decompressive craniectomy was 51.8 h (interquartile range: 39.7-77.8). Rates of inadequate decompression, 3 month death, 3 month modified Rankin Scale 5-6 and 4-6 were 50.8% (31/61), 50.9% (29/57), 64.9% (37/57) and 84.2% (48/57), respectively. The inadequate decompression group had a higher midline shift growing rate than the adequate decompression group (median: 2.7 mm/8 h vs. 1.4 mm/8 h, P=0.041). No intergroup difference of 3 month outcomes was found in terms of preoperative midline shift growing rate. Conclusion: Higher preoperative midline shift growing rate was associated with inadequate decompression of decompressive craniectomy in patients with malignant middle cerebral artery infarction.

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Decompressive Craniectomy for Traumatic Brain Injury: In-hospital Mortality-Associated Factors

Journal of Neurosciences in Rural Practice ◽

10.1055/s-0040-1715998 ◽

2020 ◽

Vol 11 (04) ◽

pp. 601-608

Author(s):

Fernando Celi ◽

Giancarlo Saal-Zapata

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Hospital Mortality ◽

Decompressive Craniectomy ◽

Univariate Analysis ◽

Midline Shift ◽

Tomographic Images ◽

Radiological Criteria ◽

The Mean ◽

Gcs Score

Abstract Objective Determine predictors of in-hospital mortality in patients with severe traumatic brain injury (TBI) who underwent decompressive craniectomy. Materials and Methods This retrospective study reviewed consecutive patients who underwent a decompressive craniectomy between March 2017 and March 2020 at our institution, and analyzed clinical characteristics, brain tomographic images, surgical details and morbimortality associated with this procedure. Results Thirty-three (30 unilateral and 3 bifrontal) decompressive craniectomies were performed, of which 27 patients were male (81.8%). The mean age was 52.18 years, the mean Glasgow coma scale (GCS) score at admission was 9, and 24 patients had anisocoria (72.7%). Falls were the principal cause of the trauma (51.5%), the mean anterior–posterior diameter (APD) of the bone flap in unilateral cases was 106.81 mm (standard deviation [SD] 20.42) and 16 patients (53.3%) underwent a right-sided hemicraniectomy. The temporal bone enlargement was done in 20 cases (66.7%), the mean time of surgery was 2 hours and 27 minutes, the skull flap was preserved in the subcutaneous layer in 29 cases (87.8%), the mean of blood loss was 636.36 mL,and in-hospital mortality was 12%. Univariate analysis found differences between the APD diameter (120.3 mm vs. 85.3 mm; p = 0.003) and the presence of midline shift > 5 mm (p = 0.033). Conclusion The size of the skull flap and the presence of midline shift > 5 mm were predictors of mortality. In the absence of intercranial pressure (ICP) monitoring, clinical and radiological criteria are mandatory to perform a decompressive craniectomy.

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Decompressive Craniectomy (DC) - Comparative Study of 30-Day Mortality in Surgeries of Severe Brain Trauma with Subdural Hematoma, with and without DC

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0036-1596050 ◽

2016 ◽

Vol 36 (01) ◽

pp. 21-25

Author(s):

Lucas Bonadio ◽

Luis Mello ◽

Leandro Haas ◽

Vitor Boer ◽

Celso Bernardes ◽

...

Keyword(s):

Comparative Study ◽

Decompressive Craniectomy ◽

Subdural Hematoma ◽

Brain Lesion ◽

Acute Subdural Hematoma ◽

Midline Shift ◽

Outcome Predictor ◽

Brain Swelling ◽

Group 2 ◽

Group 1

Objective Compare 30 days mortality of patients harboring acute subdural hematomas in two series, one treated only by wide aspiration of hematoma and other with aspiration followed by decompressive craniectomy. Methods Comparing retrospectively two series of ASD with and without DC. Involved 81 TBI patients with acute subdural hematoma and GCS ≤ 8 (Jan 2000 to Nov 2014) arranged into two groups. Group 1 - 58 cases underwent to DC. Group 2 - 23 patients underwent only hematoma aspiration. Results Group 1 showed 44.8% mortality directly due to brain lesion within 30 days. The most frequent associated lesion were contusion in 37.2%. Group 2 the mortality within 30 days was 47.8%. The majority of deaths (82%) resulted from uncontrollable brain swelling, midline shift was present in 94.7% of patients. Conclusion High admission GCS and age less than 50 remain better outcome predictor in 30 days survival for patients undergoing surgery of traumatic ASDH.

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Four Quadrant Osteoplastic Decompressive Craniotomy versus Conventional Decompressive Craniectomy for Traumatic Brain Injury: A Randomized Controlled Trial

Indian Journal of Neurotrauma ◽

10.1055/s-0038-1649329 ◽

2017 ◽

Vol 14 (02/03) ◽

pp. 156-162 ◽

Cited By ~ 1

Author(s):

Siddharth Vankipuram ◽

Sumeet Sasane ◽

Anil Chandra ◽

Bal Ojha ◽

Sunil Singh ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Randomized Controlled Trial ◽

Brain Injury ◽

Decompressive Craniectomy ◽

Controlled Trial ◽

Midline Shift ◽

Randomized Controlled ◽

Decompressive Craniotomy ◽

Four Quadrant ◽

Brain Width

Abstract Objective Four quadrant osteoplastic decompressive craniotomy (FoQOsD) has been described as a novel technique in the management of patients with traumatic brain injury requiring decompressive surgery. There has not been a randomized controlled trial comparing its outcomes with conventional decompressive craniectomy (DECRA) as yet. Methods A randomized controlled trial of 55 patients was conducted, of whom 29 underwent DECRA and 26 patients underwent FoQOsD. The preoperative baseline demographics, clinical conditions, and radiologic features were similar in both the groups. Clinical outcome was decided by the use of Glasgow coma outcome scale extended (GOS-e) at 3 months. Radiographic outcomes were assessed by measurement of the change in midline shift and brain width expansion (ipsilateral and contra-lateral to hematoma) on the postoperative computed tomographic (CT) scan. Results No significant differences were identified in baseline demographics, clinical condition, Rotterdam CT score, and radiographic characteristics between both the groups. At 3-month follow-up, the mean GOS-e score was comparable in both the groups (3.23 in DECRA group and 3.35 in FoQOsD group, p = 0.856). Mortality analysis at 3 months revealed that nine patients died in the DECRA group and eight died in FoQOsD group. Postoperative imaging characteristics, including Rotterdam score, also did not differ significantly. The percentage reduction in midline shift and percentage brain width expansion on the postoperative CT scan was similar in both the groups (p > 0.05). Conclusion FoQOsD appears to be at least as efficacious as DECRA in providing equivalent clinical outcomes with the added benefit of avoiding a second surgery.

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Factors associated with mortality after decompressive craniectomy in large basal ganglia bleeds

Journal of Neuroscience and Neurological Disorders ◽

10.29328/journal.jnnd.1001048 ◽

2021 ◽

Vol 5 (1) ◽

pp. 029-033

Author(s):

Thotakura Amit Kumar ◽

Marabathina Nageswara Rao ◽

Mareddy Rama Krishnareddy ◽

Yeddanapudi Sivaramanjaneyulu

Keyword(s):

Basal Ganglia ◽

Decompressive Craniectomy ◽

Midline Shift ◽

Hematoma Volume ◽

Mortality And Morbidity ◽

Factors Associated ◽

Mri Brain ◽

Number Of Patients ◽

Operative Complications ◽

The Mean

Aim: To assess the efficacy of decompressive craniectomy in patients with large basal ganglia (BG) bleed. To establish predictive criteria of mortality after surgery in patients with BG bleed. Materials: This prospective study includes all patients of large spontaneous BG bleed operated by decompressive craniectomy without hematoma evacuation from October 2012 to September 2015. Data was collected on patient age, gender, distribution of bleed, affected hemisphere dominancy, preexisting medical conditions, admission Glasgow Coma Score (GCS), midline shift on CT or MRI Brain, hematoma volume and anisocoria, duration (hours) between the onset of stroke and operation, post-operative complications, and the duration of hospital stay. This data was correlated with one month mortality of the patients. Results: Total number of patients were 27. Mean age was 51 years and mean GCS was 7.55(range 5-11). The mean volume of the bleed was 68.51 ml. Mortality was noted in 17 out of 27 patients (63%) in 30 days. Thirteen of the 16 patients with intraventricular extension of BG bleed had mortality. The factors that showed statistically significant correlation with one month mortality were age, GCS at admission, volume of the bleed and the intraventricular extension. Conclusion: Large BG bleed was associated with high mortality and morbidity. Age of 50 years or more and GCS ≤ 8 at presentation were poor prognostic factors for decompressive craniectomy in patients with BG bleed. Patients with large BG bleed of volume > 60 ml and intraventricular extension had poor prognosis.

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675 ICA Ligation and Malignant MCA Syndrome Secondary to A Gunshot Wound: A Case Presentation

British Journal of Surgery ◽

10.1093/bjs/znab259.313 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

G Cairns ◽

A Belshaw

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Decompressive Craniectomy ◽

Gunshot Wound ◽

Internal Carotid ◽

Mortality Rates ◽

Haemodynamic Instability ◽

Left Internal Carotid Artery ◽

Midline Shift ◽

Increased Risk

Abstract Penetrating carotid injuries occur infrequently in the UK. Without surgical intervention, mortality rates are close to 100%. Whilst vessel repair is the optimal surgical choice, zone III neck injuries or haemodynamic instability in particular often require vessel ligation, which carries higher mortality rates, increased risk of stroke and poorer outcomes overall. We present a young patient who sustained a gunshot wound to the neck. Emergency exploration revealed a penetrating injury to zone III of the left side of the neck and a complete transection of the left internal carotid artery. Due to haemodynamic instability, damage control surgery was mandated, and the internal carotid artery was ligated. The patient was admitted to ITU but had a severe acute neurological deterioration post-operation. CT head imaging revealed a large left frontal-parietal infarct with rightward midline shift, in keeping with malignant MCA syndrome. He underwent an emergency decompressive craniectomy, with resolution of the midline shift seen on subsequent imaging. At 3 months, the patient walked independently out of hospital, with a reduction in his modified Rankin Scale score from 5 to 2 following intensive therapies input. Whilst rare, the importance of timely recognition and intervention of an infrequent complication of carotid ligation is paramount. Decompressive craniectomy is the mainstay of treatment for malignant MCA syndrome, yet outcomes remain poor in all ages, highlighting the patient’s noteworthy recovery. Though emerging evidence suggests novel endovascular repair techniques may provide favourable outcomes and reduced complications in carotid injuries, open surgery remains the treatment of choice.

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Improvement in Midline Shift Is a Positive Prognostic Predictor for Malignant Middle Cerebral Artery Infarction Patients Undergoing Decompressive Craniectomy

Frontiers in Neurology ◽

10.3389/fneur.2021.652827 ◽

2021 ◽

Vol 12 ◽

Author(s):

Xin Chen ◽

Qiang Hao ◽

Shu-Zhe Yang ◽

Shuo Wang ◽

Yuan-Li Zhao ◽

...

Keyword(s):

Logistic Regression ◽

Retrospective Study ◽

Decompressive Craniectomy ◽

Univariate Analysis ◽

Binary Logistic Regression ◽

Midline Shift ◽

Middle Cerebral Artery Infarction ◽

Prognostic Predictor ◽

Operation Duration ◽

Gcs Score

Objective: The aim of this retrospective study is to evaluate the risk factors of malignant middle cerebral artery infarction (MMCAI) patients and explore an applicable prognostic predictor for MMCAI patients undergoing decompressive craniectomy (DC).Methods: Clinical data from the period 2012–2017 were retrospectively evaluated. Forty-three consecutive MMCAI patients undergoing DC were enrolled in this study. The 30-day mortality was assessed, and age, location, hypertension, pupil dilation, onset to operation duration, midline shift, and Glasgow Coma Scale (GCS) score were identified by univariate analysis and binary logistic regression.Results: In this retrospective study for DC patients, the 30-day mortality was 44.2%. In the univariate analysis, advanced age (≥60 years), right hemispheric location, hypertension, pupil dilation, shorter onset to operation duration (<48 h), improved midline shift (t = 4.214, p < 0.01), and lower pre-operation GCS score were significant predictors of death within 30 days. In binary logistic regression analysis, age [odds ratio (OR) = 1.141, 95% CI 1.011–1.287], the improvement of the midline shift (OR = 0.764, 95% CI 0.59–0.988), and pupillary dilation (OR = 15.10, 95% CI 1.374–165.954) were independent influencing factors. For the receiver operating characteristic (ROC) analysis of the relationship between post-operation outcomes and midline shift improvement, the area under the curve (AUC) was 0.844, and the cutoff point of midline shift improvement was 0.83 cm.Conclusion: Improved midline shift was a significant predictor of 30-day mortality. The improved midline shift of >0.83 cm indicated survival at 30 days.

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