Head, chest and limbs mine-explosive wounds

The article presents the experience of treating wounded K., 29 years old, who, as a result of the suicide bombing of a homemade shell-free explosive device in a moving car of the St. Petersburg Metro 03.04.2017 received a severe mine-explosive combined wound to the head, chest and limbs with a fragmented blind skull. The trauma was accompanied by brain damage, a fracture of the cranial vault bones, lungs contusion, and fragmented fracture of the right tibia bones. The patient underwent sequential bifrontal decompressive craniotomy, external fixation of the right shin bones fractures, blocked intramedullary osteosynthesis of the latter, dura mater plasty, cranioplasty with a titanium plate after its computer modeling. The complex treatment allowed the patient to be discharged from the hospital after 4 months in a satisfactory condition.

The possibility of simultaneous combined skin grafting during the installation of synthetic implants after cranial trepanation

Introduction. Over the past 20 years, with an increase in the number of decompression trepanations in the Russian Federation and abroad, the number of cranioplasties performed has increased. Despite the development of technology, these surgical interventions are inevitably accompanied by a number of complications (up to 36 %), including the for‑ mation of skin defects. The choice of the optimal algorithm for the treatment of skin defects after cranioplasty remains the subject of debate.The purpose of the publication is to demonstrate by a clinical example the possibility of simultaneous combined skin grafting during the installation of synthetic implants after cranial trepanation, as well as to analyze the outcomes and com‑ plications of such operations.Materials and methods. For the period 2017–2019 under our supervision there were 42 patients after craniotomy, 32 of which were cranioplasty, and 10 plastic surgery of the defects of the scalp after removal of synthetic implants. In the course of the analysis, the structure and terms of surgical interventions, the length of hospitalization, the frequen‑ cy and structure of complications, as well as the timing of their development were studied.The article presents one of the cases of treatment and simultaneous installation of a titanium plate, combined skin grafting in a patient who has undergone previously decompressive craniotomy, cranioplasty with protacryl.Results. Simultaneous cranioplasty with skin grafting was performed in 3 out of 42 patients. The average hospitalization time after such an intervention was significantly less than with two‑stage plastic surgery (28.0 ± 3.9 and 52.0 ± 2.7 days, respectively, p <0.05). There were no complications in the postoperative period after a single‑stage plastic surgery, but after a two‑stage one, 2 cases of divergence of the wound edges and the formation of fistulas above the implants were registered.Conclusion. The data obtained illustrate that, given the technical feasibility, as well as the satisfactory condition of the skin flap, simultaneous cranioplasty with combined skin grafting can be one of the methods of choice in the treat‑ ment of extensive defects in the skin of the head and skull.

Case Report: Minimal Neurological Deficit of Two Adult Patients With Weston–Hurst Syndrome Due to Early Craniectomy: Case Series and Review of Literature on Craniectomy

Objectives: We describe two new cases of acute hemorrhagic leucoencephalitis (AHLE), who survived with minimal sequelae due to early measures against increased intracranial pressure, particularly craniotomy. The recently published literature review on treatment and outcome of AHLE was further examined for the effect of craniotomy.Methods: We present two cases from our institution. The outcome of 44 cases from the literature was defined either as good (no deficit, minimal deficit/no daily help) or poor outcome (severe deficit/disabled, death). Patients with purely infratentorial lesions (n = 9) were excluded. Fisher's exact test was applied.Results: Two cases are presented: A 43-year-old woman with rapidly progressive aphasia and right hemiparesis due to a huge left frontal white matter lesion with rim contrast enhancement. Pathology was consistent with AHLE. The second case was a 56-year-old woman with rapidly progressive aphasia and right hemiparesis. Cranial MRI showed a huge left temporo-occipital white matter lesion with typical morphology for AHLE. Both patients received craniotomy within the first 24 h and consequent immunosuppressive-immunomodulatory treatment and survived with minimal deficits. Out of 35 supratentorial reported AHLE cases, seven patients received decompressive craniotomy. Comparing all supratentorial cases, patients who received craniotomy were more likely to have a good outcome (71 vs. 29%).Conclusion: Due to early control of the intracranial pressure, particularly due to early craniotomy; diagnosis per biopsy; and immediate start of immunosuppressive-immunomodulatory therapies (cortisone pulse, plasma exchanges), both patients survived with minimal sequelae. Craniotomy plays an important role and should be considered early on in patients with probable AHLE.

ChAdOx1 nCOV-19 vaccine-induced immune thrombotic thrombocytopenia and cerebral venous sinus thrombosis (CVST)

A 27-year-old fit and well man presented with intermittent headaches associated with eye floaters and vomiting. His symptoms started 48 hours after having the first dose of ChADOx1 nCOV-19 vaccine (Vaxzevria, previously AstraZeneca COVID-19 vaccine; AstraZeneca) and bloods showed raised D-dimer, low platelets and fibrinogen. CT venogram demonstrated significant cerebral venous sinus thrombosis. He was immediately started on intravenous immunoglobulins and dabigatran after liasing with haematologist. The next day, he complained of worsening headache and new homonymous hemianopia. Repeat CT of the head showed an acute parenchymal bleed with subdural extension and was given idarucizumab and high-dose steroids. He had an emergency decompressive craniotomy and external ventricular drain as his intracranial pressures were difficult to control. Despite full medical and surgical management, his intracranial pressures continued to rise and his brain injury was felt to be too devastating and was deemed unsurvivable.

Reasons for Diagnostic Delay of Foot Drop Caused by Parasagittal Meningioma: Two Case Reports

Foot drop is defined as an impaired ability or inability of dorsiflexion. Peripheral nervous system injuries are commonly considered as the cause of this condition. The central causes including parasagittal meningioma are also described in the literature but very rarely and commonly not recognized early. In this article, we report 2 patients with isolated unilateral foot drop as the first symptom of a parasagittal meningioma and discuss several reasons for delayed diagnosis. Two patients were treated with decompressive craniotomy. The histopathological findings demonstrated a fibroblastic meningioma and a meningothelial meningioma. During postoperative follow-up, the woman patient showed nearly complete recovery and the second case regained total muscle power over a period of 12 months. The rarity of the disease, the absence of upper motor neuron signs, the occurrence of peripheral pathologies and misinterpretation of F wave on nerve conduction study, and motor unit recruitment on electromyography lead to delay in diagnosis and treatment of the central foot drop due to parasagittal meningioma.

Reconstruction of Valular Bones Defects Using CAD/CAM Technology at the Stage of Rehabilitation: State of the Problem

The number of victims with difficult defects of the skull bones, which should restore the integrity of the skull is growing annually, both in connection with the increase in severe traumatic brain injury (TBI), and in connection with the expansion of indications for decompressive craniotomy not only in traumatic brain injury, but also vascular disease, neuro-Oncology for the relief of hypertension-dislocation syndrome. Cranioplasty at the stage of early rehabilitation of patients after decopressive craniotomy is an important condition for effective rehabilitation measures. Currently, titanium, polyether ethyl ketone (PEEK), polymethyl methacrylate (PMMA) and hydroxyapatite are actively used as the material for the implant. Unfortunately, none of the synthetic materials used meet the conditions of the perfect implant by 100%. CAD/CAM 3D printing technologies are used to achieve absolute accuracy of the implant that replicates the missing part of the patients skull bone, which is especially important in the presence of extensive and complex defects. The use of this technology at the preoperative stage directly in the medical institution where the cranioplasty will be performed avoids additional logistics, reduces the time from the patients admission to the hospital before the operation and reduces the cost of manufacturing implants, making them more accessible to healthcare institutions. also, the absence of the need for intraoperative implant adjustment significantly reduces the operation time, reduces the risk of infectious complications and complications associated with prolonged general anesthesia. The favorable course of the postoperative period allows you to resume rehabilitation activities on the third or fourth day after cranioplasty.

Everted Pedicled Temporalis Fascial Flap to Augment Pedicled Pericranial Flap for Lax Duraplasty in Decompressive Craniotomy: A Cost-Effective Procedure

Decompressive craniotomy is a commonly performed surgery to relieve raised intracranial pressure. At the end of the procedure, it is the convention to cover the exposed brain by performing a lax duraplasty which allows for both brain expansion and provides protection to the underlying parenchyma. Various commercially available dural substitutes are used for this purpose. These have the drawback of being both expensive and nonvascularized. We propose a technique of using pericranium along with everted temporalis fascia (both being locally harvested vascularized pedicle flaps) that can suffice in a vast majority of cases for covering the brain.

Decompressive craniotomy: an international survey of practice

Background Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide. Method A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019. Results We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC. Conclusion Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.

Net Water Uptake Calculated in Standardized and Blindly Outlined Regions of the Middle Cerebral Artery Territory Predicts the Development of Malignant Edema in Patients With Acute Large Hemispheric Infarction

Background and purpose: Previous studies have demonstrated that Net Water Uptake (NWU) is associated with the development of malignant edema (ME). The current study aimed to investigate whether NWU calculated in standardized and blindly outlined regions of the middle cerebral artery can predict the development of ME.Methods: We retrospectively included 119 patients suffering from large hemispheric infarction within onset of 24 h. The region of the middle cerebral artery territory was blindly outlined in a standard manner to calculate NWU. Patients were divided into two groups according to the occurrence of ME, which is defined as space-occupying infarct requiring decompressive craniotomy or death due to cerebral hernia in 7 days from onset. The clinical characteristics were analyzed, and the receiver operating characteristic curve (ROC curve) was used to assess the predictive ability of NWU and other factors for ME.Results: Multivariable analysis showed that NWU was an independent predictor of ME (OR 1.168, 95% CI 1.041–1.310). According to the ROC curve, NWU≥8.127% identified ME with good predictive power (AUC 0.734, sensitivity 0.656, specificity 0.862).Conclusions: NWU calculated in standardized and blindly outlined regions of the middle cerebral artery territory is also a good predictor for the development of ME in patients with large hemispheric infarction.