|Year : 2017 | Volume
| Issue : 2 | Page : 548-554
The outcome of early decompressive craniectomy of rapidly evolving cerebral parenchymatous mass lesion: vascular or trauma
Mohammud A Mohammud Salim, Shawky S Gad, Adel M Hanafy, Hossam A Elnoamany, Hazem M Negm
Department of Neurosurgery, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
|Date of Submission||16-Feb-2016|
|Date of Acceptance||19-Apr-2016|
|Date of Web Publication||25-Sep-2017|
Mohammud A Mohammud Salim
Department of Neurosurgery, Faculty of Medicine, Menoufia University, Shebin Elkom, 32511
Source of Support: None, Conflict of Interest: None
The objective of this study was to determine the outcome of early decompressive craniectomy (DC) in cases of increasing (evolving) parenchymatous swelling due to trauma or massive middle cerebral artery (MCA) infarction.
Intracranial hypertension is a major cause of secondary brain injury and often follows trauma or MCA infarction. Because intracranial pressure (ICP) varies with changes in the volume of the intracranial contents, we can increase cranial volume by removing the skull and opening the dura. The underlying brain can then swell under the relatively distensible skin. The use of DC to control increased ICP.
Materials and Methods
The study was a retrospective study conducted in Menoufia University, Neurosurgery Department, on patients admitted in a period of 2 years, in case of severe rapidly increasing brain swelling due to trauma or MCA infarction managed by DC. The patients were assessed by clinical examination of preoperative and postoperative Glasgow Coma Scale (GCS) and pupillary reaction, as well as immediate computed tomography brain and 24 h postoperative computed tomography brain. The patients were assessed according the Glasgow Outcome Scale.
A total of 20 cases were managed by DC. The data collected from 20 cases in this study were evaluated. The mechanism of injury was road traffic accident in 11 cases, MCA infarction in six cases and fall in three cases. All cases of bilaterally reactive pupil were clinically improved, and only one case of unilaterally reactive pupil was improved after DC. All cases with moderate GCS clinically improved after DC, and 23% (3/13) of cases with severe GCS affection were improved clinically. According to Glasgow Outcome Scale, the patients were assessed as follows: grade V as good recovery, three (15%) cases; grade IV as moderate disability, six (30%) cases; and grade I as death, 11 (55%) cases.
DC operation is the ideal solution for the management of increased ICP known by radiological improvement under the good circumstances of early intervention.
Keywords: decompressive craniectomy, intracranial hypertension, massive vascular brain strokes, severe traumatic brain injuries
|How to cite this article:|
Mohammud Salim MA, Gad SS, Hanafy AM, Elnoamany HA, Negm HM. The outcome of early decompressive craniectomy of rapidly evolving cerebral parenchymatous mass lesion: vascular or trauma. Menoufia Med J 2017;30:548-54
|How to cite this URL:|
Mohammud Salim MA, Gad SS, Hanafy AM, Elnoamany HA, Negm HM. The outcome of early decompressive craniectomy of rapidly evolving cerebral parenchymatous mass lesion: vascular or trauma. Menoufia Med J [serial online] 2017 [cited 2019 May 20];30:548-54. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/548/215431
| Introduction|| |
Brain oedema can develop after traumatic brain injury (TBI) and ischaemic stroke . Because of the rigid nature of the skull, brain oedema leads to an increase in intracranial pressure (ICP), which, in turn, causes reduction in cerebral perfusion pressure (mean arterial blood pressure − ICP), cerebral blood flow and brain oxygenation. These effects contribute to the development of additional brain oedema forming part of a 'vicious circle' that, if not interrupted, can lead to brain herniation and death .
Decompressive craniectomy (DC), a procedure in which part of the skull is removed and the underlying dura is opened, is attractive for management of evolving brain oedema, as it can provide additional space for the swollen brain, thereby avoiding the risk of ICP elevation and herniation. Strong evidence exists to suggest that DC can be used to effectively reduce ICP. Despite the passing of 100 years since Kocher's seminal description of DC in 1901, the role of this technique in patient management continues to be debated. The popularity of DC for treatment of patients who experience a TBI or stroke has waxed and waned since the 1950s. Since the 1990s, advances in neuroimaging and in prehospital and neurointensive care have led to a return of interest in the use of DC, which appeared in the publication of results from numerous randomized trials in the 2000s .
Intracranial hypertension following TBI can develop owing to diffuse brain oedema, brain contusions, pericontusional brain oedema or expanding haematomas, alone or in combination .
Brain oedema following ischaemic stroke often causes adverse effects in patients with large-volume (space-occupying) infarcts. Such infarcts are usually caused by occlusion of large vessels such as the distal internal carotid artery or the proximal middle cerebral artery (MCA). The term 'malignant MCA infarct' is often used, as up to 80% of patients with such infarcts will deteriorate and die following herniation. Approximately two-thirds of patients with malignant MCA infarcts deteriorate within 48 h of stroke onset. It has been suggested that early reperfusion therapy can increase the degree of oedema to critical levels within the first 24 h after stroke .
Evidence from noncontrolled series of patients with malignant MCA has suggested a significant survival benefit following hemicraniectomy, but the effect of DC on functional outcome remained unclear .
The use of DC to control ICP has been advocated for a number of disease processes, including stroke, tumours and trauma. The rationale for DC is to prevent secondary injury caused by intracranial hypertension .
| Aim of the Study|| |
The aim of the study was to determine the outcome of early DC in cases of increasing (evolving) parenchymatous swelling due to trauma or vascular strokes.
| Materials and Methods|| |
The study was a retrospective study in the Neurosurgery Department, Menoufia University, on patients admitted in a period of 6 months, in case of severe rapidly increasing brain swelling due to trauma or vascular strokes. This study was approved by the committee of the Ethics and values of Menoufia University at the 10th session at 21 June 2015.
The inclusion criteria were as follows:
- Failure of other therapeutic measures (hyperventilation, deep sedation, diuretics)
- Therapeutic measures are not suitable for the management [e.g., surgical acute subdural haematoma (ASDH) with rapid deterioration in the conscious level]
- Diffuse bilateral or unilateral brain swelling on computed tomography (CT) scan with clinical deterioration (evaluation will depend on the picture of CT to reveal the swelling, brain shift and effacement)
- Worsening of Glasgow Coma Scale (GCS) and/or dilation of pupil unresponsive to light
- Initial GCS 4 or higher with signs of herniation on the first day after head trauma or vascular strokes
- Massive intraoperative brain swelling during evacuation of intracranial haematoma.
The exclusion criteria were as follows:
- Patients with severe primary brainstem damage (i.e., an initial and persisting GCS score of 3 and/or bilateral fixed and dilated pupils), after exclusion of postictal and toxicity conditions
- Patients without radiological evidence of mass effect.
All patients were subjected to primary resuscitation and stabilization after admission to the hospital.
- Clinical evaluation:
- History taking: Age, sex, past history of medical diseases, mechanism of injury, time of trauma, prehospital post-traumatic fits and the presence of drugs or alcohol were recorded
- Clinical examination: General, GCS and local examination and routine trauma survey were performed, and conscious level (preoperative GCS), presenting symptoms, scalp injuries, bleeding orifices, pupils and associated injuries (spine, cardiothoracic, orthopaedic and so on) were evaluated
- Routine examinations included complete blood count, random blood sugar, serum urea, serum creatinine, bleeding profile (prothrombin time, international normalized ratio), liver enzymes (alanine transaminase, aspartate transaminase), ECG (if indicated) and abdomenopelvic ultrasound
- CT brain was performed. Patients were be diagnosed by CT scan postadmission (e.g., as ASDH, midline shift, widest thickness of the haematoma were measured)
- Imaging for associated injuries was performed
- Treatment: Airway (airway management), breathing (oxygen administration, needle or tube thoracotomy), circulation (intravenous access established and fluids administered), Disability neurologic (spine precaution). The patients were all treated with similar prehospital emergency treatment and routine brain CT scan was performed. Mannitol (0.5–1 mg/kg) and Lasix (0.25 mg/kg) were given preoperatively if there was no hypotension and antistroke measures in case of cerebral vascular strokes
- Surgical procedures: patients underwent DC, haematoma removal and augmentative duraplasty. DC was performed by removing a large portion of the frontotemproparietal cranium (>12 cm) for lesions confined to one cerebral hemisphere . A frontotemproparietal DC can also be performed for the control of intracranial hypertension secondary to diffuse brain swelling refractory to medical management. The operation increases intracranial volume, which reduces the ICP. Further ICP reduction can be achieved by opening the dura, duraplasty (covering brain by galeal graft), as part of the procedure. The bone was implanted in the subcutaneous tissue of the abdominal wall until replacement at a later date 
- The following were assessed (postoperatively after follow-up CT scan):
- Residual of any pathology
- Need for reoperation
- Postoperative treatment: on the basis of the conditions of ICP after operation, mannitol (0.5 mg/kg) and Lasix (0.25 mg/kg) were given. Antibiotics, haemostatic and neurotropic drugs were routinely used for all the patients
- Follow-up and outcome:
- Postoperatively, patients were admitted to the ICU and had at least one CT scan performed 24 h after operation. All survivors were followed up after operation with CT scan and neurological examination, including GCS and pupillary reaction, until the patients were discharged from the hospital
- They were assessed by the GCS and the outcome was graded using the Glasgow Outcome Score (GOS), which defines
- Grade I as death
- Grade II as persistent vegetative state
- Grade III as severe disability (being conscious but disabled)
- Grade IV as moderate disability (being disabled but independent)
- Grade V as good recovery.
Unfavourable outcome was defined as GOS 1–3 and favourable outcome as GOS 4 and 5 .
| Results|| |
The data collected from 20 cases in this study were evaluated. Among them, 13 were male and seven were female. The mechanism of injury was road traffic accident (RTA) in 11 cases, MCA infarction in six cases and fall in three cases. Their age ranged between 2 and 64 years.
In all, 65% were male and 35% were female [Figure 1].
Mechanisms of injury were 3/20 cases fall from height, 11/20 RTAs and 6/20 MCA infarction [Figure 2] and [Figure 3].
|Figure 2: Percentage of mechanism of injury of cases. MCA, middle cerebral artery; RTA, road traffi c accident.|
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|Figure 3: Percentage of mechanism of injury and clinical improvement of cases. MCA, middle cerebral artery; RTA, road traffi c accident.|
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Time from injury to operation: To simplify the influence of operative timings, it was subdivided as follows: less than 2, 2–6 and more than 6 h after injury. Time was less than 2 h in 6/20 cases (30%), 5/6 cases of them were clinically improved; 2–6 h in 7/20 cases (35%), 4/7 cases of them were clinically improved and more than 6 h in 7/20 cases (35%), 1/7 cases of them was clinically improved [Figure 4] and [Figure 5].
|Figure 5: Percentage of time of injury to surgery and clinical improvement of cases.|
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According to the results, the more rapid the surgery, the more the improvement.
The patients admitted were classified according to GCS; to simplify this classification, they were divided into the following groups: moderate (9–12), seven (35%) cases; and severe (3–8), 13 (65%) cases.
All cases with moderate GCS clinically improved after DC, and 23% (3/13) improved clinically [Figure 6].
|Figure 6: Percentage of GCS and clinical improvement of cases. GCS, Glasgow Coma Scale.|
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Among the patients admitted, nine (45%) cases were bilaterally reactive, 11 (55%) cases were unilaterally reactive and no cases were bilaterally nonreactive and dilated.
All cases of bilaterally reactive pupil were clinically improved, and only one case of unilaterally reactive was improved after DC [Figure 7].
|Figure 7: Percentage of pupillary reaction and clinical improvement of cases.|
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The associated medical and traumatic problems were present in 65% (13/20 cases), mainly hypertension (six cases), 30%, fractures (three cases), 15%, haemothorax (two cases), 10%, mild abdominal collection (two cases), 10% and addiction (one case), 5% [Figure 8].
|Figure 8: Percentage of associated medical and traumatic problems of cases.|
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Scalp wound infection occurred in 4/20 (20%) cases, contralateral epidural haematoma (EDH) occurred in 2/20 (10%) cases and abdominal wound infection and bone loss occurred in 3/20 (15%) cases [Figure 9].
GOS graded the outcomes as follows: grade V as good recovery (3/20 cases), 15%; grade IV as moderate disability (6/20 cases), 30%; grade I as death (11/20 cases), 55% [Figure 10].
| Discussion|| |
The concept of DC is by no means novel; it can be defined as the removal of a large area of the skull to increase the potential volume of the cranial cavity. At the beginning of the last century, Kocher asserted that 'if there is no cerebrospinal fluid pressure, but brain pressure exists, then pressure relief must be achieved by opening the skull.' Since then, DC has been recognized; although the procedure is theoretically attractive, questions remain as to whether or not it should be performed .
The incidence of TBI is more common in younger age groups (15–45 years) . In our study, we found that 66% (8/12 cases) of patients of TBI were in this age group.
In the study of Stocchetti et al. , it was reported that the epidemiology of TBI is changing in several Western countries, with an increasing proportion of elderly TBI patients admitted to the ICU. A series of 1366 adult patients were admitted to three neuro-ICUs, among whom 44% of cases were 50 years of age or older. Favourable outcomes were achieved by 50% of patients, but the proportions of unfavourable outcomes rose with age. Mortality was the main cause of unfavourable outcomes 6 months after injury in older patients.
Logistic regression analysis indicates that several parameters independently contributed to outcome, including the motor component of the GCS, pupils, CT findings and early hypotension. In addition, the odds ratios were very high for age and health status before TBI .
Preoperative GCS: the better the GCS, the better the prognosis. All cases with moderate GCS clinically improved after DC, and 23% (3/13) were improved clinically.
This was coincident with the study of Galal . Prognostic factors affecting outcome were admission GCS score, signs of herniation, patient comorbidities and midline shift in preoperative CT.
Preoperative pupillary reaction: if pupils were bilaterally reactive, this would improve the prognosis. All cases of bilaterally reactive pupil were clinically improved, and only one case of unilaterally reactive pupil was improved after DC.
According to the study of Göksu et al. , outcome in patients with bilateral nonreactive dilated pupil after severe TBI may not always be fatal or poor. Rapid DC may increase the chance of functional survival, especially in patients with admission GCS scores of 6 or 7.
The earlier the surgical decompression if indicated, the better the results. In our study, the clinical improvement in the less than 2 h group was 83.3%, whereas in the 2–6 h group clinical improvement was seen in 57% of the cases. In the more than 6 h group, clinical improvement was 14%.
This was coincident with many studies, as very early DC is indicated in the treatment of MCA infarction and TBI for better outcome ,,.
In our study, the mechanism of injury had an effect on clinical improvement. In MCA infarction, the improvement was 83% (5/6), in RTA it was 45% (5/11) and in fall cases there was no improvement (three cases).
This is coincident with the study of Vahedi et al. . In this trial, early DC in MCA infarction increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.
In our study, the complications were present in 13 cases (13/20): 65% of cases.
Wound infection in 4/20 cases (20%) was attributed to tension of sutures and sloughing after massive brain oedema 2 or 3 days postoperatively.
Delayed contralateral EDH in 2/20 cases (10%) was attributed to rapid decompression and rapid opening of the dura intraoperatively in cases of TBI; we suspected this intraoperatively by rapid swelling of the brain and we performed immediate postoperative CT brain and delayed contralateral EDH was diagnosed and operated.
Abdominal wound infection and bone loss in 3/20 cases (15%) of cases occurred when we used a wound drain and never occurred when we did not use it.
In the study of Ban et al. , it was reported that complications secondary to DC occurred in 48 (53.9%) of the 89 patients. The complications that occurred were cerebral contusion expansion, newly appearing subdural or EDH contralateral to the craniectomy defect (±1.5) epilepsy, cerebrospinal fluid leakage through the scalp incision and external cerebral herniation. Subdural effusion and postoperative infection developed between 1 and 4 weeks postoperatively. Trephined and post-traumatic hydrocephalus syndromes developed after 1 month postoperatively. A poor GCS score (≤8) and an age of 65 years or more were found to be related to the occurrence of one of the above-mentioned complications. These results should help neurosurgeons anticipate these complications, to adopt management strategies that reduce the risks of complications, and to improve clinical outcomes .
Glasgow Outcome Scale
The outcomes were graded as follows: grade V as good recovery (3/20 cases), 15%; grade IV as moderate disability (6/20 cases), 30%; and grade I as death (11/20 cases), 55%.
Intraoperative blood loss was not accurately measured; however, the amount of blood transfused is a rough indicator, as most patients had 2 U of blood.
This study has worse results in comparison with the international series. Death rate was 55% (11/20 patients); 45% of patients (9/20 patients) had favourable outcome. Some factors may have contributed negatively to the results, mainly long operative timing, as 70% of the patients were operated after 2 h from the trauma.
In our study, the factors affecting the prognosis of the patients were assessed as follows:
- Preoperative GCS: the better the GCS, the better the prognosis
- Preoperative pupillary reaction: if pupils were bilaterally reactive, this would improve the prognosis
- The earlier the surgical decompression if indicated, the better the results
- In our study, the mechanism of injury had an effect on clinical improvement
- Age, sex and associated problems had no significant effect on the clinical outcome.
The study of Gouello et al.  was as follows:
It was conducted on 60 patients after TBI, and it was operated upon by DC. Regarding the GOS; in that study: grade I (28.3%), grades II and III (21.7%) and grades IV and V (50%).
In the study by Seelig et al. , there were 82 patients suffering from ASDH after TBI; all were treated by DC. In the first 4 h, the mortality was 30 and 90% in those who had surgery after 4 h from injury.
In the study of Adamides et al. , there were 73 patients with an age of less than 60 years, and it was conducted from December 2002 through April 2010; wound infection occurred in five (7%) cases and residual haematoma with its different types occurred in three (4%) cases.
In the study of Rahmanian et al. , 60 patients with MCA infarction were considered eligible for inclusion into the study. There were 30 cases (surgical) and 30 controls (medical). Six (20%) patients died in the DC group as compared with 20 (67%) patients who died in the control group.
This study had some limitations. The most obvious is the lack of any nonoperative treatment group with which to compare the results and the small group of patients. However, conservative treatment would often be hard to justify, considering the poor clinical condition of the patients already receiving maximal medical therapy and, on the other hand, knowing that DC often normalizes increased ICP, which is the standard goal in modern neurointensive care.
As there was a lack of ICP monitoring devices (e.g., miniature strain-gauge or fibre-optic transducers) to evaluate the relief of elevated ICP after surgery, it was judged upon only radiologically.
However, the follow-up period is short, and an extended period of follow-up more than 6 months at least is required for analysis of rehabilitation and return to work to be included in the final judgment during comparison of these surgical techniques.
| Conclusion|| |
DC operation is the ideal solution for the management of increased ICP known by radiological improvement under the good circumstances of early intervention.
Apart from initial GCS and the pupillary status, time elapsed between the insult and treatment is the most important and can be improved by rapid transportation after trauma. Treatment in a specialized centre is an important contributing factor.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]