Decompressive Craniectomy as the Primary Surgical Intervention for Hemorrhagic Contusion

Abstract

The standard surgical treatment of hemorrhagic cerebral contusion is craniotomy with evacuation of the focal lesion. We assessed the safety and feasibility of performing decompressive craniectomy and duraplasty as the primary surgical intervention in this group of patients. Fifty-four consecutive patients with Glasgow Coma Scale (GCS) scores of less than or equal to 8, a frontal or temporal hemorrhagic contusion greater than 20 cm(3) in volume, and a midline shift of at least 5 mm or cisternal compression on computer tomography (CT) scan were studied. Sixteen (29.7%) underwent traditional craniotomy with hematoma evacuation, and 38 (70.4%) underwent craniectomy as the primary surgical treatment. Mortality, reoperation rate, Glasgow Outcome Scale-Extended (GOSE) scores, and length of stay in both the acute care and rehabilitation phase were compared between these two groups. Mortality (13.2% vs. 25.0%) and reoperation rate (7.9% vs. 37.5%) were lower in the craniectomy group, whereas the length of stay in both the acute care setting and the rehabilitation phase were similar between these two groups. The craniectomy group also had better GOSE score (5.55 vs. 3.56) at 6 months. Decompressive craniectomy is safe and effective as the primary surgical intervention for treatment of hemorrhagic contusion. This study also suggests that patient with hemorrhagic contusion can possibly have better outcome after craniectomy than other subgroup of patients with severe traumatic brain injury.

Ventriculoperitoneal (vp) shunt survival in patients developing hydrocephalus after cranial surgery

“…A few additions have also been made to the list of available treatment options with the most noteworthy being endoscopic third ventriculostomy The median time from shunt placement to first shunt failure noted in our study was 22.5 days, which is comparable to that reported by other studies (12,14). As mentioned previously, the development of hydrocephalus following cranial surgery (29) may be attributed to the direct collateral damage incurred during the surgical procedure (19). Theoretically, therefore, the indication for which cranial surgery was performed, the expertise of the operating surgeon, the surgical techniques employed as well as other patient factors may influence the survival of VP shunts placed in such patients.…”

“…In our study, patients who developed hydrocephalus following cranial surgery performed for brain tumors had a significantly decreased median time to first shunt failure. This may be explained by the extensive manipulation and injury to tissues incurred during resection of neoplastic disease as well as the alterations in cerebral blood flow and auto-regulation that develops after the procedure (19,29,46,47).…”

Controlled decompression for the treatment of severe head injury: a preliminary study

“…The size of the dural incision was generally no greater than 5 mm, which was often the size of the diameter of the aspirator head. After the dural incision was made, the aspirator head was placed into the incision, the hematoma was partially aspirated, the contused tissue was slowly aspirated, and ICP was gradually Although this approach has been reported to effectively reduce ICP and improve prognoses in some studies (1,2,7,8), the findings from a recent multinational randomized trial indicate that decompressive craniectomy may be associated with worse outcomes, as indicated by 6-month extended Glasgow Outcome Scale (GOS) scores, compared with standard care in patients with severe head injury (2). The authors of the report suggested that neural injury and alterations in cerebral blood flow and metabolism may have contributed to the worse outcome with decompressive craniectomy (2).…”

Factors influencing the decision to retain or remove the bone flap of adult patients with traumatic brain injury: a retrospective study

“…The hematoma volume was graded on a 10-point scale. With regards to injury/surgery time interval, previous studies have shown that the longer the time interval between injury and surgery, the greater the swelling and intracranial pressure (16,32); thus, a 10-point scale was set that ranged from 1 to 8 hours, with a longer time interval leading to a lower score, as this lowered the likelihood of preserving bone flap (undergoing the CR procedure instead of DC) (12). For the injury/surgery time interval category, we also took into consideration the uneven time distribution when designing the scale to make it more reasonable.…”