Decompressive craniectomy of post-traumatic brain injury: an in silico modelling approach for intracranial hypertension management

Abstract

Traumatic brain injury (TBI) causes brain edema that induces increased intracranial pressure and decreased cerebral perfusion. Decompressive craniectomy has been recommended as a surgical procedure for the management of swollen brain and intracranial hypertension. Proper location and size of a decompressive craniectomy, however, remain controversial and no clinical guidelines are available. Mathematical and computational (in silico) models can predict the optimum geometric conditions and provide insights for the brain mechanical response following a decompressive craniectomy. In this work, we present a finite element model of post-traumatic brain injury and decompressive craniectomy that incorporates a biphasic, nonlinear biomechanical model of the brain. A homogenous pressure is applied in the brain to represent the intracranial pressure loading caused by the tissue swelling and the models calculate the deformations and stresses in the brain as well as the herniated volume of the brain tissue that exits the skull following craniectomy. Simulations for different craniectomy geometries (unilateral, bifrontal and bifrontal with midline bar) and sizes are employed to identify optimal clinical conditions of decompressive craniectomy. The reported results for the herniated volume of the brain tissue as a function of the intracranial pressure loading under a specific geometry and size of craniectomy are exceptionally relevant for decompressive craniectomy planning.

Simulating Expansion of the Intracranial Space to Accommodate Brain Swelling after Decompressive Craniectomy: Volumetric Quantification in a 3D CAD Skull Model with Contour Elevation

“…The following methods have been addressed in current research to study the therapeutic effect of DC: (1) finite element (FE) model in experiment [ 19 ] and 3D editing FE model from magnetic resonance imaging [ 20 ] to investigate mechanical strain or brain biomechanical properties; (2) 3D printing artificial skull model from CT for skull defect-related quantitation [ 21 ]; (3) CT-based quantitative analysis in patients for skull defect [ 22 ] or contour elevation height-associated quantitation [ 23 , 24 ]; (4) hypothetic model of cerebral hemispheres with mathematical algorithm for quantitative assessment of transcalvarial brain herniation volume from skull effect [ 25 ]. Our data showed that the volume and volume-increasing rate were statistically significant when contour elevation height exceeded 6 mm.…”

“…The analysis of craniectomy size has been addressed in a number of studies to assess the postoperative outcomes in patients following DC. A correlation between craniectomy size and the potential expanded volume postoperatively has been reported in a 3D printing skull model [ 21 ] and 3D editing FE model [ 20 ]. A minimum diameter of 8.3 [ 21 ] or 12 cm [ 29 ] has been reported to lower increased ICP.…”

Relação do manejo adequado da Pressão Intracraniana nas Unidades de Terapia Intensiva com o prognóstico do paciente com Traumatismo Cranioencefálico / Relacion of proper management of Intracranial Pressure in Intensive Care Units with the prognosis of the patient with Cranioencephalic Trauma

“…Essa condição pode resultar no declínio da função neurológica em virtude de lesões primárias, ou seja, danos que ocorrem no momento do trauma, ou, ainda, manifestações secundárias à lesão inicial, como intumescimento cerebral e consequente aumento da pressão intracraniana. Desse modo, a monitorização da pressão intracraniana é um parâmetro fundamental na conduta terapêutica de traumas cerebrais, seja essa através de medicamentos ou procedimento cirúrgico (LAMBRIDE et al, 2020). Considerado padrão-ouro para mensurar a pressão intracraniana, o cateter ventricular oferece riscos sobrepujantes à operação neurocirúrgica, como infecção, hemorragia, obstrução e baixo rigor frente a lesões assimétricas entre os dois hemisférios cerebrais.…”

“…Não há consenso quanto à localização mais prudente que a craniectomia descompressiva deve ser realizada, tampouco o efeito que o tamanho da abertura craniana pode ocasionar com relação à posterior herniação. Sabe-se, contudo, que quanto mais larga a abertura feita, maior a proporção de tecido cerebral que culmina em hérnia (LAMBRIDE et al, 2020).…”

Neural Network Segmentation Algorithm-Based Magnetic Resonance Imaging to Explore the Relationship between Cerebrospinal Fluid Flow with Communicating Hydrocephalus after Decompressive Craniectomy for Craniocerebral Injury

“…Hydrocephalus under normal circumstances disrupts the balance of cerebrospinal fluid, eventually leading to accumulation of cerebrospinal fluid and swelling of the ventricles. For congenital hydrocephalus, the patient's head is significantly enlarged, and it can be identified by observing this external feature [9]. When hydrocephalus occurs in adults, the cranial volume does not change significantly, so doctors need to analyze medical images to diagnose hydrocephalus [10,11].…”