Randomized controlled study comparing 2 surgical techniques for decompressive craniectomy: with watertight duraplasty and without watertight duraplasty

Vieira, Eduardo; Guimarães, Thiago; Faquini, Igor Vilela; Silva, Jose L; Saboia, Tammy; Andrade, Rodrigo V C L; Gemir, Thaís L; Neri, Valesca C; Almeida, Nivaldo S.; Filho, Hildo Rocha Cirne de Azevedo

doi:10.3171/2017.4.jns152954

Cited by 39 publications

(33 citation statements)

References 17 publications

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“…Regarding supratentorial craniotomies, our results are in line with other studies that the watertight dural closure is not necessarily associated with an increased rate of complications [7,42]. Even in the case of larger surgeries such as decompressive craniectomies, complications related to non-watertight dural closure seem to be negligible [21,50], and may be more related to quality and technique of skin closure. We did not observe differences in outcome caused by skin closure techniques using staples or stitches.…”

Section: Effect Of Other Surgical Variables On Outcome Parameterssupporting

confidence: 90%

Surgical nuances and placement of subgaleal drains for supratentorial procedures—a prospective analysis of efficacy and outcome in 150 craniotomies

et al. 2020

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Background For supratentorial craniotomy, surgical access, and closure technique, including placement of subgaleal drains, may vary considerably. The influence of surgical nuances on postoperative complications such as cerebrospinal fluid leakage or impaired wound healing overall remains largely unclear. With this study, we are reporting our experiences and the impact of our clinical routines on outcome in a prospectively collected data set. Method We prospectively observed 150 consecutive patients undergoing supratentorial craniotomy and recorded technical variables (type/length of incision, size of craniotomy, technique of dural and skin closure, type of dressing, and placement of subgaleal drains). Outcome variables (subgaleal hematoma/CSF collection, periorbital edema, impairment of wound healing, infection, and need for operative revision) were recorded at time of discharge and at late follow-up. Results Early subgaleal fluid collection was observed in 36.7% (2.8% at the late follow-up), and impaired wound healing was recorded in 3.3% of all cases, with an overall need for operative revision of 6.7%. Neither usage of dural sealants, lack of watertight dural closure, and presence of subgaleal drains, nor type of skin closure or dressing influenced outcome. Curved incisions, larger craniotomy, and tumor size, however, were associated with an increase in early CSF or hematoma collection (p < 0.0001, p = 0.001, p < 0.01 resp.), and larger craniotomy size was associated with longer persistence of subgaleal fluid collections (p < 0.05). Conclusions Based on our setting, individual surgical nuances such as the type of dural closure and the use of subgaleal drains resulted in a comparable complication rate and outcome. Subgaleal fluid collections were frequently observed after supratentorial procedures, irrespective of the closing technique employed, and resolve spontaneously in the majority of cases without significant sequelae. Our results are limited due to the observational nature in our single-center study and need to be validated by supportive prospective randomized design.

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Section: Effect Of Other Surgical Variables On Outcome Parameterssupporting

confidence: 90%

Surgical nuances and placement of subgaleal drains for supratentorial procedures—a prospective analysis of efficacy and outcome in 150 craniotomies

et al. 2020

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“…Likewise, clinical profile and injury mechanisms of the patients in the present study was consistent with previous studies, 19,23,24 thus confirming the need for more assertive traffic policies as a measure to prevent TBI. 25,26 Vieira and colleagues 27 also conducted a study in HR and found that DC without watertight duroplasty is not associated with a higher incidence of post-operative complications, frequency of CSF leakage, or infections. Moreover, DC patients had decreased surgical time by 31 min on average, resulting in a reduction in hospital costs for treatment of critically ill patients, especially those with severe TBI, since they configure greater demand.…”

Section: Discussionmentioning

confidence: 99%

Decompressive Craniectomy in Traumatic Brain Injury: An Institutional Experience of 131 Cases in Two Years

Silva

Farias

Severo

et al. 2020

Neurotrauma Reports

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Decompressive craniectomy (DC) effectively reduces intracranial pressure (ICP), but is not considered to be a firstline procedure. We retrospectively analyzed sociodemographic, clinical, and surgical characteristics associated with the prognosis of patients who underwent DC to treat traumatic intracranial hypertension (ICH) at the Restauração Hospital (HR) in Recife, Brazil between 2015 and 2016, and compared the clinical features with surgical timing and functional outcome at discharge. The data were collected from 131 medical records in the hospital database. A significant majority of the patients were young adults (age 18-39 years old; 75/131; 57.3%) and male (118/131; 90.1%). Road traffic accidents, particularly those involving motorcycles (57/131; 44.5%), were the main cause of the traumatic event. At initial evaluation, 63 patients (48.8%) were classified with severe traumatic brain injury (TBI). Pupil examination showed no abnormalities for 91 patients (71.1%), and acute subdural hematoma was the most frequently observed lesion (83/212; 40%). Glasgow Outcome Scale (GOS) score was used to categorize surgical results and 51 patients (38.9%) had an unfavorable outcome. Only the Glasgow Coma Scale (GCS) score on admission (score of 3-8) was more likely to be associated with unfavorable outcome (pvalue = 0.009), indicating that this variable may be a determinant of mortality and prognostic of poor outcome. Patients who underwent an operation sooner after injury, despite having a worse condition on admission, presented with clinical results that were similar to those of patients who underwent surgery 12 h after hospital admission. These results emphasize the importance of early DC for management of severe TBI. This study shows that DC is a common procedure used to manage TBI patients at HR.

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“…It appears intuitive that a meticulous augmentative duraplasty and watertight scalp closure would prevent the exodus of CSF from the wound and reduce infection risk. However, a recent randomized controlled trial where watertight duraplasty was compared with rapid-closure DC without watertight duraplasty, there was no statistically significant difference in complications like CSF leak between the two groups of 29 patients each ( 30 ). Rapid closure DC without water tight duraplasty was on an average 31 min faster and hence cheaper.…”

Section: Early Complicationsmentioning

confidence: 99%

Complications of Decompressive Craniectomy

et al. 2018

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Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.

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Randomized controlled study comparing 2 surgical techniques for decompressive craniectomy: with watertight duraplasty and without watertight duraplasty

Cited by 39 publications

References 17 publications

Surgical nuances and placement of subgaleal drains for supratentorial procedures—a prospective analysis of efficacy and outcome in 150 craniotomies

Surgical nuances and placement of subgaleal drains for supratentorial procedures—a prospective analysis of efficacy and outcome in 150 craniotomies

Decompressive Craniectomy in Traumatic Brain Injury: An Institutional Experience of 131 Cases in Two Years

Complications of Decompressive Craniectomy

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