Technical aspects of decompressive craniectomy for malignant middle cerebral artery infarction

Johnson, Rebecca; Maartens, Nicholas F.; Teddy, Peter J.

doi:10.1016/j.jocn.2010.12.025

Cited by 26 publications

(10 citation statements)

References 32 publications

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“…A question mark-shaped skin incision was made frontoparietotemporally, ending approximately 10 mm anterior to the tragus, followed by retraction of the musculocutaneous flap, removal of the bone flap, and dural opening. 20,35 Before readapting the temporalis muscle and scalp flap, an intraparenchymal ICP monitor (Codman MicroSensor, Johnson & Johnson Professional Inc.) was placed ipsilaterally at the end of surgery according to the recommendations of the Milan consensus conference on ICP monitoring and current guidelines. 21,39 ICP values and mean arterial pressure were measured continuously.…”

Section: And Icp Monitoringmentioning

confidence: 99%

Intracranial pressure in patients undergoing decompressive craniectomy: new perspective on thresholds

Sauvigny¹,

Göttsche²,

Czorlich³

et al. 2018

Journal of Neurosurgery

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OBJECTIVE Decompressive craniectomy (DC) is an established part of treatment in patients suffering from malignant infarction of the middle cerebral artery (MCA) or traumatic brain injury (TBI). However, no clear evidence for intracranial pressure (ICP)-guided therapy after DC exists. The lack of this evidence might be due to the frequently used, but simplified threshold for ICP of 20 mm Hg, which determines further therapy. Therefore, the objective of this study was to evaluate this threshold's accuracy and to investigate the course of ICP values with respect to neurological outcome. METHODS Data on clinical characteristics and parameters of the ICP course on the intensive care unit were collected retrospectively in 102 patients who underwent DC between December 2007 and April 2014 at the authors' institution. The postoperative ICP course in the first 168 hours was recorded and analyzed. From these findings, ICP thresholds discriminating favorable from unfavorable outcome were calculated using conditional inference tree analysis. Additionally, survival analysis was performed using the Kaplan-Meier method. Prognostic factors were assessed via univariate analysis and multivariate logistic regression. Favorable outcome was defined as a score of 0-4 on the modified Rankin Scale. RESULTS Multivariate logistic regression revealed that anisocoria, diagnosis, and ICP values differed significantly between the outcome groups. ICP values in the favorable and unfavorable outcome groups differed significantly (p < 0.001), while the mean ICP of both groups lay below the limit of 20 mm Hg (17.5 and 11.5 mm Hg, respectively). These findings were reproduced when analyzing the underlying pathologies of TBI and MCA infarction separately. Based on these findings, optimized time-dependent threshold values were calculated and found to be between 10 and 17 mm Hg. These values significantly distinguished favorable from unfavorable outcome and predicted 30-day mortality (p < 0.001). CONCLUSIONS This study systematically evaluated ICP levels in a long-term analysis after DC and provides new, surprisingly low, time-dependent ICP thresholds for these patients. Future trials investigating the benefit of ICP-guided therapy should take these thresholds into consideration and validate them in further patient cohorts.

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Section: And Icp Monitoringmentioning

confidence: 99%

Intracranial pressure in patients undergoing decompressive craniectomy: new perspective on thresholds

Sauvigny¹,

Göttsche²,

Czorlich³

et al. 2018

Journal of Neurosurgery

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“…Some surgeons advocate resection of the temporal muscle and fascia to allow a maximum decompression [42], but this is not commonly performed. The craniotomy should include the frontal, parietal, and temporal bones and its anteroposterior length should not be inferior to 12 cm (Figure 2(a)); larger openings up to 14 cm or more are thought to allow an even better pressure relieve [43]. Particular attention has to be paid to decompression of the basal temporal area, as it represents a critical compartment with close relationship with the brainstem.…”

Section: Decompressive Techniquementioning

confidence: 99%

“…The cranioplasty clearly may have complications: infection and extra-axial hematoma formation are the most common [43] followed by hydrocephalus. Postoperative intracerebral infarction is fortunately a rare happening [51, 56].…”

Section: Cranioplastymentioning

confidence: 99%

Acute Supratentorial Ischemic Stroke: When Surgery Is Mandatory

Ronchetti

Panciani

Stefini

et al. 2014

BioMed Research International

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“…Dural opening For this step can be used three different ways of opening the dura with fish-mouth incision, stellate incision, C-shaped fashion incision and cruciate incision [66,68]. The C-shaped fashion is one of the most used incisions for dural opening, it goes from the temporal tip of the temporal lobe, and curving back about 8 cm crossing the sylvian fissure, and ending in the frontal region [66].…”

Section: Making Bone Flap For Bilateral Decompressive Craniectomiesmentioning

confidence: 99%

Decompressive craniectomy in traumatic brain injury: Quo Vadis?

et al. 2014

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Intracranial hypertension is the leading cause of mortality in patients with cranial injury. Currently the traumatic brain injury is a public health problem worldwide. Decompressive craniectomy emerges as a treatment strategy for patients with refractory intracranial hypertension. The completed surgery requires careful surgical technique and exquisite. We present a review of the literature about the technique.

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Technical aspects of decompressive craniectomy for malignant middle cerebral artery infarction

Cited by 26 publications

References 32 publications

Intracranial pressure in patients undergoing decompressive craniectomy: new perspective on thresholds

Intracranial pressure in patients undergoing decompressive craniectomy: new perspective on thresholds

Acute Supratentorial Ischemic Stroke: When Surgery Is Mandatory

Decompressive craniectomy in traumatic brain injury: Quo Vadis?

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