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A) Post decompressive craniectomy hydrocephalus in a 40-year-old woman. B) Cranioplasty and simultaneous ventriculostomy placement. c) Development of epidural hygroma. d) The opening pressure was raised and a VP shunt was placed 4 days later.
Source publication
We set out to investigate the optimal timing for shunt placement in patients with hydrocephalus after decompressive craniectomy (DC).
We studied 63 consecutive patients that underwent DC because of traumatic brain injury, middle cerebral artery infarct or intracerebral hemorrhage. Hydrocephalus was diagnosed in 23/63 patients. The 23 patients were...
Similar publications
Objective:
Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different be...
Citations
... Decompressive craniectomy (DC) is a surgical procedure which as long been used with varying usefulness for the treatment of refractory intracranial hypertension for a wide range of pathologies (1)(2)(3)(4)(5). Although the complications associated with this technique and the functional outcomes of surviving patients have not yet been fully determined (6,7), DC can be a lifesaving technique in the presence of medically intractable elevations of intracranial pressure, and may consequently increase the length of stay in intensive care units (8). ...
... However, the prolonged exposure of skull defects has been associated with various neurological manifestations, including the immediate effects of atmospheric pressure on the soft brain tissue, obstructions and hydrodynamic changes in cerebrospinal fluid, and modifications in cerebral blood flow and metabolism (6,7,9,10). Cranioplasty (CPL) is a procedure used for reconstructing skull deficits, providing cerebral protection, and enhancing the cosmetic effect (11). ...
The aim of the present retrospective study was to confer the factors that are related to bone graft absorption and affect the outcomes of patients following cranioplasty (CPL). The present retrospective study includes cases of patients that underwent CPL between February, 2013 and December, 2022. All participants had a follow-up period of 1 to 10 years from the day of discharge from the hospital. In total, 116 (62.3%) of the 186 patients that underwent decompressive craniectomy (DC) were enrolled in the present study for CPL. A total of 109 (93.9%) patients were included in group A, and 7 (6.0%) patients were included in group B. On the whole, the results of the present study suggest that a CPL after 2.5-7.7 months of DC increases the possibility of bone absorption.
... On the other hand, if DC is performed too late, the patient is at risk of irreversible brain stem damage due to herniation (59). A pre-operative GCS of at least 8/15 is critical for a positive outcome (60)(61)(62)(63). ICP monitoring is not goal-standard, since herniation signs precede the elevation of ICP (64). ...
... The complication rate is higher. Craniectomy violates dural and bony tissue planes, and creates abnormal communication among cranial spaces, predisposing post-operative fluid or cerebrospinal fluid collections, such as subdural hygromas and external hydrocephalus (63). Current data state that the extra axial fluid collection rates are lower than those of DC due to TBI, and of note, they appear to exhibit a trend to resolve spontaneously (58-60). ...
The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: ‘Malignant cerebral infarction’, ‘surgery for stroke’, ‘DC for cerebral infarction’, and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent.
... and CSF circulation, which may cause SSFS with symptoms including epilepsy, headaches, dizziness, language deficits, motor deficits, or even paradoxical herniation.[63][64][65] In contrast, initial CP can significantly improve DC-induced CSF dynamics dysfunction, thereby partially relieving symptoms of hydrocephalus and potential avoiding the need for subsequent shunting.66,67 But it is not absolute, Morton et al.68 found that post-CP was associated with a 9.0% risk of hydrocephalus. ...
Objective
To date, there is no consensus on the surgery strategies of cranioplasty (CP) and ventriculoperitoneal shunt (VPS) placement. This meta‐analysis aimed to investigate the safety of staged and simultaneous operation in patients with comorbid cranial defects with hydrocephalus to inform future surgery protocols.
Methods
A meta‐analysis of PubMed, Ovid, Web of Science, and Cochrane Library databases from the inception dates to February 8, 2023 adherent to PRISMA guidelines was conducted. The pooled analyses were conducted using RevMan 5.3 software. The outcomes included postoperative infection, reoperation, shunt obstruction, hematoma, and subdural effusion.
Results
Of the 956 studies initially retrieved, 10 articles encompassing 515 patients were included. Among the total patients, 193 (37.48%) and 322 (62.52%), respectively, underwent simultaneous and staged surgeries. The finding of pooled analysis indicated that staged surgery was associated with lower rate of subdural effusion (14% in the simultaneous groups vs. 5.4% in the staged groups; OR = 2.39, 95% CI: 1.04–5.49, p = 0.04). However, there were no significant differences in overall infection (OR = 1.92, 95% CI: 0.74–4.97, p = 0.18), central nervous system infection (OR = 1.50, 95% CI: 0.68–3.31, p = 0.31), cranioplasty infection (OR = 1.58, 95% CI: 0.50–5.00, p = 0.44), shunt infection (OR = 1.30, 95% CI: 0.38–4.52, p = 0.67), reoperation (OR = 1.51, 95% CI: 0.38–6.00, p = 0.55), shunt obstruction (OR = 0.73, 95% CI: 0.25–2.16, p = 0.57), epidural hematoma (OR = 2.20, 95% CI: 0.62–7.86, p = 0.22), subdural hematoma (OR = 1.20, 95% CI: 0.10–14.19, p = 0.88), and intracranial hematoma (OR = 1.31, 95% CI: 0.42–4.07, p = 0.64). Moreover, subgroup analysis failed to yield new insights.
Conclusions
Staged surgery is associated with a lower rate of postoperative subdural effusion. However, from the evidence of sensitivity analysis, this result is not stable. Therefore, our conclusion should be viewed with caution, and neurosurgeons in practice should make individualized decisions based on each patient's condition and cerebrospinal fluid tap test.
... 24 Regarding the surgical technique, CP, by itself, is already presented as a therapeutic approach, and is even considered sufficient, in the circumstances in which the brain is flaccid. [25][26][27] There are even reports in the literature of patients in whom the mechanism of deviation of CSF proved to be unnecessary. 22 However, in conditions of tension and brain herniation, CSF drainage may be required, 16 correcting the exteriorization of the brain and enabling the reconstruction of the skull. ...
... 16 Still, as an alternative for performing simultaneous CP to the management of post-DC HC, a study obtained better results from simultaneous ventriculostomy to CP, followed, in a few days, by the implantation of VPS. 25 On the other hand, considering the impasses related to the use of permanent shunt, for patients who need CSF drainage in the act of CP, the temporary lumbar or ventricular drainage presented themselves as valid and effective strategies. 16,22 Performing an aspiration procedure at the CP, the study by Kutty et al. could avoid the use of VPS in 10 of 11 patients with ventriculomegaly due to DC, with therapeutic success. ...
Introduction The increase in intracranial pressure (ICP) is a neurological complication resulting from numerous pathologies that affect the brain and its compartments. Therefore, decompressive craniectomy (DC) is an alternative adopted to reduce ICP in emergencies, especially in cases refractory to clinical therapies, in favor of patient survival. However, DC is associated with several complications, including hydrocephalus (HC). The present study presents the results of an unusual intervention to this complication: the implantation of an external ventricular drain (EVD) in the intraoperative period of cranioplasty (CP).
Methods Patients of both genders who presented with HC and externalization of the brain through the cranial vault after decompressive hemicraniectomy and underwent EVD implantation, to allow the CP procedure, in the same surgical procedure, were included.
Results Five patients underwent DC due to a refractory increase in ICP, due to automobile accidents, firearm projectiles, falls from stairs, and ischemic strokes. All evolved with HC. There was no uniform time interval between DC and CP. The cerebrospinal fluid (CSF) was drained according to the need for correction of cerebral herniation in each patient, before undergoing cranioplasty. All patients progressed well, without neurological deficits in the immediate postoperative period.
Conclusion There are still several uncertainties about the management of HC resulting from DC. In this context, other CP strategies simultaneous to the drainage of CSF, not necessarily related to ventriculoperitoneal shunt (VPS), should be considered and evaluated more deeply, in view of the verification of efficacy in procedures of this scope, such as the EVD addressed in this study.
... Thus, the existing controversies about the proper management for HC and CP regard the timing of CSF diversion with respect to the cranial reconstruction. When a CSF shunt is required, no evidence exists in the literature regarding the best time option (before, synchronously, or after CP) for insertion [44,51,56,57,60,70,73,93]. ...
Background
Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach.
Methods
The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP.
Results
The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations.
Conclusions
This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.
... Furthermore, these patients could present other isolated risk factors for hydrocephalus -for example, subarachnoid hemorrhage. 3,10 The management of the dynamic of fluids after hemicraniectomy can be quite a challenge as a result of problems in hemispheric change or compartmentalization, emphasizing that the definitive resolution for the accumulation of CSF is a great priority. In patients with a bulging scalp flap and ventriculomegaly (VM), some authors indicate temporary management until cranioplasty by way of frequent lumbar puncture or the placement of a ventricular or external spinal tap. ...
... This can make them predisposed for the necessity of a previous shunt, as described in this case study. 8,10,12,14 In the patients who have gone through craniectomy and whose hydrocephalus is persistent, the literature's point of view is still controversial as to the management of and the adequate time for applying shunt and cranioplasty. Recent data suggest that patients submitted for cranioplasty procedures and VPS by stages can benefit from less complicated results when compared to patients who go through the two procedures at the same time. ...
... In the case described, what was chosen was the closing of the VPS in order to permit parenchymal expansion after the cranioplasty procedure. 3,8,10,12,14 As in the majority of hydrocephalus cases, after decompressive craniectomy there is a spontaneous resolution with cranioplasty. VPS occlusion was maintained after cranioplasty, and a rigorous postoperative observation was conducted with regard to expansion inside the brain and the necessity for a shunt. ...
Decompressive craniectomy (DC) is an urgent neurosurgical procedure, effective in the reduction of intracranial pressure (ICP) in patients with elevated ICP and in complications of brain infarction that do not respond to clinical treatment; traumatic brain injury (TBI); intracerebral haemorrhage (ICH) and aneurysmal intracerebral haemorrhage. Symptomatic hydrocephalus is present in 2 to 29% of patients who undergo craniectomy. They may require a ventriculoperitoneal shunt (VPS). The literature does not yet show standard management of cranioplasty in patients who have previously undergone a shunt, showing evidence of sinking skin flap syndrome. This case shows parenchymal expansion after VPS occlusion and cranioplasty in the patient's profile. The 23-year-old male patient, right-handed, went to the hospital in January 2017 due to severe traumatic brain injury following multiple traumas. The patient underwent urgent DC surgery for the management of elevated ICP. The patient developed hydrocephalus. hydrocephalus. It was decided to perform the VPS implant. After 2 years, and with quite a sunken flap, the patient was submitted to cranioplasty procedure after shunt occlusion was performed. The patient left the hospital receiving outpatient care with no more complaints. In spite of the favourable outcome, new studies are fundamental to decide upon the best approach.
... There is lack of consensus regarding the optimal timing of CP and VPS placement in patients who require both surgeries (12,20,24,25,29,36). Usually, these operations are performed separately, although some neurosurgery centers currently attempt both procedures during a single session. ...
... CP performed before VPS placement can avoid the development of a sunken skin flap that occurs secondary to CSF diversion with early stabilization of intracranial pathophysiology (13,18), which can effectively reduce postoperative complications. Previous studies have reported that initial CP may reverse the DC-induced alterations in CSF dynamics and obviate the need for a subsequent shunt operation (8,25,26). Kutty et al. reported a reverse rate as high as 91% in asymptomatic patients with HCP without papilledema but with ventriculomegaly (16). Therefore, initial CP further reduces the overall postoperative complications, although we did not observe this phenomenon in our study. ...
... For patients with severe brain edema, preoperative CSF drainage (lumbar or ventricular) can ensure smooth insertion of the bone flap. This management strategy was introduced by Alexiou et al. and Giese et al., and the feasibility and safety of this approach has been confirmed by other studies (9,25,29,35). In our study, we did not observe the drainage-induced (lumbar or ventricular) complications in patients who underwent additional CSF drainage. ...
Aim:
In this study, we investigated the safety of combined cranioplasty (CP) and ventriculoperitoneal shunt (VPS) placement. Furthermore, we investigated whether the sequence of these procedures affects the postoperative complication rates associated with staged CP and VPS placement.
Material and methods:
We retrospectively investigated patients who developed communicating hydrocephalus after decompressive craniectomy and subsequently underwent VPS placement and CP at the hospital at which this study was performed between January 2009 and December 2019. Patients were categorized into group 1 (simultaneous CP and VPS placement) and group 2 (CP and VPS placement performed separately). Group 2 was subcategorized into subgroup 2a (CP performed before VPS placement) and subgroup 2b (VPS placement performed before CP). The Student's t and Chi square tests were used to analyze intergroup differences.
Results:
This study included 86 patients; 22 in group 1 and 64 in group 2 (24 patients in subgroup 2a and 40 patients in subgroup 2b). No statistically significant difference was observed in the overall complication rates between groups 1 and 2 (36.4% vs. 28.1%, P=0.591). However, the incidence of infections was significantly higher in group 1 than in group 2 (22.7% vs. 4.7%, P=0.024). Subgroup analysis showed that the overall complication rate was significantly lower in subgroup 2a than in subgroup 2b (12.5% vs. 37.5%, P=0.031).
Conclusion:
Simultaneous CP and VPS placement is associated with a high incidence of infections. Moreover, compared with initial CP, initial VPS placement is associated with a significantly higher risk of overall complications in patients who undergo a staged procedure.
... The disappearance of VM after CP is well-documented (23)(24)(25), and the postoperative management strategy of an unnecessary VPS placement (26)(27)(28)) is yet unclear. In patients with a bulging scalp flap and VM, external CSF drainage achieved via ventriculostomy or lumbar drainage could allow an accurate repositioning of CP without brain damage. ...
Cranioplasty (CP) after decompressive craniectomy (DC) for trauma is a neurosurgical procedure that aims to restore esthesis, improve cerebrospinal fluid (CSF) dynamics, and provide cerebral protection. In turn, this can facilitate neurological rehabilitation and potentially enhance neurological recovery. However, CP can be associated with significant morbidity. Multiple aspects of CP must be considered to optimize its outcomes. Those aspects range from the intricacies of the surgical dissection/reconstruction during the procedure of CP, the types of materials used for the reconstruction, as well as the timing of the CP in relation to the DC. This article is a narrative mini-review that discusses the current evidence base and suggests that no consensus has been reached about several issues, such as an agreement on the best material for use in CP, the appropriate timing of CP after DC, and the optimal management of hydrocephalus in patients who need cranial reconstruction. Moreover, the protocol-driven standards of care for traumatic brain injury (TBI) patients in high-resource settings are virtually out of reach for low-income countries, including those pertaining to CP. Thus, there is a need to design appropriate prospective studies to provide context-specific solid recommendations regarding this topic.
... However, there is no consensus on the treatment of hydrocephalus after DC. Shunt surgery may be performed with or without simultaneous cranioplasty (18,19). In our study, shunt surgery alone was performed in two patients. ...
... No complication was encountered in the follow-up of these patients. One previously published study reported fewer complications when cranioplasty and ventriculostomy were performed simultaneously, followed by placement of a ventriculoperitoneal shunt in a subsequent surgery (19). Although this method was found to be relatively safe, it requires three different surgical procedures to be performed in two separate surgeries. ...
Aim:
Patients with decompressive craniectomy (DC) were investigated to determine the most suitable treatment protocol to be applied.
Material and methods:
Overall, 32 patients with trauma or cerebrovascular disease underwent DC. Clinical, radiological and surgical data of surviving patients was retrospectively analysed. Favourable and unfavourable outcomes occurring during the course of their treatment were recorded.
Results:
We detected ventriculomegaly in nine out of the 32 patients (9/32, 28.1%) after DC. Of these nine, four patients (4/9, 44.4%) underwent shunt surgery. Cranioplasty performed in 29 of the 32 patients caused epidural hygroma in 13 of them (13/29, 44.8%). Of these 13 patients, three underwent surgery because of progressive increase in the size of hygromas. In the remaining patients, the epidural hygromas regressed spontaneously. Glasgow coma score (GCS) before and after DC surgery (p = 0.011 and p = 0.006, respectively), timing of cranioplasty (p = 0.028), midline shift (p = 0.048) and craniectomy size (p = 0.047) were significantly associated with ventriculomegaly.
Conclusion:
Lower GCS, delayed cranioplasty, greater midline shift and larger craniectomy size were found to be associated with hydrocephalus after DC. To avoid hydrocephalus, it may be beneficial to perform shunt surgery first followed by cranioplasty in a single surgical procedure. Additionally, epidural hygromas frequently encountered after a cranioplasty should be considered and followed up carefully.
... The disappearance of ventriculomegaly after cranioplasty is well documented. [26][27][28] This has been shown in various case series of patients who were waiting to undergo staged operation for cranioplasty and VPS. The return of the CSF and hemodynamic within the brain after the placement of the bone flap may play a role in the resolution of HCP. ...
... [29,30] Pachatouridis et al. from Greece studied the patients with PDCH with VPS as a single as well as staged procedure along with cranioplasty. [28] The single-staged surgery was accomplished with programmable shunt while staged surgery included insertion of ventricular catheter and measurement of ICP and choosing the most appropriate shunt according to the pressure. In that study, the author describes three patients, one from concomitant group and two from staged group who did not eventually require a VPS for HCP following cranioplasty. ...
... The use of programmable shunts has been very effectively proven for the PDCH in various case series. [25,28,37,38] The feasibility to titrate the pressure of the programmable valve is prominent advantage over fixed pressure valve in this situation as the blood and CSF dynamic may take time to return to normal following cranioplasty. Since this study was done in a tertiary care government hospital, the socioeconomic status of the patients is not well developed to afford a programmable shunt. ...
Introduction
Ventriculomegaly and hydrocephalus (HCP) are sometimes a bewildering sequela of decompressive craniectomy (DC). The distinguishing criteria between both are less well defined. Majority of the studies quoted in the literature have defined HCP radiologically, rather than considering the clinical status of the patient. Accordingly, these patients have been treated with permanent cerebrospinal fluid (CSF) diversion procedures. We hypothesize that asymptomatic ventriculomegaly following DC should undergo aspiration with cranioplasty and be followed up regularly.
Materials and Methods
All patients with post-DC who were scheduled for cranioplasty and satisfied the radiological criteria for HCP were included. These patients were categorized into two groups. Group 1 included ventriculomegaly with clinical signs attributable to HCP and Group 2 constituted ventriculomegaly but no clinical signs attributable to HCP. All patients in Group 1 underwent ventriculoperitoneal shunt followed by cranioplasty, whereas all patients in Group 2 underwent cranioplasty along with simultaneous ventriculostomy and temporary aspiration of the lateral ventricle. All patients were regularly followed as the outpatient basis.
Results
There were 21 patients who developed ventriculomegaly following DC. There were 10 patients in Group 1 and 11 patients in Group 2. The average duration of follow-up was from 6 months to 2 years. Two patients in the shunt group - (group 1) had over drainage and required revision. One patient in aspiration group - (group 2) required permanent CSF diversion.
Conclusions
Cranioplasty with aspiration is a viable option in selected group of patients in whom there is ventriculomegaly but no signs or symptoms attributable to HCP.
