Modified Decompressive Craniotomy for Control of Intracranial Pressure

KISEP J Korean Neurosurg Soc 36 : 260-263, 2004

Technical Note Modified Decompressive Craniotomy for Control of Intracranial Pressure

Sang Myung Jung, M.D., Seok Won Kim, M.D., Sung Myung Lee, M.D. Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea

Objective : Various surgical techniques were developed for control of intracranial pressure such as extraventricular drainage, temporal lobectomy or decompressive craniectomy. We now describe our clinical experience by using the modified decompressive craniotomy. Methods : Modified decompressive craniotomy was performed in 8 patients with severe cerebral edema from July 2000 to April 2001. The indication of this operation was severe intracranial hypertension and edema in operative field. We analyzed the result(Glasgow coma scale, GCS score, Glasgow outcome scale, GOS score) with the variables(age, sex, midline shift on brain computed tomography scan) Results : The overall rate of good recovery(GOS score 4 or 5) was 75%(6 of 8 patients), poor recovery(GOS score 2 or 3) was 12.5%(1 of 8 patients), and mortality rate was 12.5%(1 of 8 patients). All of survived patients had improved GCS score(mean : 10.02) compared to preoperative GCS score(mean : 7.82) Conclusion : The authors would like to recommend modified decompressive craniotomy for the patient of traumatic brain swelling in appropriate indication. This new operative technique has advantages such as decompressive effect and no need of delayed cranioplasty.

KEY WORDS : Modified decompressive craniotomy∙ICP.

Introduction decompressive craniotomy has some advantages such as minimization of increasing intracranial pressure and no need of erebral hemorrhage, cerebral edema and rising delayed cranioplasty. The authors introduce this new operative C intracranial pressure by head trauma causes fatal results technical procedure and report clinical outcomes with literature in patient's mental state and neurological prognosis. Although review. hyperventilation, steroid, osmotic diuretics and barbiturate have been used to treat severe cerebral edema2,11), surgical methods Materials and Methods using decompressive craniectomy has been recognized as an effective treatment for patients of rising intracranial pressure Materials with severe cerebral edema but not reacting to conservative Modified decompressive craniotomy was performed in eight treatment since execution of decompressive craniotomy by patients who came to emergency room of this hospital from July Cushing. In addition, recent several clinical reports showed that of 2000 to April of 2001. This new operative technique was early decompressive craniectomy for the patients with severe performed in head trauma patient who showed continuous cerebral edema due to head trauma achieved good outcomes noticeable brain swelling in intraoperative field despite of preventing secondary worsening factors of cerebral edema. removing cerebral hematoma, contusion or necrotic brain tissue. However, in case that bone flap was removed by decompressive Because, the aims of this technique were decompressive and craniotomy, brain was escaped to the region of skull defects, cranioplastic effects. which may cause severe compression at peripheral brain region and cerebral edema due to obstruction of venous circulation Methods and then cranioplasty should be needed later. Modified Among the cases with severe brain swelling in brain computed tomography, the authors performed emergency �Received：February 27, 2004 �Accepted：May 20, 2004 craniotomy in next cases, showing midline shift over 5mm on �Address for reprints：Seok Won Kim, M.D., Department of Neurosurgery, College of Medicine, Chosun University, 588 Seosuk- brain CT in cerebral contusion and intracerebral hematoma, dong, Dong-gu, Gwangju 501-717, Korea the thickness over 5mm and midline shift over 6mm in acute Tel：062) 220-3120, 3126, Fax：062) 227-4575 subdural hemorrhage or obliteration of basal cistern or sylvian E-mail : [email protected] cistern(Table 1). For the operation, enough free bone flap was

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vicryl after extended duroplasty. Seven cases with three burr-holes at the frontotemporoparietal areas were fixed around the only one burr-hole of frontal area using absorptive suture vicryl 1-0(Fig. 1). One case with three burr-holes at the both frontal areas due to hematoma of both frontal lobes was fixed around the uppermost only one burr- A B hole using absorptive suture vicryl 1-0 and the remained burr- hole was not fixed for free movement of bone flap(suspend bone flap) in severe brain swelling. Temporalis muscle was sutured by loosely, but scalp suture was performed tightly for the prevention of cerebrospinal fluid leakage. In these days, this method has been applied to vascular disease and in this case, it was conducted after extended duroplasty(Fig. 2). C D

Fig. 1. A : Preoperative computerized tomography(CT) scan shows Results intracranial hemorrhage on the left temporal area. Severe brain swelling is detected in intraoperative field. B : Postoperative CT scan t examined age, sex, diagnosis, mental state in admission, shows a modified decompressive craniotomy. C : Seventh postoperative day CT scan shows projection of bone flap due to brain I degree of midline shift on CT, preoperative and postoperative swelling. D : Follow-up CT scan shows good approximation of bone Glasgow coma scale(GCS) and surgical methods in patients. flap 3 month later. Treatment results after operation were ranked favorable outcome between scores 4 and 5, unfavorable outcome between scores 2 and 3 and expired of score 1 by means of Glasgow Outcome Scale (GOS) and the follow-up period was from 4 to 19 months. Age of patients was ranged from A B 17 to 69 and average was 48.8. Male patients were five (62.5%) and female patients were three (37.5%). Preoperative GCS score was ranged from 4 to 12 and average was 8.4, and midline shift on brain CT scan was between 5mm and 16mm and the average shift was C D 10.1mm. Four cases accompanied acute subdural hematoma with Fig. 2. A : Preoperative computerized tomography(CT) scan shows intracranial hemorrhage on the right basal ganglia and intraventricular hemorrhage. B : Postoperative CT scan shows removal of cerebral edema and respective two hematoma. C : Sixth postoperative day CT scan shows projection of bone flap due to brain cases had traumatic intracerebral swelling. D : Follow-up CT scan shows good approximation of bone flap 9 months later. hemorrhage and hemorrhagic obtained for easy removal of hematoma by making three burr cerebral contusion. Seven cases had one side decompressive holes at the hematoma site. Hematoma and necrotic brain craniotomy of frontotemporoparietal area and one case bifrontal tissue were removed and there is no severe brain swelling decompressive craniotomy. According to treatment results was confirmed by operator in intraoperative field. In case of using GOS, six of eight cases (75%) showed favorable traumatic subdural hematoma, because it was not directly outcomes, one (12.5%) showed unfavorable outcomes and one related to subarachnoid space, dura mater remained opened (12.5%) was expired. All survivors showed improvement in without suture and scalp was closed tightly as the second GCS scores, their preoperative average score was 8.4 and barrier but in case of ICH it was better to fix bone flap with postoperative average score was 11.1(Table 1).

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Table 1. Summary of clinical features in 8 patients undergoing modified decompressive craniotomy induced edema after it and Mental state preop. Midline shifting on operative postop. 5) Age Sex Diagnosis GOS Hatashita et al. reported decrease on admission GCS brain CT scan name GCS intracranial pressure and tissue Lt. F-T-P 17 M stupor 10 Acute SDH 6 mm 15 5 craniotomy pressure, increase of itracranial 34 M drowsy 12 Hemorrhagic 5 mm bifrontal 14 4 compensation and fall of tissue contusion craniotomy resistance in gray matter on 41 F stupor 10 Traumatic 9 mm Rt. F-T-P 13 4 ICH craniotomy biomechanical research after 52 M semicoma 7 Acute SDH 15 mm Lt. F-T-P 82removing skull in normal brain in craniotomy experiment using cat and warned 55 F semicoma 8 Hemorrhagic 10 mm Rt. F-T-P 12 4 contusion craniotomy decompressive craniectomy in 59 F coma 4 Acute SDH 16 mm Lt. F-T-P 31 craniotomy patient with increased intracranial 61 M semicoma 7 Traumatic ICH 8 mm Lt. F-T-P 13 4 pressure reduced intracranial craniotomy pressure but cerebral edema might 69 M stupor 9 Acute SDH 12 mm Rt. F-T-P 13 4 craniotomy be progressed. In addition, Venes et al.13) reported unfavorable outcomes Discussion of reperfusion after frontal decompresson in blood vessel closure by head injury and explained that detachment of any medical and surgical treatments of cerebral bone flap casued prolapse of brain into cranial defect region, M edema caused by traumatic head injury have been severe pressure at peripheral brain region occurred and introduced. General medical treatments of cerebral edema venous circulation might be worsen. Execution of removal include steroid, osmotic diuretics, free radical scavenger, bone flap using decompressive craniectomy required hypothermia, hyperventilation and barbiturate. Surgical delayed cranioplasty and it may cause several problems treatment of cerebral edema such as extraventricular such as hematoma, infection, additional cost, etc12). It has drainage, removal of necrotic brain tissues, resection of been known as desirable methods that brain tissues with temporal lobes and decompressive craniectomy have been severe contusion is removed, enough decompression is performed. Decompressive craniectomy has been steadily performed and bone flap is covered with control of cerebral conducted since temporal decompression for the patients edema with medical treatment. But, this decompressive with brain tumor by Harvey Cushing4) in 1905. Polin et al.8) method is not enough to the patient with severe brain reported favorable outcomes of bifrontal decompressive swelling and needed for decompressive craniectomy or craniectomy for the patients with refractory posttraumatic modified decompressive craniotomy. The effect of this cerebral edema compared to medical treatments and Yoo et method naturally lower than duroplasty and craniectomy al.14) published that lateral swelling was induced by (because space was lost as the volume of bone within frontotemporoparietal decompressive craniectomy and then limited scalp). brain herniation could be prevented. According to comparison But, in case with brain swelling in some degree, when of results of decompressive craniectomy and those of bone flap was closed and mannitolization was conducted, conservative medical treatment based on related literatures, swelling was not controlled well and reoperation Aldrich et al.1) analyzed results of conservative medical (craniectomy) should be conducted. In author’s opinion, this treatment with 138 cases diagnosed as cerebral edema by case will be best indication. Of course, it is better to measure trauma and reported 44% of mortality in 1992 and Lang et and compare ICP and research on it will be conducted. The al.6) reported that among 59 children and 59 adults of authors also considered duroplasty is good treatment. But, traumatic cerebral edema receiving conservative treatment, 35 for subdural hematoma case, it is important to have rapid children (59%) and 12 adults (20%) showed favorable treatment operation time and for preventing adhesion in cranioplasty, outcomes. operation is completed by covering artificial dura and there However, on negative sides of decompressive craniectomy, were no complications like CSF leakage. Although there Park et al.7) reported decompressive craniectomy is not an has been dispute on removal necrotic cerebral tissues due to effective surgical method due to its high mortality, morbidity severe contusion, the authors didn’t remove tissues except and possible harmful effect such as enhanced edema formation visible contusion tissues as suggested by Rengachary et al.9) and hastend delayed lesions. Cooper et al.3) reported cold- and Rieke et al.10)

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because it was very difficult to discriminate between 4. Cushing H : The establishment of cerebral hernia as a decompressive measure for inaccessible brain tumors : with the description of intramuscular necrotic and normal brain tissues. methods of making the bone defect in temporal and occipital regions. Surg Gynecol Obstet 1 : 297-314, 1905 5. Hatashita S, Hoff JT : The effect of craniectomy on the biomechanics of Conclusion normal brain. J Neurosurg 67 : 573-578, 1987 6. Lang DA, Teasdale GM, Macpherson P, Lawrence A : Diffuse brain f applied for adequate indication, in case that cerebral edema swelling after head injury : more often malignant in adults than children? J Neurosurg 80 : 675-801, 1994 I due to intracerebral hemorrhage by head injury is not 7. Park JK, Lee KS, Doh JW, Bae DH, Yun IG, Lee IS : Results of controlled by medical conservative treatment, execution of decompressive craniectomy in severe head injury. J Korean Neurosurg modified decompressive craniotomy that extensive free bone Soc 20 : 161-166, 1991 8. Polin RS, Shaffrey ME, Bogaev CA, Tisdale N, Germanson T, Bocchicchio flap is made early, hematoma is removed and then bone flap can B, et al : Decompressive bifrontal craniectomy in the treatment of severe be freely moved depending to intracranial pressure will be very refractory posttraumatic cerebral edema. Neurosurgery 41 : 84-94, 1997 9. Rengachary SS, Batnitzky S, Morantz RA, Arjunan K, Jeffries B : helpful in recovering patients’ life, function and their economic Hemicraniectomy for acute massive cerebral infarction. Neurosurgery 8 : problems. 321-328, 1981 10. Rieke K, Schwab S, Krieger D, von Kummer R, Aschoff A, Schuchardt V, et al : Decompressive surgery in space-occupying hemispheric infarction : References results of an open, prospective trial. Crit Care Med 23 : 1576-1587, 1995 11. Selman WR, Spetzler RF : Therapeutics for focal cerebral ischemia. 1. Aldrich EF, Eisenberg HM, Saydjari C, Luerssen TG, Foulkes MA, Jane Neurosurgery 6 : 446-452, 1980 JA, et al : Diffuse brain swelling in severely head-injured children. A 12. Shim YB, Hwang HS, Lee JI, Oh SM, Choi SK, Kang SK : A clinical report from the NIH Traumatic Coma Data Bank. J Neurosurg 76 : 450- analysis of cranioplasty using methyl methacrylate. J Korean Neurosurg 454, 1992 Soc 19 : 360-366, 1990 2. Camarata PJ, Heros RC, Latchaw RE : “Brain attack” : the rationale for 13. Venes JL, Collins WF : Bifrontal decompressive craniectomy in the treating stroke as a medical emergency. Neurosurgery 34 : 144-158, 1994 management of head trauma. J Neurosurg 42 : 429-433, 1975 3. Cooper PR, Hagler H, Clark WK, Barnett P : Enhancement of experimental 14. Yoo DS, Kim DS, Cho KS, Huh PW, Park CK, Kang JK : Ventricular cerebral edema after decompressive craniectomy : implications for the pressure monitoring during bilateral decompression with dural expansion. management of severe head injuries. Neurosurgery 4 : 296-300, 1979 J Neurosurg 91 : 953-959, 1999

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