Bulging brains.

The aim of this study was to analyze decompressive craniectomy (DC) in the setting of subarachnoid hemorrhage (SAH) with bleeding, infarction, or brain swelling as the underlying pathology in a large cohort of consecutive patients. Decompressive craniectomy was performed in 79 of 939 patients with SAH. Patients were stratified according to the indication for DC: 1) primary brain swelling without or 2) with additional intracerebral hematoma, 3) secondary brain swelling without rebleeding or infarcts, and 4) secondary brain swelling with infarcts or 5) with rebleeding. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months (mRS Score 0-3 favorable vs 4-6 unfavorable). Overall, 61 (77.2%) of 79 patients who did and 292 (34%) of the 860 patients who did not undergo DC had a poor clinical grade on admission (World Federation of Neurosurgical Societies Grade IV-V, p < 0.0001). A favorable outcome was attained in 21 (26.6%) of 79 patients who had undergone DC. In a comparison of favorable outcomes in patients with primary (28.0%) or secondary DC (25.5%), no difference could be found (p = 0.8). Subgroup analysis with respect to the underlying indication for DC (brain swelling vs bleeding vs infarction) revealed no difference in the rate of favorable outcomes. On multivariate analysis, acute hydrocephalus (p = 0.009) and clinical signs of herniation (p = 0.02) were significantly associated with an unfavorable outcome. Based on the data in this study the authors concluded that primary as well as secondary craniectomy might be warranted, regardless of the underlying etiology (hemorrhage, infarction, or brain swelling) and admission clinical grade of the patient. The time from the onset of intractable intracranial pressure to DC seems to be crucial for a favorable outcome, even when a DC is performed late in the disease course after SAH.

The treatment of severe traumatic brain injury (TBI) with brain herniation is challenging because outcomes are often associated with high mortality and morbidity. Our aim was to identity factors contributing to decompressive craniectomy (DC) and evaluate treatment outcomes in patients with severe TBI with brain herniation.In this retrospective study, we analyzed medical records of severe TBI with brain herniation from May 2009 to December 2013. We reviewed their demographic data, mechanism of injury, Glasgow Coma Scale (GCS) score, pupil status, computed tomography findings, surgical treatment methods, time interval between brain herniation and surgery, as well as outcomes. GCS and pupil status are clinical parameters for detecting increase intracranial pressure while brain parenchyma bulged above the inner plate of the skull during operation indicated brain swelling as well as increased intracranial pressure on which basis the decision to perform DC or craniotomy was determined intraoperatively.One hundred ninety-four patients were included in the study. We performed DC in 143 of the patients while 51 of them we performed craniotomy. There were no statistically significant differences in the age, gender, or injury mechanism between the 2 groups. GCS, pupillary dilation, midline shift, hematoma type and timing of surgery were associated with DC. Nevertheless, logistic regression analysis revealed that hematoma type and timing of surgery were significantly associated with favorable DC outcomes (P < .001 and P = .023). Subdural hematoma and timing of surgery >1 hour were both identified as risk factors for DC. Six months after TBI, 34.0% of patients exhibited favorable outcomes. Overall mortality rate was 30.4%. Age, GCS, pupil dilation, hematoma type, and timing of surgery were all associated with patient outcomes. Further logistic regression analysis revealed that, lower GCS, bilateral pupil dilation, timing of surgery >1 hour, and advanced age were independent risk factors for poor outcomes (P = .001, P = .037, P = .028, and P = .001, respectively).Our study revealed that, DC is not mandatory for all TBI patients with brain herniation. Nevertheless, DC decreases mortality rate in severe TBI patients with brain herniation. Subdural hematoma and timing of surgery >1 hour are key indicators for DC. Lower GCS, bilateral pupil dilation, delayed timing of surgery and advance age are indicators of poor outcomes.

Objective To analyze the effects of bifrontal decompressive craniectomy on patients with refractory brain swelling after severe traumatic brain injuries.Methods We retrospectively reviewed 25 patients with refractory brain swelling after severe head injuries.Bifrontal decompressive craniectomy was carried out in 14 patients while the other 11 patients were nursed with non-operative treatments.All patients were managed by the intracranial pressure monitoring.The Glasgow Outcome Scale (GOS) at the 6-months follow-up was used as the outcome measure.Results The admission ICP in the operative group was (35.8 ±6.8) mm Hg,which fell to (17.6 ±5.7) mm Hg after the operation.In the non-operative group,ICP fell from (33.2 ±5.6) mm Hg to (30.2 ±4.9) mm Hg 10.1 h after the admission.6 of the 14 patients in the operative group scored between 4 ～ 5 on the GOS compared with 2 of the 11 patients in the non-operative group.Conclusions Bifrontal decompressive craniectomy was a suitable measure to decrease the ICP in the patients with refractory brain swelling.If carried out early,it could provide better outcome for these patients. Key words: Diffuse brain swelling; Decompressive craniectomy; Traumatic brain injury

The aim of this study was to assess outcome following decompressive craniectomy for malignant brain swelling due to closed traumatic brain injury (TBI). During a 48-month period (March 2000-March 2004), 50 of 967 consecutive patients with closed TBI experienced diffuse brain swelling and underwent decompressive craniectomy, without removal of clots or contusion, to control intracranial pressure (ICP) or to reverse dangerous brain shifts. Diffuse injury was demonstrated in 44 patients, an evacuated mass lesion in four in whom decompressive craniectomy had been performed as a separate procedure, and a nonevacuated mass lesion in two. Decompressive craniectomy was performed urgently in 10 patients before ICP monitoring; in 40 patients the procedure was performed after ICP had become unresponsive to conventional medical management as outlined in the American Association of Neurological Surgeons guidelines. Survivors were followed up for at least 3 months posttreatment to determine their Glasgow Outcome Scale (GOS) score. Decompressive craniectomy lowered ICP to less than 20 mm Hg in 85% of patients. In the 40 patients who had undergone ICP monitoring before decompression, ICP decreased from a mean of 23.9 to 14.4 mm Hg (p < 0.001). Fourteen of 50 patients died, and 16 either remained in a vegetative state (seven patients) or were severely disabled (nine patients). Twenty patients had a good outcome (GOS Score 4-5). Among 30-day survivors, good outcome occurred in 17, 67, and 67% of patients with postresuscitation Glasgow Coma Scale scores of 3 to 5, 6 to 8, and 9 to 15, respectively (p < 0.05). Outcome was unaffected by abnormal pupillary response to light, timing of decompressive craniectomy, brain shift as demonstrated on computerized tomography scanning, and patient age, possibly because of the small number of patients in each of the subsets. Complications included hydrocephalus (five patients), hemorrhagic swelling ipsilateral to the craniectomy site (eight patients), and subdural hygroma (25 patients). Decompressive craniectomy was associated with a better-than-expected functional outcome in patients with medically uncontrollable ICP and/or brain herniation, compared with outcomes in other control cohorts reported on in the literature.

Traumatic brain injuries (TBIs) still put a high burden on public health worldwide. Medical and surgical treatment strategies are continuously being studied, but the role and indications of primary decompressive craniectomy (DC) remain controversial. In medically refractory intracranial hypertension after severe traumatic brain injury, secondary decompressive craniectomy is a last resort treatment option to control intracranial pressure (ICP). Randomized controlled studies have been extensively performed on secondary decompressive craniectomy and its role in the management of severe traumatic brain injuries. Indications, prognostic factors, and long-term outcomes in primary decompressive craniectomy during the evacuation of an epidural, subdural, or intracerebral hematoma in the acute phase are still a matter of ongoing research and controversy to this day. Prospective trials have been designed, but the results are yet to be published. In isolated epidural hematoma without underlying brain injury, osteoplastic craniotomy is likely to be sufficient. In acute subdural hematoma (ASDH) with relevant brain swelling and preoperative CT signs such as effaced cisterns, overly proportional midline-shift compared to a relatively small acute subdural hematoma, and accompanying brain contusions as well as pupillary abnormalities, intraventricular hemorrhage, and coagulation disorder, primary decompressive craniectomy is more likely to be of benefit for patients with traumatic brain injury. The role of intracranial pressure monitoring after primary decompressive craniectomy is recommended, but prospective trials are pending. More refined guidelines and hopefully class I evidence will be established with the ongoing trials: randomized evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural hematoma (RESCUE-ASDH), prospective randomized evaluation of decompressive ipsilateral craniectomy for traumatic acute epidural hematoma (PREDICT-AEDH), and pragmatic explanatory continuum indicator summary (PRECIS).

Decompressive craniectomy (DC) is a rescue operation performed for reduction of intracranial pressure due to progressive brain swelling, mandating the need for cranioplasty. To describe expansile craniotomy (EC) as a noninferior technique that may be effectively utilized in situations requiring standard DC. A decision to perform DC or EC was taken by consecutively allocation to either of the procedures. The bone flap was divided into three pieces, which were tied loosely to each other and to the skull using silk threads. The primary outcome included functional assessment using Glasgow outcome scale (GOS) score at 1 year. Total 67 patients were included in the analyses, of which, 31 underwent EC and 36 underwent DC. Both the cohorts were matched in terms of baseline determinants for age, Glasgow coma scale, and Rotterdam score at admission. There was no significant difference in GOS scores and the extent of volume expansion obtained by EC as compared to DC. Complication rates though less in EC group did not differ significantly between the groups. EC appears to be the safe and effective alternative to DC in the management of brain swelling due to TBI with a potential to obviate the need of cranioplasty.

Globally, severe traumatic brain injury (TBI) is a significant cause of death and disability, particularly among young adults in their productive years. The management of elevated intracranial pressure (ICP) following TBI remains one of the greatest challenges in neurotrauma care, with decompressive craniectomy (DC) being a prominent, albeit contentious, treatment option. DC, a surgical procedure that involves removing a portion of the skull to accommodate brain swelling, has emerged as a potential life-saving intervention in such scenarios. The rationale is that by reducing ICP and enhancing cerebral perfusion, DC may mitigate further neurological damage. However, while DC effectively reduces mortality, its association with a high prevalence of severe disability and poor long-term functional outcomes has led to ongoing debate regarding its clinical utility, ethical justification, and cost-effectiveness. From a health care economics standpoint, DC has been shown to be more cost-effective than alternatives like barbiturate coma, particularly in younger patients with less severe injuries. Yet, this advantage diminishes in older populations or those with profound neurological impairment, where survival often comes at the cost of substantial long-term care needs and significantly impaired quality of life. Additionally, the decision to perform DC often occurs under critical circumstances where inherent prognostic uncertainty of early outcome prediction and emotional stress further complicate the shared decision-making process. To aid in navigating these complex choices and to guide ethical resource allocation, prognostic models such as Corticosteroid Randomization After Significant Head injury (CRASH) and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) have been developed, offering evidence-based predictions of functional outcomes based on preoperative clinical and radiographic variables. Nevertheless, these models have limitations. This review synthesizes current evidence on the clinical effectiveness, cost utility, and ethical dimensions of DC in severe TBI. It also explores the role of predictive tools in facilitating evidence-informed and ethically responsible decisions. A literature review was conducted using major biomedical databases to identify and synthesize clinical, ethical, and economic evidence related to DC in severe TBI. We also sought the opinion of various experts and tried to provide a comprehensive, multidimensional understanding of DC in neurotrauma care to support clinicians in navigating the complexities of managing severe TBI patients.

Objective To present our experiences on the treatment of severe traumatic brain injury on patients with herniation and discuss the indication for decompressive craniectomy (DC) and prognostic factors.Methods From May 2009 to Dec.2011,139 patients aged between 3 and 83 years with severe traumatic cerebral herniation were included.The patients' Glasgow Coma Scale score (GCS),pupil reaction,diagnosis,surgical treatment methods,and prognosis were analyzed retrospectively.Results 102patients underwent DC and 37 patients underwent non-decompressive craniectomy.Amongst 106 patients with GCS≤6,there were 85 patients undergoing DC (80.1％).Thirty-five patients with bilateral pupil dilation underwent DC (88％,35/40),and 67 (68％,67/99) patients with unilateral pupil dilation underwent DC(P ＜0.05).Based on the Glasgow Outcome Scale,42 patients were dead,31 in vegetative state,16 with severe disabilities,8 with moderate disabilities,and 42 had good recovery at the 3-month follow-up.Overall mortality was 30.2％.As for patients with GCS =3,the mortality was 63％ (19/30).Lower GCS was associated with worse outcomes.The mortality was 60％ in 40 patients with bilateral pupil dilation and 18％ in 99 patients with unilateral pupil dilation (P ＜ 0.05).The mortality was 5％ (2/37) in patients with epidural hematoma and 43％ (26/61) with subdural hematoma (P ＜ 0.05).The mortality was 74％ (14/19) when ICP 30 ～40 mm Hg,and the mortality was 100％ (8/8) when ICP ＞40 mm Hg.Conclusions Low GCS,bilateral pupil dilations,and ICP ≥ 30 mm Hg suggest higher mortality and unfavorable outcomes.GCS≤6,bilateral pupil dilations,and intraoperative brain swelling can be viewed as indications for DC in severe traumatic brain injury patients with herniation.Smart surgical technique is helpful for the treatment of herniation. Key words: Craniocerebral trauma; Encephalocele ; Decompressive craniectomy; Intracranial pressure; Prognosis

[0] Introduction [1] On the Illusion of Physical Space [2] On Material Frame Indifference [3] Updating <em>The Non-Linear Field Theories of Mechanics</em> [4] The Theory of Simple Semi-Liquids, a Conceptual Framework for Rheology [5] Nematic Semi-Liquids

Let A be a second order tensor in a finite dimensional space. In this work we determine the gradient of the principal invariants of A and obtain some trace and determinant identities using only some standard rigorous statements concerning Grassmann calculus. We recover some of the results of Dui et al. (J. Elast. 75:193–196, 2004) and of Truesdell and Noll (The Non-linear Field Theories of Mechanics, Springer, Berlin, 2002) and solve an old problem proposed in SIAM Review concerning a determinant identity from a new perspective in a concise and simple manner.

Traumatic brain injury (TBI) patients often exhibit an increase in their intracranial volume due to blood collection or brain tissue edema, affecting the intracranial compliance. When the volume of any intracranial compartment exceeds a critical threshold, the compensatory mechanisms become overwhelmed, compromising intracranial compliance and blood supply, which leads to Intracranial Compartment Syndrome (ICCS). This condition exacerbates brain damage through secondary injury. When less aggressive measures to treat ICCS are insufficient, cranial decompression is recommended, with decompressive craniectomy (DC) currently being the preferred technique. Although its effectiveness has been demonstrated, DC is also associated with a high incidence of complications, including cerebral spinal fluid (CSF) disturbances and surgical site infections. Expansive craniotomy (EC) has been proposed as an alternative that leverages the benefits of cranial decompression provided by DC while reducing the associated adverse effects. The E-SPACE clinical study is a prospective, multicenter, observational, comparative-effectiveness study enrolling adult TBI patients diagnosed with ICCS who require cranial decompression. This multicenter comparative-effectiveness observational study will compare the functional outcomes and complications associated with DC and EC over a 12-month period.

Decompressive craniectomy has defined this era of damage-control wartime neurosurgery. Injuries that in previous conflicts were treated in an expectant manner are now aggressively decompressed at the far-forward Combat Support Hospital and transferred to Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center (NNMC) in Bethesda for definitive care. The purpose of this paper is to examine the baseline characteristics of those injured warriors who received decompressive craniectomies. The importance of this procedure will be emphasized and guidance provided to current and future neurosurgeons deployed in theater. The authors retrospectively searched a database for all soldiers injured in Operations Iraqi Freedom and Enduring Freedom between April 2003 and October 2008 at WRAMC and NNMC. Criteria for inclusion in this study included either a closed or penetrating head injury suffered during combat operations in either Iraq or Afghanistan with subsequent neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all cases in which primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow Coma Scale (GCS) score and injury severity score (ISS) at admission, and Glasgow Outcome Scale (GOS) score at discharge, 6 months, and 1-2 years. Four hundred eight patients presented with head injury during the study period. In this population, a total of 188 decompressive craniectomies were performed (154 for penetrating head injury, 22 for closed head injury, and 12 for unknown injury mechanism). Patients who underwent decompressive craniectomies in the combat theater had significantly lower initial GCS scores (7.7 +/- 4.2 vs 10.8 +/- 4.0, p < 0.05) and higher ISSs (32.5 +/- 9.4 vs 26.8 +/- 11.8, p < 0.05) than those who did not. When comparing the GOS scores at hospital discharge, 6 months, and 1-2 years after discharge, those receiving decompressive craniectomies had significantly lower scores (3.0 +/- 0.9 vs 3.7 +/- 0.9, 3.5 +/- 1.2 vs 4.0 +/- 1.0, and 3.7 +/- 1.2 vs 4.4 +/- 0.9, respectively) than those who did not undergo decompressive craniectomies. That said, intragroup analysis indicated consistent improvement for those with craniectomy with time, allowing them, on average, to participate in and improve from rehabilitation (p < 0.05). Overall, 83% of those for whom follow-up data are available achieved a 1-year GOS score of greater than 3. This study of the provision of early decompressive craniectomy in a military population that sustained severe penetrating and closed head injuries represents one of the largest to date in both the civilian and military literature. The findings suggest that patients who undergo decompressive craniectomy had worse injuries than those receiving craniotomy and, while not achieving the same outcomes as those with a lesser injury, did improve with time. The authors recommend hemicraniectomy for damage control to protect patients from the effects of brain swelling during the long overseas transport to their definitive care, and it should be conducted with foresight concerning future complications and reconstructive surgical procedures.

Background: Decompressive craniectomy (DC) is performed to accommodate life-threatening brain swelling when medical treatment fails. This procedure carries the risk of developing traumatic subdural hygroma (TSH) that can adversely affect the neurological status of the patient. The treatment for persistence of TSH includes drainage and shunt placement or drainage and membranectomy. In this paper, we present treatment of two patients whose TSH was effectively treated with simple drainage and cranioplasty. Case Presentation: Patient 1: The patient is a 34-year-old female who had bilateral craniectomy for brain swelling. Four weeks later she became less interactive. CT scan showed bilateral subdural hygroma with 2 cm midline shift to the left. Her clinical status improved and CT scans showed resolution of the hygroma after simple evacuation of the hygroma and cranioplasty. Patient 2: The patient is a 57-year-old male who had post-traumatic acute subdural hematoma and brain swelling on the left side. The clot was evacuated and the bone flap was left out. After showing initial improvement, 10 weeks after the initial surgery the patient progressively worsened and became unresponsive. CT scans showed a large subdural hygroma on the right with midline shift to the left. Simple evacuation of the hygroma and cranioplasty was done. This resulted in radiological and clinical improvement of the patient. Conclusions: Both patients underwent simple drainage and cranioplasty, which resulted in clinical and radiological improvement. This finding suggests that other procedures such as membranectomy and shunting may not be necessary to treat TSH.

Introduction: Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical–surgical consultation.

To the Editor: We read with great interest the paper titled “Review of Cerebrospinal Fluid Physiology and Dynamics: A Call for Medical Education Reform.”1 The classic theory of cerebrospinal fluid (CSF) circulation presupposes that CSF is produced in the choroid plexus and then circulates from the ventricles along the subarachnoid spaces to be reabsorbed at the level of the dural sinuses through the pacchionian granulations. This paradigm has been challenged by the studies of Bulat–Klarika–Oreskovic2,3 according to which CSF, driven by osmotic and hydrostatic forces, is continuously produced and absorbed in the entire CSF system. The last hypothesis is well integrated into the recent description of the “glymphatic system,” a wide perivascular pathway supporting CSF and interstitial fluid exchange.4,5 Basal cisternostomy has been proposed as a novel treatment for severe brain trauma (sTBI), based on the idea that sTBI produces an impairment of CSF circulation using the perivascular network, leading to a shift of fluid toward the parenchyma, now referred to as CSF-shift oedema that finally results in brain swelling.6 The opening of basal cisterns (often clogged by subarachnoid blood) could restore this circulation, thereby alleviating the brain oedema. Our group has developed an interest in the application of cisternostomy in the setting of surgery for sTBI.7,8 We believe that our clinical experience with TBI surgery strongly supports the modern theories focusing on the existence of an extensive perivascular pattern that communicates with the cisternal subarachnoid space. The results from our clinical series showed that cisternostomy contributed effectively to the treatment of raised intracranial hypertension after sTBI. This surgical maneuver, in most cases, provides remarkable brain relaxation and continued cisternal drainage (approximately for 1 week), prevented the worsening and allowed the resolution of brain oedema, and in most cases obviated the need for prolonged ventilation and treatment with mannitol, hypertonic saline, or hypothermia.7 In comparison, the previous gold standard namely hemicraniectomy only provided increase space for the prolapse of the brain outside the confines of the cranium and did not address the brain edema to any degree. Another observation that seems to support this hypothesis is the huge quantity of CSF (approximately 200 mL/day) that can be drained through the cisternal drain in these patients. The fact that this large quantity of CSF is obtained because of the perivascular network (that is in communication with the basal cisterns) needs to be proved clinically, although there are several laboratory studies that indicate it quite well.9 One of the main criticisms to this promising surgical technique is that CSF can also be drained from the ventricles. However, it is widely acknowledged in common neurosurgical practice that external ventricular drainage rarely provides enough CSF (like the cisternal drain), quite frequently malfunctions and is often insufficient in the control of raised intracranial hypertension in sTBI.10 The effects of cisternal drainage in terms of control of intracranial pressure and outcome in the few series published to date attest to its utility in sTBI when compared with the decompressive craniectomy.11 These observations lends credence to the fascinating idea that cisternal drainage could ultimately address the issue of brain edema, although further clinical research needs to be performed across larger patient cohorts. Fundamental to the application of cisternostomy in general neurosurgical practice is an acceptance of the basic CSF physiology as proposed by Atchley et al.1 In addition, further clinical studies in this field has the potential of developing clinical interventions along these lines for a host of neurological pathologies including chronic hydrocephalus, aneurysmal subarachnoid hemorrhage, and even neurodegenerative disease.