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Decompressive Craniectomy.pptx

  1. 1. Dr. Shahnawaz Alam Resident; MCh-Neurosurgery Moderated by: Dr. V. C. Jha HOD, Dept. of Neurosurgery Decompressive Craniectomy Indication, Technique and Trials
  2. 2. INTRODUCTION • Decompressive craniectomy (DC) has been used as a final option in the management of refractory intracranial hypertension/edema. • Medically refractory cerebral edema is defined as ICP >20 mmHg for >15 minutes in a given hour despite standard medical interventions and external ventricular drainage. • A method of “giving room to the swelling brain” and can be “ a life-saving procedure.” • First described by Annandale in 1894; Performed as palliative procedure for inoperable brain tumor. • Kocher(1901) first proposed DC as treatment of raised ICP. • Cushing: Sub-temporal and suboccipital decompression.
  3. 3. PATHOPHYSIOLOGY OF RAISED ICP • ICP is pressure with in cranial vault, a rigid structure with fixed volume. • Contents of cranial vault: – Brain parenchyma – CSF – Blood Monro-Kellie Doctrine: • Beyond compensatory mechanisms rise in any of these, will increase ICP exponentially • ICP is one of the factors that govern cerebral perfusion pressure.
  4. 4. FEED FORWARD CYCLE OF RAISED ICP • Cranial vault compartmentalized by thick dural folds like falx, tentorium. • Raised ICP leads to herniation across these compartments. • Herniation distort vascular anatomy and CSF flow pathways leading to further increase in ICP.
  5. 5. ROLE OF DC • Increases buffering capacity of cranium. • Allows outward herniation, preventing compression of brainstem structures and reconstruct brain perfusion. • ICP reduction vary from 15-85% depending on size of bone removed. • Durotomy further decreases ICP. AIMS OF DECOMPRESSIVE CRANIECTOMY • Reduce ICP; Improve blood flow. • Reduce damage to surrounding brain tissue i.e. reduce secondary brain injury.
  6. 6. COMMON INDICATIONS OF DC • Traumatic brain injury; Malignant cerebral infarction. • Aneurysmal SAH; Others- Cerebral venous sinus thrombosis, Intracerebral hematoma. RECOMMENDATIONS FOR DECOMPRESSIVE CRANIECTOMY • By American Association of Neurological Surgeons for patients with TBI and refractory IH if some or all of the following criteria were met: – Diffuse cerebral swelling on cranial CT imaging – Within 48 hours of injury – No episodes of sustained ICP > 40 mmHg before surgery – GCS >3 at some point subsequent to injury – Secondary clinical deterioration – Evolving cerebral herniation syndrome – Pupillary abnormalities but respond to mannitol (Guidelines for the Management of Severe Traumatic Brain Injury- 4th Edition Brain Trauma Foundation)
  7. 7. TYPES OF DC Primary/Prophylactic DC • Any surgical decompression performed, with or without brain tissue removal, in patients undergoing surgery primarily for the evacuation of any type of intra-dural lesion. • Aim: not to control refractory ICP but to avoid increase in ICP. • Decision taken based on CT, not on ICP. Secondary/Therapeutic DC • Continuous ICP monitoring is conducted. • DC performed when ICP is refractory to medical treatment.
  8. 8. RECOMMENDATION OF BRAIN TRAUMA FOUNDATION • General maneuvers – head elevation & neutral position (to avoid venous congestion) – Normothermia (36.5-37.5 F) – sedation – volume resuscitation • First line therapy: CSF drainage, hypocapnia (PaCO2 30-35mmHg), mannitol administration. • Second tier: high dose barbiturates, intense hyperventilation (PaCO2- <30mmHg), increase in MAP, mild to moderate hypothermia, decompressive craniectomy. • Inadequate craniectomy size is associated with parenchymal hemorrhage- infarction and increased mortality. (Wagner S et al. Journal of Neurosurgery, May 2001, vol./is. 94/5(693-6)
  9. 9. • TBI: most common indication for DC; Pathophysiology of TBI: Primary injury Vs Secondary injury. • Secondary injury is amenable to treatment. Aim of the treatment is to prevent secondary injury.
  10. 10. APPROACHES OF DC Fronto-temporo-parietal approach. Bifrontal decompressive approach. Temporal approach.
  11. 11. FTP APPROACH • A large reverse question mark incision is made starting at the level of the zygoma and curving posteriorly above the ear, over the parietooccipital region, then superiorly and anteriorly, approximately 2 cm lateral to the midline, and stopping just behind the hairline. • The posterior extent of the incision should be more than 15 cm behind the keyhole to allow for an adequate craniectomy flap. • Medially, the craniectomy should extend to only about 2 to 3 cm from the midline to prevent damage to any draining veins and arachnoid granulations near the superior sagittal sinus.
  12. 12. • The temporalis dissection should be carried down to the zygoma to adequately expose the temporal bone and maximize the temporal decompression. • Preferences for the location and number of burr holes vary, but typically three burr holes are made: one at the keyhole, one more inferiorly in the temporal bone and posterior to the sphenoid bone, and one supero-posteriorly in the parietal bone. • Large FTP DC (standard trauma craniectomy-12x15cm2) significantly improved the outcome in severe TBI patients with refractory intracranial hypertension, compared with routine temporoparietal craniectomy (6x8cm2), and had a better effect in terms of decreasing ICP. • Small size craniectomies associated with pericraniectomy hemorrhage and infarct (diameter < 8 cm).
  13. 13. • A suboptimal DC will lead to exacerbated external brain herniation and shear forces at the bone edges, which can cause intraparenchymal hemorrhage and kinking of the cerebral veins. • Durotomy enhances further decrease in ICP; Durotomy with augmentative duraplasty recommended. • Only durotomy without duraplasty; increase risk of herniation of parenchyma; epilepsy; CSF leak.
  14. 14. In a decompressive hemicraniectomy, the dural opening is just as important as the craniectomy. Hemostasis should be obtained prior to dural opening (A), and the dura should be opened in a stellate fashion to maximize cerebral decompression (B and C). The dura can be left open and the dural flaps laid over a dural substitute prior to skin closure (D).
  15. 15. BIFRONTAL CRANIECTOMY • In contrast to DHC, the bifrontal craniectomy used in situations of bifrontal contusions or diffuse cerebral edema. • An incision is made beginning at the level of the zygomatic arch just anterior to the tragus on one side, coursing back 2 to 3 cm behind the coronal suture, and down the contralateral zygomatic arch. • The myocutaneous flap is then brought forward over the orbital rim. Care should be taken to dissect out the supraorbital nerves from the supraorbital notch on either side. • A series of symmetric burr holes are then made in the bilateral keyholes, bilateral squamous portions of the temporal bone, and straddling the superior sagittal sinus just posterior to the coronal suture. Some authors advocate drilling burr holes adjacent to the anterior most portion of the superior sagittal sinus as well.
  16. 16. • The superior sagittal sinus can be dissected away from the overlying bone by passing a Penfield 3 between the posterior and anterior burr holes. The burr holes are then connected with a cutting drill bit and footplate, making sure to cross the superior sagittal sinus last. • Once the bone flap is elevated, bleeding from the superior sagittal sinus can be controlled with strips of Gelfoam. The temporal portion of the craniectomy is then extended downward to the floor of the middle fossa. • The key to opening the dura with a bifrontal craniectomy is to divide the anterior portion of the superior sagittal sinus and underlying falx. Without this step, the brain is not free to expand and can be damaged by herniation against a tight dural edge.
  17. 17. • As with DHC, the dural opening must be wide. It begins at the floor of the middle fossa and courses anteriorly along the course of the craniectomy, spanning the entire anterior width of the craniectomy and crossing the anterior portion of the superior sagittal suture to reach the contralateral middle fossa floor. • The dural opening should then also be taken from the middle fossa floor posteriorly to within approximately 2 cm of the posterior portion of the superior sagittal sinus on either side. • To cross the anterior superior sagittal sinus, two heavy sutures are passed around the sinus and tied to occlude it. The sinus is then divided with scissors. The underlying falx should then be divided, with care taken to avoid the bilateral anterior cerebral arteries.
  18. 18. • Polin technique bifrontal craniectomy – anteriorly roof of orbit; posteriorly 3-5 cm behind coronal suture – base of temporal bone – Saggital sinus ligation and division  Subtemporal decompression: area 26-33 cm3 • decreases ICP; unable to improve blood flow • temporal lobe herniation and necrosis
  19. 19. Complications
  20. 20. Syndrome of the Trephined • Overall prevalence of 10%; initially described by Grant and Norcross in 1939. • The sinking of the scalp due to lack of bony support causes cerebral blood flow anomaly and dysfunction in the underlying cortex due to impaired CSF flow dynamics. • Most common symptoms: motor weakness (61.1%) followed by cognitive deficits (44.4%), language deficits (29.6%), altered level of consciousness (27.8%), headache (20.4%), psychosomatic disturbances (18.5%), seizures or electroencephalographic changes (11.1%), and cranial nerve deficits (5.6%). • It manifests either as new symptoms causing deterioration of the patient condition or as failure to retain the early gains. It could manifest as early as 3 days to as late as 7 years (with an average of 5 months). • These symptoms, as well as, cerebral blood flow abnormalities improve dramatically after a cranioplasty. Yang has suggested it is safe to do early cranioplasty within 5-8 weeks to mitigate this risk.
  21. 21. DECRA trail (Decompressive Craniectomy in Diffuse Traumatic Brain Injury . N Engl J Med. 2011 Apr 21;364(16):1493-502) • Multicenter, randomized, controlled trial to test the efficacy of bi-fronto- temporo-parietal DC in adults under the age of 60 years with TBI in whom first-tier intensive care and neurosurgical therapies had not maintained intracranial pressure below accepted targets; Dec 2002- April 2010; 15 tertiary care centres in Australia, New Zealand, Saudi Arabia. • Inclusion criteria: Age 15-59 yrs, Non penetrating traumatic brain injury, GCS 3-8, Marshall class III (moderate diffuse injury on CT); Exclusion: dilated non reactive pupil, mass lesion, spinal cord injury or cardiac arrest at scene. • Treatment protocol: Standard treatment Vs surgery + standard treatment; Within 72 hrs; ICP measurement in all patient (12 before and 36 hrs after randomization). • Surgery: BFTP craniectomy with bilateral Dural opening (modified Polin technique); Sagittal sinus and falx not divided. • Results compared based on extended Glasgow outcome scale at 6 months
  22. 22. RESULTS Conclusion  In adults with severe diffuse traumatic brain injury and refractory IH , early bi-fronto- temporo-parietal DC decreased ICP and the length of stay in the ICU but was associated with more unfavourable outcomes.
  23. 23. RESCUEicp TRIAL • (Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP); 2004-2014; International, multicenter, parallel-group, randomized trial; 52 centers in 20 countries. • Aim: Provide class I evidence as to whether decompressive is effective for the management of patients with raised and refractory ICP following traumatic brain injury (TBI). • n=398; Surgery (n=202) vs Control (n=196); With refractory intracranial hypertension following TBI.
  24. 24. • Primary outcome: Extended Glasgow Outcome Scale (GOS-E) at 6 months after randomization • Secondary outcomes: – GOS-E results at 12 and 24 months after randomization – Mortality at 6, 12, and 24 months after randomization – Quality of life at 6, 12, and 24 months after randomization – Glasgow Coma Scale (GCS) score at discharge from the neurosciences hospital – Assessment of intracranial-pressure control – Time in the ICU – Time to discharge from the neurosciences hospital – Economic evaluation.
  25. 25. • Inclusion Criteria – Age 10 and 65 years – TBI with an abnormal brain CT – Intracranial pressure monitor already in place – Raised ICP (>25 mm Hg for 1 to 12 hours) despite intensive medical management. – Patients who had undergone an immediate operation for evacuation of an intracranial hematoma were included as long as the operation was not a craniectomy. – Trial sites were hospitals that provided acute neurosciences care for patients with severe TBI and that have 24-hour neurosurgical services. • Exclusion Criteria – Bilateral fixed and dilated pupils – Bleeding diathesis – Injury that was deemed to be unsurvivable
  26. 26. PRIMARY OUTCOMES • Comparisons are surgery vs. control groups. • GOS-E distributions at 6 months: – Death: 26.9% versus 48.9% – Vegetative state: 8.5% versus 2.1% – Lower severe disability (dependent on others for care): 21.9% versus 14.4% – Upper severe disability (independent at home): 15.4% versus 8.0% – Moderate disability: 23.4% versus 19.7% – Good recovery: 4.0% versus 6.9% • Favorable outcomes (upper severe disability or better on the GOS-E) at 6 months: 42.8% versus 34.6% (P = 0.12).
  27. 27. SECONDARY OUTCOMES • GOS-E distributions at 12 months – Death:30.4% versus 52.0% – Vegetative state: 6.2% versus 1.7% – Lower severe disability: 18.0% versus 14.0% – Upper severe disability: 13.4% versus 3.9% – Moderate disability: 22.2% versus 20.1% – Good recovery: 9.8% versus 8.4% • Favorable outcomes (upper severe disability or better) at 12 months: 45.4% versus 32.4% of those in the medical group (P=0.01) • Median time to discharge among survivors: 15.0 days vs. 20.8 days (P=0.01) • Control of ICP: Better in surgical group than in the medical group.
  28. 28. ADVERSE EVENTS & CRITICISMS Adverse event • 16.3% vs. 9.2% (P=0.03); Most commonly pneumonia, SSI, postoperative hematoma Criticism • Recruitment was slow, taking over 10 years. Half of centers recruited 3 or fewer patients. • Clinical teams who cared for the patients were aware of trial group assignments, although this was mitigated by outcome adjudication. • A large proportion of patients in the medical group underwent decompressive craniectomy (37%)
  29. 29. PRESENT STATUS OF DC IN TBI • Pediatric population: DC reduces risk of death and unfavorable outcome. • For adults: Role of DC in raised ICP due to TBI as second tier treatment is still controversial. • Early DC reduces brain edema formation by more than 50% and prevents secondary brain damage when performed early enough (i.e., during the first 3 h after trauma). • Malignant Cerebral Infarction: Large territorial parenchymal infarction with post ischemic edema and associated with uncal or axial herniation; Occlusion of proximal MCA, more than 50% of supplied territory involved. • Treatment: medical management or surgery (DC); DC clearly reduce mortality however survivors suffered high morbidity .
  30. 30. • Malignant MCA Infarction: An infarction of at least two thirds MCA territory upward; Present clinically with severe hemispheric stroke syndrome and progressive deterioration of consciousness within the first 2 days. • Thereafter, symptoms of transtentorial herniation occur within 2-4 days of stroke onset; Prognosis is poor and mortality is as high as 80%. • Very high mortality despite maximal medical treatment: 70% (37/ 53 ) died in NICU (33/37 died within first 5 days); 78% (35/45) died within 1 week • 3 RCTs conducted and results published:  DECIMAL (DEcompressive Craniectomy In MALignant middle cerebral artery infarction)  DESTINY (DEcompressive Surgery for Treatment of INfarction of malignant middle cerebral arterY)  HAMLET ( Hemicraniectomy After Middle cerebral artery infarction with Life - threatening Edema Trial )
  31. 31. POOLED ANALYSIS Results: • Only patient underwent decompression with in 48 hrs were considered for pooled analysis; n=109, Surgery-58, Medical-51. • Effect on mortality:  DECIMAL: absolute reduction in risk 53% at 6 months.  DESTINY: 12% mortality in surgical and 53% in medical group at 30 days.  HAMLET: 38% reduction in risk at 1 year.
  32. 32. • Effect on mortality: all 3 trial shows significant reduction in mortality; Absolute reduction in mortality is 49.9%. • Effect on severe disability (mRS score 5): absolute reduction in risk of bad functional outcome was 41.9%. • Conclusion: surgical decompression with in 48 hrs of onset of stroke reduced risk of significant morbidity. • Disability in survivors: while demonstrating an undeniable increase in the number of survivors among surgical patients, also showed an increase in the number of survivors with moderately severe disability (mRS score of 4). • Pooled analysis of all 3 trials provides Class I evidence for the performance of early decompressive craniectomy in the setting of large unilateral infarcts (volume > 145 cc) within 48 hours of the ischemic event.
  33. 33. Current algorithm for use of DC  The only Class I data (recently published from the DECRA trial) suggest that primary DC may increase morbidity with equal chance of survival compared to medical management.  The current standard practice of performing secondary DC (red arrow) is up to the discretion of the treating neurosurgeon (though the results of the RESCUEicp trial may provide Class I evidence for this management decision in the future).
  34. 34. Neurological Outcome Scores
  35. 35. References: • Youmans and Winn neurological surgery 8th edition • Ramamurthi & Tandon's textbook of neurosurgery 3rd edition • Schmidek and Sweet: Operative Neurosurgical Techniques 6th edition • Internet THANK YOU