Objective： To investigate the role of large decompres- sive craniectomy （LDC） in the management of severe and very severe traumatic brain injury （TBI） and compare it with routine decompressive craniectomy （RDC）...Objective： To investigate the role of large decompres- sive craniectomy （LDC） in the management of severe and very severe traumatic brain injury （TBI） and compare it with routine decompressive craniectomy （RDC）. Methods： The clinical data of 263 patients with severe TBI （GCS^8） treated by either LDC or RDC in our department were studied retrospectively in this article. One hundred and thirty-five patients with severe TBI, including 54 patients with very severe TBI （GCS ≤ 5）, underwent LDC （LDC group）. The other 128 patients with severe TBI, including 49 patients with very severe TBI, underwent RDC （RDC group）. The treatment outcome and postoperative complications of the two treatment methods were compared and analyzed in a 6-month follow-up period. Results： Ninety-six patients （71.7 %） obtained satisfactory treatment outcome in the LDC group, while only 75 cases （58.6 %） obtained satisfactory outcome in the RDC group （P〈 0.05）. Moreover, the efficacy of LDC in treating very severe TBI was higher than that of RDC （63.0 % vs. 36.7 %, P 〈 0.01）. The chance of reoperation due to refractory intracranial pressure （ICP） in the LDC group was significantly lower than that of the RDC group （P 〈 0.05）, while the incidences of delayed intracranial hematoma and subdural effusion were significantly higher than those of the RDC group （ P 〈 0.05）. Conclusions： LDC is superior to RDC in improving the treatment outcome of severe TBI, especially the very severe ones. LDC can also efficiently reduce the chances of reoperation due to refractory ICP. However, it increases the incidences of delayed intracranial hematoma and contralateral subdural effusion.展开更多
Purpose:Rapid decompressive craniectomy(DC)was the most effective method for the treatment of hypertensive intracerebral hemorrhage(HICH)with cerebral hernia,but the mortality and disability rate is still high.We susp...Purpose:Rapid decompressive craniectomy(DC)was the most effective method for the treatment of hypertensive intracerebral hemorrhage(HICH)with cerebral hernia,but the mortality and disability rate is still high.We suspected that hematoma puncture drainage(PD)+DC may improve the therapeutic effect and thus compared the combined surgery with DC alone.Methods:From December 2013 to July 2019,patients with HICH from Linzhi,Tibet and Honghe,Yunnan Province were retrospectively analyzed.The selection criteria were as follows:(1)altitude≥1500 m;(2)HICH patients with cerebral hernia;(3)Glascow coma scale score of 4-8 and time from onset to admission≤3 h;(4)good liver and kidney function;and(5)complete case data.The included patients were divided into DC group and PD+DC group.The patients were followed up for 6 months.The outcome was assessed by Glasgow outcome scale(GOS)score,Kaplan-Meier survival curve and correlation between time from admission to operation and prognosis.A good outcome was defined as independent(GOS score,4-5)and poor outcome defined as dependent(GOS score,3-1).All data analyses were performed using SPSS 19,and comparison between two groups was conducted using separatet-tests or Chi-square tests.Results:A total of 65 patients was included.The age ranged 34-90 years(mean,63.00±14.04 years).Among them,31 patients had the operation of PD+DC,whereas 34 patients underwent DC.The two groups had no significant difference in the basic characteristics.After 6 months of follow-up,in the PD+DC group there were 8 death,4 vegetative state,4 severe disability(GOS score 1-3,poor outcome 51.6%);8 moderate disability,and 7 good recovery(GOS score 4-5,good outcome 48.4%);while in the DC group the result was 15 death,6 vegetative state,5 severe disability(poor outcome 76.5%),4 moderate disability and 4 good recovery(good outcome 23.5%).The GOS score and good outcome were significantly less in DC group than in PD+DC group(Z=-1.993,p=0.046;χ2=4.38,p=0.043).However,there was no significant difference regarding the survi展开更多
Objective： To investigate the occurrence of posttraumatic hydrocephalus （PTH） in severe braininjured patients who underwent decompressive craniectomy （DC） and to discuss the management. Methods： A total of 389 p...Objective： To investigate the occurrence of posttraumatic hydrocephalus （PTH） in severe braininjured patients who underwent decompressive craniectomy （DC） and to discuss the management. Methods： A total of 389 patients suffering from severe head trauma between January 2004 and May 2010 were enrolled in this study. Clinical data were analyzed retrospectively. Of them, 149 patients who underwent DC were divided into two groups according to the presence of PTH： hydrocephalus group and nonhydrocephalus group. Clinical factors including preoperative Glasgow Coma Score （GCS）, bilateral or unilateral decompression, and duraplasty in DC were assessed by single factor analysis to determine its relationship with the occurrence of PTH. Results： Of the 149 patients undergoing DC, 25 （16.8%） developed PTH; while 23 developed PTH （9.6%） among the rest 240 patients without DC. Preoperative GCS, bilateral or unilateral decompression, duraplasty in DC were significantly associated with the development of PTH. Ventriculoperitoneal shunt was performed on 23 of 25 patients with PTH after DC. Frontal horn was preferred for the placement of the catheter. Sixteen of them were operated upon via frontal approach and 7 via occipital approach. After shunt surgery, both radiological and clinical improvemerits were confirmed in 19 patients. Radiological improvement was found in 2 patients. One patient died eventually of severe pneumonia. Shunt-related infection occurred in 1 patient, which led to the removal of the catheter. Conclusions： It is demonstrated that the occurrence of PTH is high in patients with large decompressive skull defect. Patients with low GCS and bilateral decompression tend to develop PTH after DC. Duraplasty in DC might facilitate reducing the occurrence of PTH. Patients with PTH concomitant skull defect should be managed deliberately to restore the anatomical and physiological integrity so as to facilitate the neurological resuscitation.展开更多
Objective： To present our experience in using decompressive craniectomy （DC） among severe trau- matic brain injury （TBI） patients during operation and to discuss its indication. Methods： From October 2008 to Ma...Objective： To present our experience in using decompressive craniectomy （DC） among severe trau- matic brain injury （TBI） patients during operation and to discuss its indication. Methods： From October 2008 to May 2009, 41 patients aged between 18 and 75 years with severe TBI were in- cluded in this study. They underwent DC or non-DC （NDC） according to their intraoperative findings. Postoperative intracranial pressure （ICP）, complications, requiring second operation or not and outcomes were observed. Results： Fifteen patients underwent DC and 26 pa- tients did not. The average postoperative ICP of each pa- tient was lower than 20 mm Hg. For patients received DC, 2 had seizures after operation and 1 developed cerebrocele in the follow-up period; only matic seizures, but none of 1 NDC patient had post-trau- them had delayed haematoma, cerebrospinal fluid fistula, cerebrocele or infections. At the end of follow-up, 10 patients died, 6 had the GOS of 2, 2 of 3, 9 of 4 and 14of 5. Conclusions： DC is necessary to manage fulminant intracranial hypertension or intraoperative brain swelling. If there was not brain swelling after removal of the haematoma and necrotized neural tissues, it is safe to replace skull flap. The intraoperative finding is an important factor to decide whether to perform DC or not.展开更多
Objective: Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients presenting malign...Objective: Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients presenting malignant MCA infarction compared with those receiving medical treatment alone. Methods: Patients with malignant MCA infarction treated in our hospital between January 1996 and March 2004 were included in this retrospective analysis. The National Institute of Health Stroke Scale (NIHSS)was used to assess neurological status on admission and at one week after surgery. All patients were followed up for assessment of functional outcome by the Barthel index (BI) and modified Rankin Scale (RS) at 3 months after infarction. Results: Ten out of 24patients underwent decompressive craniectomy. The mean interval between stroke onset and surgery was 62.10 h. The mortality was 10.0% compared with 64.2% in patients who received medical treatment alone (P<0.001). The mean NIHSS score before surgery was 26.0 and 15.4 after surgery (P<0.001). At follow up, patients who underwent surgery had significantly better outcome with mean BI of 53.3, RS of 3.3 as compared to only 16.0 and 4.60 in medically treated patients. Speech function also improved in patients with dominant hemispherical infarction. Conclusion: Decompressive craniectomy in patients with malignant MCA infarction improves both survival rates and functional outcomes compared with medical treatment alone. A randomized controlled trial is required to substantiate those findings.展开更多
Objective： To compare the effect of extensive duraplasty and subsequent early cranioplasty on the recovery of neurological function in management of patients with severe traumatic brain injuries received decompressiv...Objective： To compare the effect of extensive duraplasty and subsequent early cranioplasty on the recovery of neurological function in management of patients with severe traumatic brain injuries received decompressive craniectomy. Methods： The computer-aided designation of titanium armor plate was used as a substitute for the repair of skull defect in all the patients. The patients were divided into three groups. Twenty-three patients were in early cranioplasty group who received extensive duraplasty in craniectomy and subsequent cranioplasty within 3 months after previous operation （Group I）. Twenty-one patients whose cranioplasty was performed more than 3 months after the first operation were in the group without duraplasty （Group Ⅱ）; while the other 26 patients in the group with duraplasty in previous craniotomy （Group Ⅲ）. Both the Barthel index of activity of daily living （ADL） 3 months after craniotomy for brain injuries and 1 month after cranioplasty and Kamofsky Performance Score （KPS） at least 6 months aftercranioplasty were assessed respectively. Results： The occurrence of adverse events commonly seen in cranioplasty, such as incision healing disturbance, fluid collection below skin flap, infection and onset of postoperative epilepsy was not significantly higher than other 2 groups. The ADL scores at 3 months after craniotomy in Groups Ⅰ-Ⅱ/were 58.9±26.7, 40.8±20.2 and 49.2±18.6. The ADL scores at 1 month after cranioplasty were 70.2±425.2, 50.8±24.8 and 61.2±21.5. The forward KPS scores were 75.4±19.0, 66.5±24.7 and 57.6±24.7 respectively. The ADL and KPS socres were significantly higher in group I than other 2 groups. Conclusion： The early cranioplasty in those with extensive duraplasty in previous craniotomy is feasible and helpful to improving ADL and long-term quality of life in patients with severe traumatic brain injuries.展开更多
Aim of Study: Reviewing the large number of publications about DC in the case of severe traumatic brain swelling, there is no clear position on which one is preferable for the patient. Bifrontal or bilateral fronto-pa...Aim of Study: Reviewing the large number of publications about DC in the case of severe traumatic brain swelling, there is no clear position on which one is preferable for the patient. Bifrontal or bilateral fronto-parieto-temporo-partial occipital craniectomy. One of the most critical points, the behaviour of brainstem and its vascular structures during the protrusion of the traumatized swelling brain, which can expand in different directions, depending on where the skull has been opened. Method: After the high ICP created on a simple fresh cadaver model, we examined the brainstem displacements and compressions with the help of an endoscope-guided transnasal transsphenoidal transclival and analyzed their possible harmful effects on brainstem structures and blood vessels. Results: In bilateral bifronto-parieto-temporo-partial occipital craniotomy, no significant bulging or forward movement of the brainstem was detected. In the course of bifrontal craniectomy, significant forward movement and thus compression of vascular structures and pons were detected. Conclusion: Our assumption has been confirmed. In bifrontal craniectomy, the expansion is not parallel to the course of the brainstem, but perpendicular so that the pons and the blood vessels running along its anterior surface are compressed by moving forward against the clivus, which leads to circulatory compression and damage to the brainstem. In bilateral DC, the expansion is axially parallel to the course of the brainstem. Based on the fresh cadaver model, the use of the latter method is preferable for the traumatized swelling brain. In both cases, bridging veins of the protruding brain at the bone edge must be protected by the vascular tunnel method against compression. We examined this scientific question not only from a neurosurgical perspective but also in terms of the general ethical possibilities and psychological difficulties of conducting fresh cadaver practices. Additionally, we provided an answer on how we can ease the work of research doctors pract展开更多
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 ...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.展开更多
Background:Craniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue,resulting in the loss of function of a certain area or other fatal damage to the human brain.Cran...Background:Craniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue,resulting in the loss of function of a certain area or other fatal damage to the human brain.Craniocerebral gunshot injury is usually life-threatening and is very common in modern warfare,accounting for the majority of battle casualties.Most of the patients suffer from acute cerebral infarction caused by vascular injury.Lack of early and solid battlefield emergency medical interference adds to the risk of death among the wounded.Case presentation:We present a 24-year-old man who was shot with a shotgun from a distance of 15m in an accidental injury.Forty-seven grape shots were found on his body surface by physical examination.A computed tomography(CT)scan demonstrated large areas of low-density shadows in his right parietal lobe and right temporal lobe with the midline shifting to the left side 2 days later.Afterwards,the patient was transferred to our emergency medical center at Changzheng Hospital in Shanghai.Cranial computed tomography angiography(CTA)showed a high-density shadow in the initial part of the right middle cerebral artery.The branches after the initial part were obliterated.Prompt medical attention and decompressive craniotomy(DC)surgery contributed to the final recovery from cerebral infarction of this patient.Conclusion:Bullets can penetrate or be lodged in the brain,causing intracranial hypertension.The bullets lodged in the brain can result in stenosis and embolism of a cerebral artery,causing acute cerebral infarction.Combining dura turning-over surgery with DC surgery can not only decrease intracranial pressure,which can increase the blood supply for hypertension-induced vessel stenosis,but also help vessels outside the dura mater grow into ischemic areas of the cerebral cortex.However,this new pattern of surgery needs further support from evidence-based medicine.展开更多
文摘Objective： To investigate the role of large decompres- sive craniectomy （LDC） in the management of severe and very severe traumatic brain injury （TBI） and compare it with routine decompressive craniectomy （RDC）. Methods： The clinical data of 263 patients with severe TBI （GCS^8） treated by either LDC or RDC in our department were studied retrospectively in this article. One hundred and thirty-five patients with severe TBI, including 54 patients with very severe TBI （GCS ≤ 5）, underwent LDC （LDC group）. The other 128 patients with severe TBI, including 49 patients with very severe TBI, underwent RDC （RDC group）. The treatment outcome and postoperative complications of the two treatment methods were compared and analyzed in a 6-month follow-up period. Results： Ninety-six patients （71.7 %） obtained satisfactory treatment outcome in the LDC group, while only 75 cases （58.6 %） obtained satisfactory outcome in the RDC group （P〈 0.05）. Moreover, the efficacy of LDC in treating very severe TBI was higher than that of RDC （63.0 % vs. 36.7 %, P 〈 0.01）. The chance of reoperation due to refractory intracranial pressure （ICP） in the LDC group was significantly lower than that of the RDC group （P 〈 0.05）, while the incidences of delayed intracranial hematoma and subdural effusion were significantly higher than those of the RDC group （ P 〈 0.05）. Conclusions： LDC is superior to RDC in improving the treatment outcome of severe TBI, especially the very severe ones. LDC can also efficiently reduce the chances of reoperation due to refractory ICP. However, it increases the incidences of delayed intracranial hematoma and contralateral subdural effusion.
基金supported by Grant No.SWH2017JSZD07 from The First Affiliated Hospital of Army Medical University's"Science and Technology Innovation Program",Grant No.81571116 from the National Natural Science Foundation of China.
文摘Purpose:Rapid decompressive craniectomy(DC)was the most effective method for the treatment of hypertensive intracerebral hemorrhage(HICH)with cerebral hernia,but the mortality and disability rate is still high.We suspected that hematoma puncture drainage(PD)+DC may improve the therapeutic effect and thus compared the combined surgery with DC alone.Methods:From December 2013 to July 2019,patients with HICH from Linzhi,Tibet and Honghe,Yunnan Province were retrospectively analyzed.The selection criteria were as follows:(1)altitude≥1500 m;(2)HICH patients with cerebral hernia;(3)Glascow coma scale score of 4-8 and time from onset to admission≤3 h;(4)good liver and kidney function;and(5)complete case data.The included patients were divided into DC group and PD+DC group.The patients were followed up for 6 months.The outcome was assessed by Glasgow outcome scale(GOS)score,Kaplan-Meier survival curve and correlation between time from admission to operation and prognosis.A good outcome was defined as independent(GOS score,4-5)and poor outcome defined as dependent(GOS score,3-1).All data analyses were performed using SPSS 19,and comparison between two groups was conducted using separatet-tests or Chi-square tests.Results:A total of 65 patients was included.The age ranged 34-90 years(mean,63.00±14.04 years).Among them,31 patients had the operation of PD+DC,whereas 34 patients underwent DC.The two groups had no significant difference in the basic characteristics.After 6 months of follow-up,in the PD+DC group there were 8 death,4 vegetative state,4 severe disability(GOS score 1-3,poor outcome 51.6%);8 moderate disability,and 7 good recovery(GOS score 4-5,good outcome 48.4%);while in the DC group the result was 15 death,6 vegetative state,5 severe disability(poor outcome 76.5%),4 moderate disability and 4 good recovery(good outcome 23.5%).The GOS score and good outcome were significantly less in DC group than in PD+DC group(Z=-1.993,p=0.046;χ2=4.38,p=0.043).However,there was no significant difference regarding the survi
文摘Objective： To investigate the occurrence of posttraumatic hydrocephalus （PTH） in severe braininjured patients who underwent decompressive craniectomy （DC） and to discuss the management. Methods： A total of 389 patients suffering from severe head trauma between January 2004 and May 2010 were enrolled in this study. Clinical data were analyzed retrospectively. Of them, 149 patients who underwent DC were divided into two groups according to the presence of PTH： hydrocephalus group and nonhydrocephalus group. Clinical factors including preoperative Glasgow Coma Score （GCS）, bilateral or unilateral decompression, and duraplasty in DC were assessed by single factor analysis to determine its relationship with the occurrence of PTH. Results： Of the 149 patients undergoing DC, 25 （16.8%） developed PTH; while 23 developed PTH （9.6%） among the rest 240 patients without DC. Preoperative GCS, bilateral or unilateral decompression, duraplasty in DC were significantly associated with the development of PTH. Ventriculoperitoneal shunt was performed on 23 of 25 patients with PTH after DC. Frontal horn was preferred for the placement of the catheter. Sixteen of them were operated upon via frontal approach and 7 via occipital approach. After shunt surgery, both radiological and clinical improvemerits were confirmed in 19 patients. Radiological improvement was found in 2 patients. One patient died eventually of severe pneumonia. Shunt-related infection occurred in 1 patient, which led to the removal of the catheter. Conclusions： It is demonstrated that the occurrence of PTH is high in patients with large decompressive skull defect. Patients with low GCS and bilateral decompression tend to develop PTH after DC. Duraplasty in DC might facilitate reducing the occurrence of PTH. Patients with PTH concomitant skull defect should be managed deliberately to restore the anatomical and physiological integrity so as to facilitate the neurological resuscitation.
文摘Objective： To present our experience in using decompressive craniectomy （DC） among severe trau- matic brain injury （TBI） patients during operation and to discuss its indication. Methods： From October 2008 to May 2009, 41 patients aged between 18 and 75 years with severe TBI were in- cluded in this study. They underwent DC or non-DC （NDC） according to their intraoperative findings. Postoperative intracranial pressure （ICP）, complications, requiring second operation or not and outcomes were observed. Results： Fifteen patients underwent DC and 26 pa- tients did not. The average postoperative ICP of each pa- tient was lower than 20 mm Hg. For patients received DC, 2 had seizures after operation and 1 developed cerebrocele in the follow-up period; only matic seizures, but none of 1 NDC patient had post-trau- them had delayed haematoma, cerebrospinal fluid fistula, cerebrocele or infections. At the end of follow-up, 10 patients died, 6 had the GOS of 2, 2 of 3, 9 of 4 and 14of 5. Conclusions： DC is necessary to manage fulminant intracranial hypertension or intraoperative brain swelling. If there was not brain swelling after removal of the haematoma and necrotized neural tissues, it is safe to replace skull flap. The intraoperative finding is an important factor to decide whether to perform DC or not.
基金Project (No. 2003C24003) supported by Science Bureau of Zhejiang Province, China
文摘Objective: Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients presenting malignant MCA infarction compared with those receiving medical treatment alone. Methods: Patients with malignant MCA infarction treated in our hospital between January 1996 and March 2004 were included in this retrospective analysis. The National Institute of Health Stroke Scale (NIHSS)was used to assess neurological status on admission and at one week after surgery. All patients were followed up for assessment of functional outcome by the Barthel index (BI) and modified Rankin Scale (RS) at 3 months after infarction. Results: Ten out of 24patients underwent decompressive craniectomy. The mean interval between stroke onset and surgery was 62.10 h. The mortality was 10.0% compared with 64.2% in patients who received medical treatment alone (P<0.001). The mean NIHSS score before surgery was 26.0 and 15.4 after surgery (P<0.001). At follow up, patients who underwent surgery had significantly better outcome with mean BI of 53.3, RS of 3.3 as compared to only 16.0 and 4.60 in medically treated patients. Speech function also improved in patients with dominant hemispherical infarction. Conclusion: Decompressive craniectomy in patients with malignant MCA infarction improves both survival rates and functional outcomes compared with medical treatment alone. A randomized controlled trial is required to substantiate those findings.
文摘Objective： To compare the effect of extensive duraplasty and subsequent early cranioplasty on the recovery of neurological function in management of patients with severe traumatic brain injuries received decompressive craniectomy. Methods： The computer-aided designation of titanium armor plate was used as a substitute for the repair of skull defect in all the patients. The patients were divided into three groups. Twenty-three patients were in early cranioplasty group who received extensive duraplasty in craniectomy and subsequent cranioplasty within 3 months after previous operation （Group I）. Twenty-one patients whose cranioplasty was performed more than 3 months after the first operation were in the group without duraplasty （Group Ⅱ）; while the other 26 patients in the group with duraplasty in previous craniotomy （Group Ⅲ）. Both the Barthel index of activity of daily living （ADL） 3 months after craniotomy for brain injuries and 1 month after cranioplasty and Kamofsky Performance Score （KPS） at least 6 months aftercranioplasty were assessed respectively. Results： The occurrence of adverse events commonly seen in cranioplasty, such as incision healing disturbance, fluid collection below skin flap, infection and onset of postoperative epilepsy was not significantly higher than other 2 groups. The ADL scores at 3 months after craniotomy in Groups Ⅰ-Ⅱ/were 58.9±26.7, 40.8±20.2 and 49.2±18.6. The ADL scores at 1 month after cranioplasty were 70.2±425.2, 50.8±24.8 and 61.2±21.5. The forward KPS scores were 75.4±19.0, 66.5±24.7 and 57.6±24.7 respectively. The ADL and KPS socres were significantly higher in group I than other 2 groups. Conclusion： The early cranioplasty in those with extensive duraplasty in previous craniotomy is feasible and helpful to improving ADL and long-term quality of life in patients with severe traumatic brain injuries.
文摘Aim of Study: Reviewing the large number of publications about DC in the case of severe traumatic brain swelling, there is no clear position on which one is preferable for the patient. Bifrontal or bilateral fronto-parieto-temporo-partial occipital craniectomy. One of the most critical points, the behaviour of brainstem and its vascular structures during the protrusion of the traumatized swelling brain, which can expand in different directions, depending on where the skull has been opened. Method: After the high ICP created on a simple fresh cadaver model, we examined the brainstem displacements and compressions with the help of an endoscope-guided transnasal transsphenoidal transclival and analyzed their possible harmful effects on brainstem structures and blood vessels. Results: In bilateral bifronto-parieto-temporo-partial occipital craniotomy, no significant bulging or forward movement of the brainstem was detected. In the course of bifrontal craniectomy, significant forward movement and thus compression of vascular structures and pons were detected. Conclusion: Our assumption has been confirmed. In bifrontal craniectomy, the expansion is not parallel to the course of the brainstem, but perpendicular so that the pons and the blood vessels running along its anterior surface are compressed by moving forward against the clivus, which leads to circulatory compression and damage to the brainstem. In bilateral DC, the expansion is axially parallel to the course of the brainstem. Based on the fresh cadaver model, the use of the latter method is preferable for the traumatized swelling brain. In both cases, bridging veins of the protruding brain at the bone edge must be protected by the vascular tunnel method against compression. We examined this scientific question not only from a neurosurgical perspective but also in terms of the general ethical possibilities and psychological difficulties of conducting fresh cadaver practices. Additionally, we provided an answer on how we can ease the work of research doctors pract
文摘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.
文摘Background:Craniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue,resulting in the loss of function of a certain area or other fatal damage to the human brain.Craniocerebral gunshot injury is usually life-threatening and is very common in modern warfare,accounting for the majority of battle casualties.Most of the patients suffer from acute cerebral infarction caused by vascular injury.Lack of early and solid battlefield emergency medical interference adds to the risk of death among the wounded.Case presentation:We present a 24-year-old man who was shot with a shotgun from a distance of 15m in an accidental injury.Forty-seven grape shots were found on his body surface by physical examination.A computed tomography(CT)scan demonstrated large areas of low-density shadows in his right parietal lobe and right temporal lobe with the midline shifting to the left side 2 days later.Afterwards,the patient was transferred to our emergency medical center at Changzheng Hospital in Shanghai.Cranial computed tomography angiography(CTA)showed a high-density shadow in the initial part of the right middle cerebral artery.The branches after the initial part were obliterated.Prompt medical attention and decompressive craniotomy(DC)surgery contributed to the final recovery from cerebral infarction of this patient.Conclusion:Bullets can penetrate or be lodged in the brain,causing intracranial hypertension.The bullets lodged in the brain can result in stenosis and embolism of a cerebral artery,causing acute cerebral infarction.Combining dura turning-over surgery with DC surgery can not only decrease intracranial pressure,which can increase the blood supply for hypertension-induced vessel stenosis,but also help vessels outside the dura mater grow into ischemic areas of the cerebral cortex.However,this new pattern of surgery needs further support from evidence-based medicine.
