Context: Patients with malignant middle cerebral artery (MCA) infarction are prone to a mortality rate of 70-80%. Decompressive craniectomy (DC) has been used as an important treatment modality to control refractory intracranial hypertension. Aim: In this study, we aimed to evaluate the impact of DC in reducing mortality rate and improving the functional outcome in the patients who underwent DC surgery for malignant MCA infarction Settings and design: The prospective clinical case study included 24 patients with refractory intracranial hypertension due to malignant MCA infarction Patients and methods: All patients enrolled in the study have refractory intracranial hypertension due to malignant MCA infarction; they were allocated to undergo decompressive craniectomy between 2014 and 2017. Each patient was evaluated clinically using the Glasgow Coma Scale (GCS) and the modified Rankin Scale (mRS). Results: All patients on admission have the GCS of 5-12 score (mean 8). Fourteen patients underwent DC in the first 48 h while 10 patients were operated upon after 48 h. Postoperatively, two patients (9%) had a score of 3 on the modified Rankin Scale, six patients (25%) had a score of 4, and eight patients (33%) had a score of 5. Mortality occurred in eight patients (33%) with the worst score of 6. Similar unfavorable outcome was reported at 6-and 12-month follow-up with different degrees of disability. Conclusion: Decompressive craniectomy for malignant MCA infarction has an effective role in decreasing the mean intracranial pressure, reducing the mortality rate, and increasing the number of patients with a favorable outcome.
Background: Severe traumatic brain injury is correlated to increased incidence of mortality and severe disability. In the acute phase, medical and surgical management is aimed to prevent intracranial hypertension and to maintain adequate cerebral perfusion pressure. Decompressive craniectomy is a surgical intervention that revealed much interest in the management of refractory intracranial hypertension after severe traumatic brain injury.
Background: Traumatic subdural hematoma is one of the severe injuries to brain with high mortality rates. Dural opening is often associated with brain herniation against the dural edges due to associated edema that would lead to venous infarction. Aim: The objective of this study is to describe a technical note that would allow fast and effective closure of the dura after hematoma evacuation via duraplasty with analysis of the safety and competency of the technique. Subjects and Methods: The fast-track technique was implemented in 15 successive cases with acute subdural hematoma where the fascia lata flap was prepared and sutured to the planned dural incision before opening the dura, which allowed fast and effective closure of the dura before brain herniation. Subdural bridges were planned by using Gelfoam to prevent venous compression. Analysis of the technique effectiveness was performed by the operative detection of brain herniation, as well as clinical and radiological follow-up of patients. Results: All patients had a Glasgow coma score (GCS) below six before the operation. Mean time from trauma to surgery was five hours. The dura could be effectively closed with no brain herniation in all cases. Nine patients survived (60%), where five of them ended up in a vegetative state. Of these two recovered and three continued in a persistent vegetative state. The mortality rate was 40%. Post-operative infarction was detected in post-operative imaging of four patients. Conclusion: The fast-track duraplasty technique is fast and effective in prevention of brain herniation during surgery with favorable clinical outcome in comparison with the poor and severely deteriorated preoperative clinical presentation. More studies to evaluate the impact of the technique on the survival rate are warranted.
Background: Insertion of External Ventricular Drain (EVD) is associated with considerable risk of Cerebrospinal Fluid (CSF) infection which is a life-threatening complication. Infection occurs when microorganisms colonize along the catheter surface. Aim of Study: The aim of this study is to compare the safety & efficacy of EVD catheters impregnated with Clindamycin & rifampin with those of standard control catheters for prevention of the catheter-related infections. Subjects and Methods: The prospective study was conducted on forty patients between April 2013-November 2014. All patients were randomly assigned to undergo placement of an EVD with a catheter impregnated with Clindamycin & rifampin or a standard non-impregnated catheter (control group). Each group included twenty patients. Standard silicone catheter was the EVD used in both cohorts. Patients diagnosed with a known or suspected CSF infection were excluded from this study. Initial cell counts and cultures were obtained from the CSF, repeated at intervals (72 hours) and at time of Catheter removal. CSF infection rate and its impacton the clinical outcome were evaluated in both groups. Results: Among this series of forty patients with EVDs, three had an EVD-associated CSF infection in the control group giving an infection rate within this group of 15% per patient. Only one case in the Antibiotics-impregnated Catheter (AIC) group had CSF infection. Positive CSF cultures were obtained on day 10, 12 & 14 respectively. Organism isolated from CSF cultures was mainly gram-negative infection. AIC group showed a significant low infection rate compared to the uncoated one (p<0.001). Conclusion: The Catheters impregnated with the antibiotic combination of Clindamycin and rifampin appears to be safe and effective in reducing the risk of infectious complications associated with the placement of an EVD.
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