A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Hinge craniotomy (HC) has recently been described as an alternative to decompressive craniectomy (DC). Although HC may obviate the need for cranial reconstruction, an analysis comparing HC to DC has not yet been published.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A retrospective review was conducted of 50 patients who underwent cranial decompression (20 with HC, 30 with DC). Baseline demographics, neurological examination results, and underlying pathology were reviewed. Clinical outcome was assessed by length of ventilatory support, length of intensive care unit stay, and survival at discharge. Control of intracranial hypertension was assessed by average daily intracranial pressure (ICP) for the duration of ICP monitoring and an ICP therapeutic intensity index. Radiographic outcomes were assessed by comparing preoperative and postoperative CT scans for: 1) Rotterdam score; 2) postoperative volume of cerebral expansion; 3) presence of uncal herniation; 4) intracerebral hemorrhage; and 5) extraaxial hematoma. Postoperative CT scans were analyzed for the size of the craniotomy/craniectomy and magnitude of extracranial herniation.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>No significant differences were identified in baseline demographics, neurological examination results, or Rotterdam score between the HC and DC groups. Both HC and DC resulted in adequate control of ICP, as reflected in the average ICP for each group of patients (HC = 12.0 ± 5.6 mm Hg, DC = 12.7 ± 4.4 mm Hg; p &gt; 0.05) at the same average therapeutic intensity index (HC = 1.2 ± 0.3, DC = 1.2 ± 0.4; p &gt; 0.05). The need for reoperation (3 [15%] of 20 patients in the HC group, 3 [10%] of 30 patients in the DC group; p &gt; 0.05), hospital survival (15 [75%] of 20 in the HC group, 21 [70%] of 30 in the DC group; p &gt; 0.05), and mean duration of both mechanical ventilation (9.0 ± 7.2 days in the HC group, 11.7 ± 12.0 days in the DC group; p &gt; 0.05) and intensive care unit stay (11.6 ± 7.7 days in the HC group, 15.6 ± 15.3 days in the DC group; p &gt; 0.05) were similar. The difference in operative time for the two procedures was not statistically significant (130.4 ± 71.9 minutes in the HC group, 124.9 ± 63.3 minutes in the DC group; p &gt; 0.05). The size of the cranial defect was comparable between the 2 groups. Postoperative imaging characteristics, including Rotterdam score, also did not differ significantly. Although a smaller volume of cerebral expansion was associated with HC (77.5 ± 54.1 ml) than DC (105.1 ± 65.1 ml), this difference was not statistically significant.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Hinge craniotomy appears to be at least as good as DC in providing postoperative ICP control and results in equivalent early clinical outcomes.</jats:p></jats:sec>

Letter to the Editor: Decompression for ischemia

“…This is probably due to several limitations: 1) Frantzen et al 2 and Ye et al 3 published studies with small sample size. 2) Frantzen et al and Abadie et al 1 both indicate increased surveillance but have been executed in a retrospective setting.…”

“…However, they calculated the annual hemorrhage rate after the initial 2-year follow-up to be 1.74% (3 hemorrhages/172.4 patient-years). We examined several other studies 1,[3][4][5] in which annual hemorrhage rates were calculated. We found the method used by Lee et al to determine the annual hemorrhage rate after the initial 2-year follow-up period to be quite different from the method used in those studies.…”

“…In the field of brainstem CM therapies, we still have a lot of work to do in the future. 3 The authors evaluated serial clinical and imaging findings in 9 pregnant and 27 nonpregnant women with VHL disease and concluded that pregnancy does not lead to hemangioblastoma or peritumoral cyst development or progression in patients with VHL disease. They concluded that serial imaging should take place before conception and postpartum, but that pregnancy alone does not substantiate medical indication for extra imaging of the brain.…”

“…1,[3][4][5][6] In a future study, a randomized controlled prospective multicenter trial is recommended to compare the effectiveness between different treatment methods-surgery and GKS-and observation with close follow-up evaluation. statistics, and we thank them for sharing their thoughts with the Journal of Neurosurgery readers and us.…”

“…Because the study by Abadie and colleagues 1 mentioned has not been published (data were presented at a medical symposium and we do not have access to that information), we can only comment on the study by Frantzen and colleagues. 3 The Frantzen study retrospectively examined records from VHL centers in the Netherlands of 29 patients with VHL who became pregnant 48 times (49 newborns) between the years 1966 and 2010 (40% became pregnant before 1990). Only 15 pregnancies (31%) had imaging records available to assess the effect on craniospinal hemangioblastoma progression.…”