Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and shunt-dependency

Abstract

Purpose Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC. Methods Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared. Results Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6–5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9. Conclusions Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.

Size of Craniectomy Predicts Approach-Related Shear Bleeding in Poor-Grade Subarachnoid Hemorrhage

“…The recommendation given on the size of the DC so far is the minimum of 12 × 15 cm large bone flap recommended by the TBI guideline [ 11 ], which also strongly emphasizes the sufficient temporobasal decompression. In the contemporary literature, some authors already postulate craniectomies overreaching the 180 cm 2 proposed by the TBI guideline [ 9 , 15 ]. These authors emphasize that larger DC size positively impacts both approach-related surgical complications and long term outcome in patients with traumatic brain injury, spontaneous intracerebral hemorrhage, and cerebral infarction [ 9 , 14 , 15 , 16 , 17 ].…”

“…In the contemporary literature, some authors already postulate craniectomies overreaching the 180 cm 2 proposed by the TBI guideline [ 9 , 15 ]. These authors emphasize that larger DC size positively impacts both approach-related surgical complications and long term outcome in patients with traumatic brain injury, spontaneous intracerebral hemorrhage, and cerebral infarction [ 9 , 14 , 15 , 16 , 17 ]. Our findings support the benefit of the larger bone flap in poor-grade SAH patients undergoing DC.…”

“…The size of the decompression was measured in postoperatively performed CT scan according to the DeBonis equation [ 14 ]. Moreover, the CT scans were examined for the presence of postoperative complications such as shear bleeding [ 9 ]. According to those findings, the patients were divided into two groups: patients with approach-related shear bleeding vs. patient without approach-related complications.…”

“…On the other hand, a clear demonstration between ICP reduction and DC in patients with SAH was proven in study of Schimmer et al [ 8 ]. Retrospectively, larger DC size seems to prevent the development of shear bleeding at the margin of the craniectomy [ 9 ].…”

Postoperative Hematoma Expansion in Patients Undergoing Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage

“…After the bone-flap removal, the dura mater was opened in stellar fashion. According to the institutional algorithm and our already published data, we did not perform surgical hematoma evacuation [ 15 ]. For closure, we used a rapid closure technique [ 16 ].…”