Vascular tunnel construction in the treatment of severe brain swelling caused by trauma and SAH. (Evidence based on intra-operative blood flow measure)

Abstract

Decompressive craniectomy with durotomy, is possible as a last resort therapy for severe traumatic brain swelling. Although the method successfully diminishes the ICP, partial or total vascular insufficiency occurs in the herniated part of the brain. The actual cause of the insufficiency is most likely due to the compression of the cortical veins and arteries supplying the herniated brain, caused by shearing and pressure forces between the dural edge and brain tissue. Furthermore venous congestion may induce edema in the protruding parts of the brain, thus further compromising neurone viability. The new surgical technique consists of a stellate type durotomy and the creation of a vascular tunnel around the main cortical veins and arteries, with the aim that the vessels do not become compressed by the dural or bone edge. The effect of the novel vascular tunnel technique was proven by measuring the blood flow of the protected and nonprotected veins with Doppler UH, intra-operatively. In the last two years 28 patients were operated on with this method. One case of edema was caused by SAH. All were in severe GCS 3 or GCS 4 status, with more than 30 mmHg ICP. In comparison with the traditional surgical and nonsurgical treatment, where the reported mortality rates are 80%-90% in these severe cases the mortality rate was reduced to 40%, and recovery (GOS 4, 5) rate also increased significantly. With this technique the ICP was significantly reduced and further edema and vascular insufficiency was prevented. This was due to protection of the arterial circulation and venous drainage of the herniated part of the brain, by the formation of a vascular tunnel at the durotomy edges.

Primary or Secondary Decompressive Craniectomy: Different Indication and Outcome

“…Table 6 gives the odd ratios of having a poor outcome (GOS < 4) or of dying (GOS 1) for the different determinants. In the secondary DC group, none of the early characteristics of head trauma (pupil dilatation, severity of trauma, mechanism of Primary DC= from the onset of management; early DC= within 24 hours= secondary DC= after 24 hours; uDC= unilateral DC; bDC= bilateral DC; MMM= maximum medical management; PVS= persistent vegetative state 41 22 patients all secondary DC 41% good recovery, 18% severe disability, 23% PVS and 18% died Taylor 2001 12 27 patients secondary bDC ICP is lower post bDC ; reduced risk of death; reduced risk of PVS with bDC compared to MMM Coplin 2001 42 29 patients, primary DC (12) vs craniotomy (17) DC reduced mortality while yielding equivalent neurologic outcome for survivors Csokay 2002 43 28 patients all secondary DC Reduced mortality from 80-90% with MMM to 40% with DC Kontopoulos 2002 44 9 patients, DC day 1 to11 Mortality rate 22%, severe disability 11%, good recovery 66% Albanèse 2003 8 40 patients, primary < 24 h (27) secondary > 24h (13) Early DC: 20% good recovery, 30% PVS, 50% died Secondary DC: 38% good recovery, 38% PVS, 20% died Meier 2003 45 80 patients Primary (53) vs secondary (27) Pooled outcome analysis 47 19 patients 68% good outcome, 16% poor outcome, 11% mortality Chibbaro 2007 10 48 patients, early < 18 h (28) secondary > 18h (20) Determinants of good outcome: early DC, younger age, higher preDC GCS; 56% good GOS with early DC Jagannathan 2007 48 23 patients 30% mortality. Of survivors, 83% good outcome at 2 years, Olivecrona 2007 21 patients 71% favorable outcome (vs 61% in non-DC controls), mortality 14% in both groups Howard 2008 24 40 patients Primary (16) vs secondary (24) Pooled analysis.…”

Step-Ladder Expansive Cranioplasty after Decompressive Craniotomy and Expansive Duraplasty: Discussing Possibilities on a Mathematical Model

“…Efforts have been made to alleviate some of these problems by resorting to various alternative, novel surgical techniques, [13][14][15] and modifications 16,17 with varied amount of success; however, neither have they gained universal acceptance nor have they been able to take care of all the drawbacks. A wide durotomy and expansive duraplasty have been advocated to accommodate the surplus brain volume caused by the postoperative edema 18 in view of the perceived inevitability of the postcraniectomy cerebral edema.…”

Neurological Monitoring and Management of Intracranial Hypertension

“…In one study, significant reductions in brain edema and vascular insufficiency were reported, together with a 40% improvement in mortality. 66 We believe that hemicraniectomy does improve survival. However, our experience failed to demonstrate a significant difference in functional outcome in patients matched with comparable initial GCS and trauma score.…”