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Decompressive Craniectomy Complications.pptx

Decompressive Craniectomy Complications

Education◦
Causes, Consequences and Measures to Avoid or Treat Complications Following Decompressive Craniectomy (DC) Dhaval Shukla Department of Neurosurgery NIMHANS, Bangalore, India
Timing of Complications Early – Hemorrhage (hematoma expansion) – External cerebral herniation – Wound complications – CSF leak/fistulae – Postoperative infection – Seizures Late or delayed – Subdural hygroma – Hydrocephalus – Syndrome of the Trephined One in ten patients who underwent DC develop a complication for which additional medical or neurosurgical intervention or both were required Kurland, et al. Neurocrit Care 2015.
Hemorrhage (hematoma expansion) Causes • Loss of tamponade effect compounding the natural tendency of contusions to progress Consequences • Deterioration in sensorium • Need for evacuation Measures to mitigate • Reversal of coagulopathy • Early and more frequent scans after DC especially in patients with contusions and contralateral calvarial fractures Gopalakrishnan MS, et al. Front Neurol 2018.
External cerebral herniation Causes • Brain oedema • Inadequate size of DC Consequences • Venous compromise at bone edge leading to further bulge Measures to mitigate • Minimum 15 x 12 cm • Re-exploration to increase size of decompression (rescue decompression) • Inserting ‘vascular cushion at draining veins • EVD Gopalakrishnan MS, et al. Front Neurol 2018.
Wound Complications
Wound Complications
Infections Gopalakrishnan MS, et al. Front Neurol 2018.
Subdural Effusion and Hydrocephalus Causes • CSF flow abnormality Consequences • Spontaneous resolution • Retardation of improvement • Secondary deterioration Measures to mitigate • Superior and medial margin of the craniotomy should not be closer than 2.5 cm from midline • Early cranioplasty • CSF diversion 06.09.2018 09.09.2018 16.09.2018 25.09.2018 24.09.2019
Syndrome of the Trephined Causes • Sinking scalp flap due to lack of support • Sub-atmospheric pressure • Changes in blood flow and fluid shifts Consequences • Multiple new symptoms • Failure to hold gains of initial improvement • Delayed deterioration Measures to mitigate • Early cranioplasty Gopalakrishnan MS, et al. Front Neurol 2018.
Alternative to DC – Hinge Craniotomy (Expansile Craniotomy (EC)) Kishore K, et al. J Neurotrauma 2018.
Alternative to DC – Hinge Craniotomy (Expansile Craniotomy (EC)) EC leads to a comparable brain volume expansion as in DC surgery precluding the need for cranioplasty after index surgery in TBI Kishore K, et al. J Neurotrauma 2018.
Take Home Message • DC should be a last resort for treatment of raised ICP – 1/10 patients develop a complication for which additional medical or neurosurgical intervention is required – Consider EVD, removal of ICH/ Contusion • The commonest error is to make the craniectomy too small, which results in inadequate relief of intracranial hypertension and results in brain herniation out of the defect and further secondary brain injury • Cranioplasty should be done as soon as brain swelling subsides
Decompressive Craniectomy Complications.pptx