Advances in diagnosis and treatment of syndrome of trephined and paradoxical herniation after decompressive craniectomy / 中华创伤杂志

The efficacy of decompressive craniectomy (DC) in reducing traumatic brain injury mortality has been affirmed,but there are also many serious complications.Syndrome of the trephined (ST) and paradoxical herniation (PH) are rare complications.ST is characterized by a series of neurological deterioration due to skin flaps subsidence from weeks to months after DC.These neurological impairments are closely related to the subsequent repair of skull defects.PH shows progressive decrease in consciousness on the basis of ST,changes in pupils on the side of skull defects,low touch pressure at the defect window,and obvious midline shift and brain stem compression on CT.ST and PH have common inducements in pathophysiology,including cerebrospinal fluid dynamics,atmospheric pressure,cerebral blood flow and brain material metabolism.There is no consensus on the diagnosis of ST and PH,and early cranioplasty is suggested in terms of treatment.This article reviews the clinical manifestations,pathophysiological changes,diagnosis and treatment of ST and PH after DC operation,so as to provide references for clinicians to further understand ST and PH.

Coma secundario a síndrome del trefinado / Coma due to syndrome of the trephined

El síndrome del trefinado o craniectomizado abarca manifestaciones neurológicas asociadas a la depresión del flap cutáneo y se distingue del síndrome postraumático por su reversibilidad con el tratamiento reparador del defecto craneano. El coma no es una forma habitual de presentación. Comunicamos un caso de presentación atípica en un hombre de 36 años de edad con antecedente de craniectomía descompresiva, que presentó un cuadro de deterioro neurológico profundo atribuible al síndrome del trefinado, el cual revirtió tras la craneoplastía. En la fisiopatología del síndrome intervienen trastornos cerebrovasculares, metabólicos, hidrodinámicos del líquido cefalorraquídeo e hiperdinamismo de las estructuras encefálicas. El gold standard terapéutico es la craneoplastía. Se requieren estudios de mayor peso estadístico para determinar el tiempo quirúrgico apropiado.

The syndrome of the trephined or craniectomized is commonly referred as neurological manifestations associated to skin flap depression and reversible after craneoplasty, which allows its differentiation from post-traumatic syndrome. We present the case of a male patient, 36 years old, with history of decompressive craniectomy. He evolved with sudden neurological worsening associated to syndrome of the trephined and recovery after craneoplasty. Physiopathology of the syndrome involves cerebrovascular, metabolic and cerebrospinal fluid hydrodynamic disturbances as well as parenchymal hyperdynamic mechanisms. Cranioplasty is the gold standard treatment. Still, studies with statistical power are needed to assess correct surgical timing.

Asymmetric optic nerve sheath diameter as an outcome factor following cranioplasty in patients harboring the 'syndrome of the trephined' / Assimetria do diametro da bainha do nervo optico como fator prognostico apos cranioplastia em pacientes portadores da 'sindrome do trefinado'

Decompressive craniectomy (DC) is gaining an increasing role in the neurosurgical treatment of intractable intracranial hypertension, but not without complications. A rare complication is the “syndrome of the trephined” (ST). It occurs when the forces of gravity overwhelm intracranial pressures, leading the brain to become sunken. Objective To determine the usefulness of asymmetric optic nerve sheath diameter (ONSD) as an outcome factor after cranioplasty. Method We followed-up 5 patients submitted to DC and diagnosed with ST. All were submitted to brain MRI to calculate the ONSD. Results Only two patients presented an asymmetric ONSD, being ONSD larger at the site of craniectomy. Surprisingly these patients had a marked neurological improvement after cranioplasty. They became independent a week after and statistically earlier than others. Conclusion It is presumed that the presence of an asymmetric ONSD in trephined patients is an independent factor of good outcome after cranioplasty. .

A craniectomia descompressiva (CD) tem papel fundamental no tratamento da hipertensão intracraniana refratária, mas não é isenta de complicações. Uma complicação rara é a “síndrome do trefinado” (ST). Ela ocorre quando as forças gravitacionais se sobrepõem à pressão intracraniana. Objetivo Determinar a utilidade do diâmetro da bainha do nervo óptico (DBNO) como fator prognóstico após cranioplastia. Método Foram acompanhados 5 pacientes trefinados portadores da ST. Estes pacientes foram submetidos à ressonância magnética com medida do diâmetro da bainha do nervo óptico (DBNO). Resultados Dois pacientes apresentaram uma assimetria do DBNO, sendo o diâmetro maior do lado craniectomizado. Para nossa surpresa estes evoluíram melhor do que os que apresentavam o DBNO simétrico. Estes pacientes se tornaram independentes uma semana após, e estatisticamente mais cedo do que os outros. Conclusão Há evidências de que a assimetria do DBNO sirva como fator de bom prognóstico após cranioplastia no pacientes portadores da ST. .