Stroke and Craniectomy.

Neurosurgical involvement in the care of major stroke complications has yielded striking results in the subtentorial region but equivocal outcomes in the supratentorial compartment. Most neurosurgeons want to see some degree of deterioration before proceeding; thus, timing will be debated. Viewpoints have changed over the years regarding surgical or medical intervention, but in many patients the procedure has not produced a definitive change in outcome other than preventing death from terminal brainstem shift. The introduction of craniectomy (and craniotomy) to treat swollen ischemic brain or intracranial hemorrhage has historical interest.

Trepanation Practices in Asclepieia: Systematizing a Neurosurgical Innovation.

BACKGROUND: As ancient Greeks started looking for deities that could fulfill the pragmatic needs of common people, local heroes started being mythologized and worshipped through cults. METHODS: The most widespread such example was Asclepius, possibly a skilled war surgeon who followed military expeditions to Colchis and Troy. Our study investigates the possibility of the early neurosurgery to have been started inside Asclepieia by Asclepius and his followers. RESULTS: Asclepius was worshipped at religious temples called Asclepieia where certain specific medical and surgical techniques were followed. The most advanced technique was skull trepanation, which was most likely done as an acute operation to release intracranial pressure. The contemporary Hippocratic corpus provided extensive descriptions of the technique, and archaeologic evidence has shown that many patients survived the operation. CONCLUSIONS: Decompressive craniectomy techniques have been practiced for millennia but it is possible that they were first systematized as a neurosurgical innovation through the Ancient Greek religious cult followed in Asclepieia.

Craniectomía descompresiva para trauma craneoencefálico severo / Decompressive craniectomy for severe head trauma

La hipertensión intracraneal es la principal causa de mortalidad en los pacientes con lesiones craneales. En la actualidad la lesión traumática cerebral es un problema de salud pública en todo el mundo. La craniectomía descompresiva surge como una estrategia de tratamiento para los pacientes con hipertensión intracraneal refractaria a manejo médico. Este procedimiento requiere una técnica quirúrgica cuidadosa y exquisita, presentamos una revisión actualizada del procedimiento dirigida a los residentes en formación y a los neurocirujanos latinoamericanos.

Intracranial hypertension is the leading cause of mortality in patients with head injuries. Currently, traumatic brain injury is a public health problem worldwide. Decompressive craniectomy emerges as a treatment strategy for patients with intracranial hypertension refractory to medical management. This procedure requires careful surgical technique and exquisite, we present a review of the procedure intended for residents in training and Colombian neurosurgeon.

Decompressive craniectomy: past, present and future.

Decompressive craniectomy (DC)--a surgical procedure that involves removal of part of the skull to accommodate brain swelling--has been used for many years in the management of patients with brain oedema and/or intracranial hypertension, but its place in contemporary practice remains controversial. Results from a recent trial showed that early (neuroprotective) DC was not superior to medical management in patients with diffuse traumatic brain injury. An ongoing trial is investigating the clinical and cost effectiveness of secondary DC as a last-tier therapy for post-traumatic refractory intracranial hypertension. With regard to ischaemic stroke (malignant middle cerebral artery infarction), a recent Cochrane review concluded that DC improves survival compared with medical management, but that a higher proportion of DC survivors experience moderately severe or severe disability. Although many patients have a good outcome, the issue of DC-related disability raises important ethical issues. As DC and subsequent cranioplasty are associated with a number of complications, indiscriminate use of this surgery is not appropriate. Here, we review the evidence and present considerations regarding surgical technique, ethics and cost-effectiveness of DC. Prospective clinical trials and cohort studies are essential to enable optimization of patient care and outcomes.

History of the Kleeblattschädel deformity: origin of concepts and evolution of management in the past 50 years.

The history and evolution of surgical strategies for the treatment of Kleeblattschädel deformity are not well described in the medical literature. Kleeblattschädel anomaly is one of the most formidable of the craniosynostoses, requiring a multidisciplinary team for surgical treatment. The initial descriptions of this cloverleaf deformity and the evolution of surgical treatment are detailed in the present report. Two illustrative cases of Kleeblattschädel deformity, syndromic and nonsyndromic craniosynostoses treated by the senior authors, are also described along with insights into operative strategies.