Treatment of severe double spinal cord injuries.

This is a case report describing an injury--sustained by a 25-year-old man during a car accident, and characterized by fracture dislocation of the spine at the level of C7 and T4 accompanied by pulmonary contusion. He had an incomplete spinal cord lesion at the level of C7 and a complete lesion at the level of T4 (T4 ASIA A). Imaging of the spine showed three column fractures with ventral spinal cord compression at both levels. Discussants of this case comment on the concept of acute treatment of severe double spinal cord injuries, and present their chosen way of management in this particular case.

[Vascular tunnel creation to improve the effect of decompressive craniectomy in severe traumatic cerebral edema]. / Vascularis alagútképzés mint új mütéti módszer a decompressiv craniectomia hatásának fokozására, súlyos, traumás agyduzzadás esetén.

More than million people/year die after head injury. The cause of death in 50% is the secondary brain swelling with incuneation. Today decompressive craniectomy with durotomy for traumatic brain swelling is performed as second--tier therapy at many clinics and hospitals. The literature mentions this method only as an option. The problem so far existed in the following fact: although the above mentioned method successfully diminished the ICP still despite this result, partial or total lesion occurred in the herniated part of the brain. The actual cause of these symptoms is found in the blockage of the veins and arteries, caused by shearing and compressive forces between the dural edge and brain tissue. Venous congestion induces further edema in the protruding parts of the brain, thus causing lesion by strangulated necrosis and hypoxia. The new surgical technique consists of a stellate manner durotomy and of creating a vascular tunnel by supporting pilasters made of haemostatic sponge around the main cortical veins and arteries of herniated brain. With the help of new technique the authors managed not only to reduce the intracranial pressure significantly but they could avoid further edema and vascular lesion as well. This due to the fact that with this method we assure the blood circulation and venous drainage of the herniated part of the brain. We think, that in this case despite of the initially severe status, the properly indicated combination of craniectomy, durotomy and vascular tunnel creation, could be the main factor of the surprisingly favorable outcome.

Avoidance of vascular compression in decompressive surgery for brain edema caused by trauma and tumor ablation.

BACKGROUND: In case of severe brain swelling especially caused by trauma or other operative manipulation (tumor ablation), decompressive craniectomy with durotomy has not resulted in significant chances of recovery. Decompressive craniectomy has been defined only as an option within guidelines. METHOD: A new operative technique was developed to improve the efficacy of decompressive surgery. With an increase in intracranial pressure (ICP) threatening with brainstem herniation, wide bilateral craniectomy was carried out, followed by dura opening and subsequent formation of a vascular tunnel in a simple way--using hemostatic sponge cushions--around the main cortical veins at the entering points of the herniated area. The maintenance of vessel patency prevents the herniated brain segment from venous congestion, i.e., from further swelling and necrosis. RESULTS: Twenty operations with traumatic brain edema were performed using this vascular tunnel method. All patients were exposed to surgery in the state of coma. One operation was performed after tumor removal. The results were promising in comparison with the well-known surgical or conservative treatment. DISCUSSION: Applying very strict selection criteria (Glasgow coma scale < 6, signs of severe edema on CT, or intracranial pressure permanently > or = 30 mmHg) in this small series of patients with severe brain injury, good results were achieved using the new operative technique. In case of postoperative edema after tumor ablation, it also showed promising results.