Complications Following Decompressive Craniectomy.

BACKGROUND: Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications. METHODS: We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed. RESULTS: DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome. CONCLUSIONS: The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.

Patient Satisfaction with General versus Local Anesthesia during Carotid Endarterectomy.

BACKGROUND AND STUDY AIMS: Both general and local anesthesia are used in our department for carotid endarterectomy (CEA). The decision as to which anesthetic technique to use during surgery is made individually. The aim of our study was to evaluate patient satisfaction and preference with the anesthesia type used. MATERIAL AND METHODS: The satisfaction of a group of 205 patients with regard to anesthesia used and their future preferences were evaluated prospectively through a questionnaire. The reasons for dissatisfaction were assessed. RESULTS: CEA was performed under general anesthesia (GA) in 159 cases (77.6%) and under local anesthesia (LA) in 46 cases (22.4%). In the GA group, 148 patients (93.1%) were satisfied; 30 patients (65.2%) in the LA group were satisfied (p < 0.0001). The reason for dissatisfaction with GA were postoperative nausea and vomiting (7 patients), postoperative psychological alteration (3), and fear of GA (1). The reasons for dissatisfaction with LA were intraoperative pain (9 patients), intraoperative discomfort and stress (5), and intraoperative breathing problems (2). Of the GA group, 154 (96.9%) patients would prefer GA again, and of the LA group, 28 (60.9%) patients would prefer LA if operated on again (p < 0.0001). Overall, 172 patients (83.9%) would prefer GA in the future, and 33 patients (16.1%) would prefer LA. CONCLUSION: Overall patient satisfaction with CEA performed under both GA and LA is high. Nevertheless, in the GA group, patient satisfaction and future preference were significantly higher. Both GA and LA have advantages and disadvantages for CEA. An optimal approach is to make use of both anesthetic techniques based on their individual indications and patient preference.

Indications for General versus Local Anesthesia during Carotid Endarterectomy.

BACKGROUND AND STUDY AIMS: Both general anesthesia (GA) and local anesthesia (LA) are used in our department for carotid endarterectomy. The decision of which anesthetic technique to use during surgery is made on an individual basis. The aim of our study was to analyze the reasons for using GA or LA. MATERIAL AND METHODS: The reasons that led to the selection of either GA or LA were analyzed retrospectively in a group of 409 patients. RESULTS: GA was used in 304 patients (74%) and LA in 105 patients (26%). The reasons for a preference for GA were clopidogrel use (88 patients), patient preference (80), increased risk of shunt insertion (43), unfavorable anatomical conditions (41), surgeon preference (21), simultaneous carotid endarterectomy and cardiac surgery (18), emergent carotid endarterectomy (12), and sleep apnea syndrome (1). The reasons for selecting LA were internal comorbidities (46 patients), patient preference (39), unavailability of intraoperative electrophysiologic monitoring (15), and pacemaker (5). CONCLUSION: GA is the dominant choice for carotid endarterectomy in our department because of its prevailing benefits and its preference among neurosurgeons and patients. However, in some subgroups of patients, LA is preferable. An optimal approach is therefore an individual indication for both anesthesia techniques.

Complications of cranioplasty using a bone flap sterilised by autoclaving following decompressive craniectomy.

BACKGROUND: Increasing use of decompressive craniectomies has led to a corresponding number of cranioplasties performed to replace the subsequent bone defect created. We aimed to evaluate the morbidity associated with cranioplasty using an autologous bone flap sterilised in an autoclave. METHODS: We retrospectively analysed data from 149 patients who underwent cranioplasty following decompressive craniectomy during the time period January 1998 to December 2012. Autologous bone flaps were sterilised in an autoclave and stored in a refrigerator at a temperature of 8 degrees above zero until cranioplasty was performed. Complications were registered and patient data were analysed in order to identify risk factors for surgical site infection and bone flap resorption after cranioplasty. Only the patients with a follow-up period of >24 months were included in the analysis of bone flap resorption (110 patients). RESULTS: Surgical side infection occurred in only five patients (3.3%), whereas bone flap resorption developed in 22 patients (20%). The multivariate analysis of the presented data identified the operating time of >120 min (p = 0.0277; OR, 16.877; 95% CI, 1.364-208.906) and the presence of diabetes mellitus (p = 0.0016; OR, 54.261; 95% CI, 4.529-650.083) as independent risk factors of development of infection and the presence of ventriculo-peritoneal (VP) shunt (p < 0.0001; OR, 35.564; 95% CI, 9.962-126.960) as independent risk factor of development of the bone flap resorption. CONCLUSIONS: Reimplantation of the autoclaved autologous bone flap following decompressive craniectomy is a simple and cheep alternative to other techniques and is available to any institution that provides autoclaving sterilisation services. This method is associated with a low rate of surgical site infection, but with a significant rate of the bone flap resorption.

Urgent extracranial-intracranial bypass in the treatment of acute hemodynamic ischemic stroke: case report.

Extracranial-intracranial (EC-IC) bypass surgery is performed to allow flow augmentation in selected cases of occlusive cerebrovascular disease. The majority of EC-IC bypasses are described as an elective procedure in the prevention of hemodynamic ischemic stroke. There is only limited and controversial experience of superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis performed under urgent circumstances as a treatment of acute cerebral ischemia. We describe a unique case of a 75-year-old patient presenting with acute progressive hemodynamic ischemia after carotid endarterectomy (CEA), which developed contralaterally to the performed CEA in the region of chronic internal carotid artery (ICA) occlusion. Urgent performance of a standard STA-MCA bypass rapidly improved the cerebral hemodynamic and had an excellent therapeutic effect. The patient had recovered completely within 4 weeks of surgery. The role of urgent EC-IC bypass for stroke treatment is discussed.

The impact of general versus local anesthesia on early subclinical cognitive function following carotid endarterectomy evaluated using P3 event-related potentials.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is detected in 25% of patients undergoing carotid endarterectomy (CEA). The mechanism of POCD is poorly understood, but it is believed that general anesthesia (GA) itself may contribute significantly to POCD. The aim of our prospective study was to compare, with the aid of event-related potentials, the impact of general anesthesia (GA) and local anesthesia (LA) on POCD in patients undergoing CEA. METHODS: Sixty patients were included in this study and were divided into two groups: CEA was performed in 30 patients placed under GA (total intravenous anesthesia), herein the GA group, while 30 patients underwent CEA under LA (cervical plexus block), herein LA group. Cognitive outcome was assessed with the use of auditory event-related potentials (ERPs), P3 response. The measurements were taken before surgery (pre-op) and on the first (1.post-op) and the sixth postoperative days (6.post-op). RESULTS: Preoperative cognitive functions did not differ significantly between the two groups. A significant decrease in P3 amplitude was found on the first postoperative day (1.post-op) in the GA group (p = 0.0005), but normalization of P3 amplitude was detected at the second postoperative measurement (6.post-op). The patients operated on under local anesthesia (LA group) showed stable P3 amplitudes in all three measurements. No significant changes in P3 latencies were observed in either group. There were no significant differences between the two groups regarding demographic characteristics, preoperative and postoperative clinical condition, percentage significance of carotid artery stenosis, duration of carotid cross-clamping or in the frequency of shunt use (zero frequency for both groups). CONCLUSIONS: Our study showed that general anesthesia, used for patients undergoing CEA, negatively influenced cognitive function during the immediate period after surgery (the first postoperative day). However, by the sixth postoperative day, this cognitive impairment was no longer being detected. POCD occurring shortly after carotid endarterectomy is the result of general anesthesia, which is probably an independent evoking factor in itself. The cognitive deficit recorded only during the immediate postoperative period, is not a negative effect of GA but merely a side-effect and thus GA should not be considered inferior to LA for use during CEA.

[The impact of neuroprotection on brain metabolism during carotid endarterectomy]. / Vliv neuroprotekce na mozkové metabolické parametry pri karotické endarterektomii.

BACKGROUND: The primary objective of this study was to evaluate the impact of neuroprotection, administered during carotid endarterectomy, on brain metabolism. The secondary objective was to assess the impact on clinical outcome of the resulting changes to brain metabolism. METHODS: A total of 35 patients underwent carotid endarterectomy with prophylactic combined neuroprotection (Sendai cocktail: Manitol, Phenhydan, Solumedrol, Tokoferol; Cerebrolysin; fraction of inspired oxygen (FiO2) = 1, middle arterial pressure (MAP) = 100 mm Hg, total intravenous anaesthesia--TIVA). The influence of neuroprotection on brain metabolism (S100B, glycaemia, lactate, pH, jugular vein bulb oxygen saturation--SvjO2) was evaluated. Metabolic parameters were acquired from the jugular bulb during surgery, just before unclamping of the vessel. The clinical outcome was evaluated by NIHSS (National Institutes of Health Stroke Scale). There were 35 patients in the control group who where operated on without any neuroprotection. The results from both groups of patients were compared and statistically analyzed. RESULTS: Postoperative NIHSS did not change in any patients in either group. An intraoperative shunt was not inserted in any patients in either group. In the group with neuroprotection there were significantly higher levels of S100B (median 0.117 vs. 0.088; p < 0.0182), lactate (median 1.92 vs. 1.020; p < 0.0006), glycaemia (median 9.5 vs. 8.2; p < 0.0243), and SvjO2 (median 0.79 vs. 0.65; p < 0.0001). There were no postoperative changes to NIHSS in either group. CONCLUSIONS: Neuroprotection administered before carotid endarterectomy influences some parameters of brain metabolism both positively and negatively, but with no impact on clinical outcome.

Osteoplastic decompressive craniotomy--an alternative to decompressive craniectomy.

BACKGROUND: In spite of various degrees of brain expansion, decompressive surgery is usually carried out using decompressive craniectomy (DC). After craniectomy it is necessary to perform cranioplasty, which prolongs hospitalization and is not always without complications. Hence, in situations when cranial decompression is indicated, but DC would be too radical, we do not remove the bone flap, and we perform so-called osteoplastic decompressive craniotomy (ODC). The technique is detailed. OBJECTIVE: To demonstrate the effectiveness of ODC. METHODS: Twenty patients underwent ODC for brain edema under various pathological conditions. The diagnoses were as follows: 13 subdural hematomas, 3 cerebral contusions, 2 middle cerebral artery infarcts, 1 epidural hematoma and 1 arteriovenous malformation. The effect of ODC was assessed using postoperative ICP monitoring and the midline shift on CT. The ICP threshold for the additional removal of the bone flap was 25 mmHg. Clinical outcome was evaluated 6 months after surgery using the Glasgow Outcome Scale (GOS). RESULTS: Postoperative ICP was up to 25 mmHg in 18 patients and exceeded 25 mmHg in 2 cases. The mean midline shift on CT was 10 mm preoperatively and 3 mm postoperatively. The decompression during ODC was sufficient in 18 patients and insufficient in 2 in whom an additional removal of the bone flap was performed. Eight survivals had a favorable outcome (GOS 4-5); 12 patients had an unfavorable outcome (GOS 1-3), and of these, 4 died. CONCLUSION: Our limited study shows that ODC is effective in the treatment of intracranial hypertension in the selected subgroup of patients in whom DC would be too radical. The main advantage of this method is the elimination of further cranioplasty.