Consensus statement from the international consensus meeting on post-traumatic cranioplasty.

BACKGROUND: Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach. METHODS: The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP. RESULTS: The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations. CONCLUSIONS: This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Post-operative remnants of brainstem cavernomas: incidence, risk factors and management.

INTRODUCTION: The risk of leaving a remnant after surgery for a cavernous malformation in the brainstem is generally not stressed enough, even though such remnants appear to have a high risk of re-bleeding. At least 40% of known cavernoma remnants after surgery have further bleeding episodes. A retrospective analysis of 30 patients with brainstem cavernoma who underwent surgery is presented, focusing on incidence, risk factors and management of post-surgical residuals. The sites were, medulla in three patients, pons-medulla in four, pons in 16, pons-midbrain in four and midbrain in three. All 30 patients came to our clinical observation with at least one episode of acute-onset neurological deficit and all were operated in the sub-acute phase. Only one patient had a worse stable outcome than the pre-surgical state, and 29 did better or were stable. All patients had a brain MRI scan within 72 h after surgery to confirm that complete removal had been achieved. In three, although the surgical cavity and its border appeared clean at the end of surgery, with no lesion remaining, post-operative MRI detected a residuum. These three patients were re-operated, but one had a further bleed prior to excision. MATERIALS AND METHODS: In our series, the surgical finding of a multi-lobular cavernoma (as opposed to the more frequent finding of a discrete lesion with a thick capsule), with a thin wall and satellite nodules separated by a thin layer of apparently intact white matter, was common (seven patients). This group included the three patients with evidence of residuum on post-operative MRI. In our experience, the surgical finding of a multi-lobular cavernoma carries a higher risk of residuum and post-surgical re-bleeding. CONCLUSION: Immediate post-operative brain MRI scans are therefore strongly recommended for their detection, especially in this group of patients, and if a residual is detected early re-intervention is less risky than the natural history.

Intracranial pressure monitoring.

Recent studies have demonstrated that bedside cranial burr hole and insertion of intraparenchymal catheters for intracranial pressure monitoring performed by intensive care physicians is a safe procedure, with a complication rate comparable to other series published by neurosurgeons. The overall morbidity rate is comparable to, or even lower than, that caused by central vein catheterization. The procedure is also quite simple and modern disposable intracranial procedural kits are available. After the skin is prepped the landmark for skin incision, called the 'Kocher's point', located about 2-4 cm lateral to the midline (mid-pupillary line) and 2-3 cm anterior to the coronal suture, is found. Then the surgical field is prepared with the sterile drapes and the skin infiltrated with local anaesthetic (0.5% lidocaine with 1 : 200000 epinephrine). After skin incision and retraction of the skin and subcutaneous tissue, the periosteum should be scraped off in order expose the skull. The skin is then divaricated, exposing the underlying bone. The hole is drilled with either an electric drill or a twist drill (the drilling procedure must be performed with the drill held within 10 degrees of the perpendicular position to the incision site). The hole is then irrigated with sterile saline and an 18-G spinal needle may be used to open the dura (exercise caution when perforating the dura so as to avoid damage to the underlying structures). Following opening of the dura, the Bolt, containing a stylet, is screwed manually into the skull at approximately 5 mm to 1 cm for adults. The stylet is then removed after the bolt has been screwed in, after which the bolt should be filled with saline. Finally, the zeroing of the transducer is performed by simply holding the tip in air while zeroing on the monitor. The transducer is inserted inside the bolt and the screw tightened. The intracranial pressure value can then be read.

Bi-occipital decompressive craniectomy in refractory post traumatic intracranial hypertension: first report of one case.

Decompressive craniectomy (DC) is considered a 'second tier' therapy to control posttraumatic intracranial hypertension refractory to maximal medical treatment. The authors present a case of refractory intracranial hypertension due to diffuse brain swelling and a large (>25 ml) non-surgically-treatable haematoma of the splenium of the corpus callosum successfully treated with bi-occipital DC and augmentative duraplasty.

A complicated case of intracranial hypotension: diagnostic and management strategies.

We report a case of a patient aged 66 years, with spontaneous intracranial hypotension presenting initially with postural headache, complicated by subdural haematomas and followed by progressive decline of his clinical condition evolving in obtundation state, cranial nerve involvement and gaze paralysis. The patient underwent a long course of different therapeutical approaches: medical and surgical treatment, intrathecal saline infusion and epidural blood patching (EBP). Rapid and dramatic relief of the patient's symptoms was obtained after a third lumbar EBP and he was discharged asymptomatic two weeks later.

Traumatic acute subdural haematomas of the posterior fossa: clinicoradiological analysis of 24 patients.

BACKGROUND: We report 24 patients with a traumatic acute subdural haematoma of the posterior fossa managed between 1997 and 1999 at 8 Italian neurosurgical centres. METHOD: Each centre provided data about patients' clinico-radiological findings, management, and outcomes, which were retrospectively reviewed. FINDINGS: A poor result occurred in 14 patients (58.3%). Ten patients (41.7%) had favourable results. Patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (12/24 cases; GCS score, > or =8), the outcome was favourable in 75% of cases. In Group 2 (12/12 cases; GCS score, <8), the outcome was poor in 91.6% of cases. Nineteen patients underwent posterior fossa surgery. Factors correlating to outcome were GCS score, status of the basal cisterns and the fourth ventricle, and the presence of supratentorial hydrocephalus. Multivariate analysis showed significant independent prognostic effect only for GCS score (P<0.05). INTERPRETATION: acute posterior fossa subdural haematomas can be divided into two distinct groups: those patients admitted in a comatose state and those with a moderate/mild head injury on admission. Comatose patients present usually with signs of posterior fossa mass effect and have a high percentage of bad outcomes. On the contrary, patients admitted with a GCS of 8 or higher are expected to recover. In these patients the thickness of the haematoma (<1 cm) seems to be a guide to indicate surgical evacuation of the haematoma.

Bedside burr hole for intracranial pressure monitoring performed by anaesthetist-intensive care physicians. Extending the practice to the entire ICU team.

BACKGROUND: To evaluate the effects of extending the practice of bedside burr hole for intracranial pressure (ICP) monitoring to the entire ICU team. DESIGN: a 10-year observational cohort study. SETTING: A general-neurologic 12-bed ICU of a University Hospital with 10 full-time specialists in anaesthesia-intensive care. PATIENTS: patients admitted for acute neurologic lesions requiring ICP monitoring. MEASUREMENTS: ICP monitoring was performed by means of intraparenchymal fiberoptic cathe-ters. Rates of successfully performed procedures and complications were compared between 2 study periods: January 1990 - August 1997, in which the procedure was performed by 2 experienced physicians (group 1), and September 1997-July 2000 in which the procedure was extended to the entire team (group 2). RESULTS: Two hundred and seventy patients had 293 catheters positioned (group 1=180; 2=113). The procedure was successfully performed in all cases. Occurrence of complications was similar in the 2 groups: minor surgical wound infections (3.3%; 2.6%); meningitis (0.5%; 0); scalp (3.9%; 2.6%) and dural (5.0%; 6.2%) bleeding; intracranial haematoma (1.1%; 1.8%). Two of these latter (1 for each group) required surgical evacuation. Twelve anaesthetist-intensive care physicians were trained, and they were able to perform burr hole for ICP monitoring without help after 2-3 assisted procedures. CONCLUSIONS: Extending the practice of ICP monitoring to the entire ICU team is safe and feasible. To decide whether or not to implement this technique, one should consider the high costs on one side and prompt availability of ICP monitoring on the other. Haemorrhagic and infectious complications are comparable to those of neurosurgical series.

Limits of intermittent jugular bulb oxygen saturation monitoring in the management of severe head trauma patients.

OBJECTIVE: To evaluate, in a prospective, observational study, whether bilateral monitoring of jugular bulb oxyhemoglobin saturation (SjO2), in addition to standard monitoring, results in modification of the management of severe head trauma. METHODS: The patients underwent bilateral jugular bulb cannulation and observation at 8-hour intervals, during which SjO2 was measured and the neurological condition and physiological variables were assessed. The study group was responsible for evaluating whether the physician's decision-making process was influenced by the detection of SjO2 abnormalities. The SjO2 discrepancy in simultaneous bilateral samples was also evaluated to determine whether it interfered with the interpretation of data and with clinical decision-making. The SjO2-related complications were monitored. RESULTS: Thirty patients underwent 319 observations. In 96% of patients, SjO2 was normal or high and had no influence on the diagnostic or therapeutic strategies. Treatment decisions were dictated by changes in clinical status and in intracranial and cerebral perfusion pressure. When these parameters were abnormal, treatment was administered, even if SjO2 was normal (101 observations). Conversely, when SjO2 was the only detected abnormality (34 observations), no treatment was administered. Abnormally low SjO2 values, caused by hypovolemia and hypocapnia, were detected in 3.4% of observations and actually modified the management. The discrepancies in simultaneous bilateral samples were substantial and gave rise to relevant interpretation problems. Fifteen percent of jugular catheters showed evidence of bacterial colonization. CONCLUSION: Intermittent SjO2 monitoring did not substantially influence the management of severe head trauma. Therefore, recommendation for its routine use in all patients seems inadvisable, and indications for this invasive method should no longer be defined on the basis of experts' opinions, but rather on randomized, prospective studies.

Emergent decompressive craniectomy in patients with fixed dilated pupils due to cerebral venous and dural sinus thrombosis: report of three cases.

OBJECTIVE AND IMPORTANCE: Cerebral venous and dural sinus thrombosis is a rare cause of stroke. Although morbidity and mortality have greatly decreased in recent years as a result of early diagnosis and timely medical treatment, when coma occurs the prognosis remains poor. We evaluated whether emergent decompressive craniectomy has a role in the treatment of patients with brain herniation from dural sinus thrombosis and hemorrhagic infarct. CLINICAL PRESENTATION: Three patients developed large hemorrhagic infarct with coma and bilaterally fixed and dilated pupils resulting from aseptic dural sinus thrombosis. INTERVENTION: Two patients underwent emergent surgical decompression as soon as brain herniation developed, and these patients had complete functional recovery. One underwent delayed surgical decompression and remained severely disabled. CONCLUSION: Our results provide preliminary evidence that emergent decompressive craniectomy is effective in patients with brain herniation from dural sinus thrombosis, provided that the clinical onset is recent. We therefore recommend consideration of this aggressive surgical technique for such patients, who may survive with good outcomes.

Acute quadriplegia with delayed onset and rapid recovery. Case report.

The authors describe a patient with severe head injury and sepsis who became acutely quadriplegic 3 days postinjury because of a critical illness polyneuropathy (CIP) and critical illness myopathy (CIM), which resolved rapidly after treatment of the underlying infection. In only 3 days the patient developed septic shock together with flaccid quadriplegia and absent deep tendon reflexes with no clinical or radiological evidence of central nervous system deterioration. Neurophysiological studies showed an acute axonal sensorimotor polyneuropathy, whereas the clinical course strongly suggested a concurrent myopathy. A severe Staphylococcus epidermidis infection accompanied by bacteremia was treated and the patient recovered fully within a few days. Although the case described here is unique because of its very early onset and rapid resolution, CIP and CIM are frequent complications of sepsis and multiple organ failure. The authors suggest that severely head injured patients with sepsis should be evaluated for CIP and CIM when presenting with unexplained muscle weakness or paralysis.

High-dose-rate brachytherapy for poor-prognosis, high-grade glioma: (phase II) preliminary results.

AIMS AND BACKGROUND: The purpose of this study was to investigate the palliative effectiveness of an interstitial fractionated high-dose-rate (HDR) brachytherapy regimen in patients with poor-prognosis, high-grade glioma. METHODS: An after-remote-loading microSelectron HDR lr-192 370 GBq unit was used. A unique coaxial after-loading catheter was stereotactically inserted through the center of the target volume. The treatment schedule was: 5 fractions, 5 Gy per fraction, or alternatively 7 fractions, 3.85 Gy per fraction, at the dose specification surface, 2 fractions per day. Twenty-four patients have been treated: in 17 of them (T1 G3-4) the catheter was implanted during stereotactic biopsy procedure; in the other 7 cases (T2 G3-4), subjected to partial resection and reduced to yT1, the catheter was implanted following surgery with a mean delay of 15 days. RESULTS: The treatment was feasible and well tolerated. The complete course takes no more than 7 days. The acute complication rate (2/24) seems to be acceptable. The median survival was 8 months. No less than 45% of the patients had a WHO grade 2 score or better at any time of follow-up. At 4 months of follow-up, functional status, assessed using a verbally administered Barthel index, had improved from the pretreatment level in 29.1% of the 18 surviving patients and remained stable in another 22.2%. A minimal response or stable disease, according to CT scan, was obtained in about half of the assessable survivors at any time of follow-up. CONCLUSIONS: The short course of brachytherapy provides a good palliation in terms of functional improvement in a high proportion of patients, with low and acceptable toxicity.