Article
Modified linear durotomies in severe stroke decompressive craniotomy – a pilot study comparing decompressive craniotomy with modified linear durotomies versus classic durotomy and duroplasty
Modifizierte lineare Durotomien bei Dekanpressionskraniotomie mit schwerem Schlaganfall – Eine Pilotstudie zum Vergleich der Dekompressionskraniotomie mit modifizierten linearen Durotomien im Vergleich gegen klassischen Durotomie und Duroplastie
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Published: | May 8, 2019 |
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Objective: Massive brain swelling is a catastrophic complication of decompressive craniotomy with wide durotomy and classic duroplasty (DCCD) and it has been a challenge for neurosurgeons to avoid brain extrusion and the secondary injury in consequence of it. Previous studies have shown that decompressive craniotomy with linear durotomies not only prevents brain extrusion but also treats critically elevated intracranial pressure (ICP) with safety and efficacy.
The objective of our pilot study was to compare the safety and efficacy of a modified Decompressive Craniotomy with Linear Durotomies (DCLD) versus DCCD in patients with severe ischemic stroke (SIS).
Methods: We proposed a modified linear durotomy technique in decompressive craniotomy for SIS. It consists in three vertical frontoparietal and two horizontal temporal linear durotomies and then duroplasty with autologous graft over the durotomies. It is a modification from the linear durotomies described by Burger R. (2008).
Results: Nineteen patients with SIS of the middle cerebral artery were enrolled between 2012 and 2015. Ten underwent DCCD and nine DCLD. The mean age of the patients was 52.2 years, 12 men and 7 women, with a mean period from ictus to surgery of 1.2 days.
In the DCCD group the mean Glasgow Coma Score (GCS) on admission was 12, two patients had GCS less than 9, four presented with anisocoria. In DCLD group, mean GCS was 12, one with GCS less than 9, one with anisocoria.
The midline structures deviation was related to the prognosis with 7–12mm showing a higher mortality rate.
Preoperative and postoperative computed tomography perfusion of the head were performed and had evidenced significant improvement in the cerebral blood flow, cerebral blood volume, and mean transit time in addition to the control of brain extrusion in patients in the DCLD group. The overall mortality rate was 50% in the DCCD group and 33% in the DCLD.
Conclusion: Our study suggests that DCLD is a safe and effective alternative for patients with SIS. It allows ICP reduction avoiding extrusion of brain tissue. The importance of this is study is a description of a new surgical technique, reducing complications as brain extrusion. We assume that a randomized prospective study associated with intraventricular ICP monitoring is needed to strengthen our findings.
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