FTP Decompressive Craniotomy: How I do it?

FTP Decompressive Craniotomy: How I do it?

1. FTP Decompressive Craniotomy: How I do it? Dr Amit Agrawal , MCh Professor of Neurosurgery Narayana Medical College and Hospital Nellore (AP)

2. Conflict of interest None

3. Background Introduction Indications Contraindications Surgical technique Post-operative care Complications Cranioplasty Follow up

4. Decompressive craniectomy helps to prevent secondary brain injury due to uncontrolled brain edema* Malig­nant cerebral edema-mortality is nearly 100 %** Background * Grindlingerv et al. Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis *Brain Trauma Foundation (2007) Guidelines for the management of severe traumatic brain injury. J Neurotrauma 24:1-106 **Miller et al. Sig­nificance of intracranial hypertension in severe head injury. J Neurosurg 47:503-516

5. Decompressive hemicraniectomy Removal of bone flap followed by duroplasty and thus allows edematous brain to herniate externally rather than downwards Prevents brainstem compression and its sequel

6. Neurosurg Clin N Am 24 (2013) 375-391; Tarek Y . El Ahmadieh et al Indications Severe TBI Focal (contusions/hematoma) and diffuse Coma or semicoma (GCS < 9) Refractory ICP despite best conventional therapy Pupillary abnormalities, but responding to mannitol Malignant MCA infarction Cerebral venous thrombosis Deep seated intracerebral hematoma

7. Contraindications Signs of fatal brain stem damage GCS < 4 or fixed and dilated bilateral pupils Poor general condition with abnormal parameters particularly coagulation profile

8. How I do it? Being taught to us Being described in the literature With regular updates with contemporary literature Customized to the circumstances

9. Essentials Detail clinical evaluation Detail radiological interpretation A proper informed consent Verify the correct indication Identify the correct patient/site Cervical spine precautions Detail counseling to the relatives including discussions regarding expectations

10. Decompressive hemicraniectomy Supine Foam/rubber horseshoe No pins Rolled towel beneath ipsilateral shoulder Head towards contralateral side Make sure the jugulars are not compressed and endotracheal tube is in position

11. Identification of anatomical landmarks Mark midline Mark coronal sutures Mark the incision outline Mark the bone flap outline

12. DHC Surgical technique Incision - Reverse question mark Posterior extent -15 cm behind key hole Deepened down to cranium Myocutaneous flap Five burr holes Temporal squamous bone superior to the zygomatic process inferiorly Keyhole area behind the zygomatic arch anteriorly Along the superior temporal line posteroinferiorly Parietal and Frontal parasagittal areas

13. Beez T, Munoz- Bendix C, Steiger H-J, Beseoglu K. Decompressive craniectomy for acute ischemic stroke. Critical Care 2019;23:209.

14. Timofeev I, Santarius T, Kolias AG, Hutchinson PJ. Decompressive craniectomy - operative technique and perioperative care. Adv Tech Stand Neurosurg . 2012;38:115-36

15. Surgical technique Dural dissection from beneath the bone Burr-holes connected Bone flap removed (try not to cause dural tears) Wax the bone edges Dural tack-up stitches Dural opening (controlled manner)

16. Handling brain Do not touch (irritate) the angry brain Try to remove the clots by irrigation or just gentle traction and irrigation Do not pull the clots Particularly those are near to the midline and venous sinuses

17. Dural closure Closure of the dura with dural substitute ( pericranium ) Dural closure Place the thin piece of gel foam under the dural along the length of the dural incision Move needle from free graft to dura Start early dural closure It takes approximately 10-15 minutes to close the dura Sufficient time to achieve hemostasis

18. Surgical technique Subgaleal suction drain (maintain low pressure) Standard scalp closure

19. Additional steps Removal of any intracranial hematomas Subtemporal decompression Temporal lobectomy

20. Please remember Opening the dura has been shown to improve the reduction in ICP from 30% (dura left intact) to 85% (dura opened) Smaller craniectomy can lead to the damage to cortical veins and parenchyma Avoid burr holes near to the midline and venous sinuses Opened frontal air sinus will need exteriorization Be careful of mastoid air cells

21. Post-operative care Standard post-operative care Early tracheostomy Aggressive physiotherapy

22.   Complications Refractory ICP elevation Hydrocephalus Ventriculitis /meningitis Seizures CSF leak Coagulopathy DVT/PE Decubitus ulcer

23. Subcutaneous pocket in the abdomen Or in a bone bank facility (at a temperature < 70°C)* Bone flap *Sinha et al. Decompressive craniectomy in traumatic brain injury: A single-center, multivariate analysis of 1,236 patients at a tertiary care hospital in India. Neurol India 2015;63:175-83.

24. Results Early decompressive craniectomy improves both functional and mortality outcomes*  An overall favorable outcome with an acceptable morbidity and mortality** * Juttler et al. Decompressive surgery for the treat­ment of malignant infarction of the middle cerebral artery (DESTINY) a randomized, controlled trial. Stroke 38:2518-2525 **Sinha et al. Decompressive craniectomy in traumatic brain injury: A single-center, multivariate analysis of 1,236 patients at a tertiary care hospital in India. Neurol India 2015;63:175-83.

25. Financial constraints Difficult follow up Challenges *Sinha et al. Decompressive craniectomy in traumatic brain injury: A single-center, multivariate analysis of 1,236 patients at a tertiary care hospital in India. Neurol India 2015;63:175-83.

26. Customizing the procedure Decompressive craniectomy (DC) has been used as a final option in the management of refractory intracranial hypertension Aggressive home based physiotherapy (training the relatives)

27. Conclusions Decompressive craniectomy (DC) is an effective treatment to manage malignant cerebral edema and thus help to reduce mortality Improve neurological outcome in patients with massive brain swelling We need to further understand the cost involved and long term functional outcomes There is a need for randomized trials showing the effects of DC

28. Thank you!