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Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and
Martin Vychopen1, Matthias Schneider2, Valeri Borger2
1Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany. martin.vychopen@gmail.com.
Insights
Decompressive hemicraniectomy (DC) with superior sagittal sinus exposure (SE) significantly reduces shear-bleeding complications compared to standard DC. This suggests aggressive craniectomy approaches are optimal for managing malignant intracranial pressure.
Area of Science:
- Neurosurgery
- Neurology
- Surgical Complications
Background:
- Decompressive hemicraniectomy (DC) is a standard treatment for elevated intracranial pressure.
- The optimal size and extent of DC remain undefined, potentially influencing complication rates.
Purpose of the Study:
- To investigate the relationship between DC size and associated complications.
- To compare complication rates between DCs with and without superior sagittal sinus exposure (SE).
Main Methods:
- A retrospective analysis of 306 patients undergoing DC between 2013 and 2019.
- Patients were categorized into SE and non-exposed (SC) groups based on postoperative CT scans.
- Complications, including shear-bleeding and hydrocephalus, were evaluated and compared between groups.
Main Results:
- The SE group exhibited larger craniectomy dimensions (anteroposterior diameter and surface area).
- Shear-bleeding rates were significantly lower in the SE group (11%) compared to the SC group (27%).
- No significant difference was observed in the incidence of shunt-dependent hydrocephalus between the groups.
Conclusions:
- Complete hemispheric exposure with SE during DC is associated with reduced iatrogenic shear-bleedings.
- Aggressive craniectomy strategies, including SE, may be the preferred surgical approach for malignant intracranial pressure.
- While no significant outcome difference was found, SE demonstrates a favorable safety profile regarding specific complications.
Purpose:
Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC.
Methods:
Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared.
Results:
Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6-5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9.
Conclusions:
Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.
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