The syndrome of the trephined (original) (raw)
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Ideggyógyászati szemle, 2016
Decompressive craniectomy (DC) is still a matter of debate, with a numerous complications as expansion of haemorrhagic contusions, external cerebral herniation, subdural hygromas, post-traumatic hydrocephalus (HC). The often overlooked "syndrome of the trephined" (ST) as a delayed complication of DC also known as sinking skin flap sy initially described in 1939.ST is characterised by the neurological changes associated with alteration of the pressure/volume relationship between intracranial pressure (ICP), volume of cerebrospinal fluid (CSF), blood, and brain tissue in patients with large bone defects. This review aims at elucidating the mechanisms responsible for the development of ST, and providing useful tips and red-flag signs for healthcare professionals involved with care of post DC patients. Symptoms identified on time could help to develop appropriate treatment strategies for this suddenly deteriorating, but possible reversible condition. Although the treatment strategy is straightforward, calling for a prompt cranioplasty, the correction of HC through CSF diversion devices might require a lengthy optimisation period. Continuous changes in the setting of the shunting systems or spinal tap might lead to dangerous swinging of the midline structures causing further neurological deterioration. Thus, finding the right balance in terms of clinical management often represents a significant challenge.
Neurosurgical Review
Syndrome of the trephined (SoT) is an underrecognized complication after decompressive craniectomy. We aimed to investigate SoT incidence, clinical spectrum, risk factors, and the impact of the cranioplasty on neurologic recovery. Patients undergoing a large craniectomy (> 80 cm2) and cranioplasty were prospectively evaluated using modified Rankin score (mRS), cognitive (attention/processing speed, executive function, language, visuospatial), motor (Motricity Index, Jamar dynamometer, postural score, gait assessment), and radiologic evaluation within four days before and after a cranioplasty. The primary outcome was SoT, diagnosed when a neurologic improvement was observed after the cranioplasty. The secondary outcome was a good neurologic outcome (mRS 0–3) 4 days and 90 days after the cranioplasty. Logistic regression models were used to evaluate the risk factors for SoT and the impact of cranioplasty timing on neurologic recovery. We enrolled 40 patients with a large craniectom...
Clinical spectrum and radiographic features of the syndrome of the trephined
Journal of Neurosciences in Rural Practice, 2015
Object: Craniectomy is a common neurosurgical procedure. Syndrome of the trephined (ST) occurring after craniectomy results in neurologic symptoms that are reversible with cranioplasty. While well-documented, previous literature consisted of case reports, symptom spectrum and risk factors have not been well characterized. Materials and Methods: A retrospective review of 29 consecutive cases who underwent decompressive craniectomy within a 30-month period was performed. Patients were considered affected by ST if a previously stable neurological deficit improved within 3 weeks after cranioplasty. Prevalence of ST was measured and association with demographic information, clinical symptoms patterns, indication for and size of craniectomy, as well as radiological signs were tested. Results: Seven patients (24%) developed ST. Chronic rehabilitation arrest was more common than acute neurologic decline. Factors such as craniectomy size and patient age did not reach statistical significance in development of ST. Radiographic factors were predictive, with a sunken skin flap contour being most sensitive, while ventricular effacement was most specific. Conclusion: ST may have a higher incidence than previously thought, with a chronic rehabilitation arrest being a more common presentation than an acute decline. Medical providers involved in the post surgical care and rehabilitation of these patients should maintain a high index of suspicion for ST.
Orthostatic mesodiencephalic dysfunction after decompressive craniectomy
Journal of Neurology, Neurosurgery & Psychiatry, 2006
An extreme syndrome of the trephined following decompressive craniectomy is reported. The most extensive clinical syndrome observed installed over four weeks and consisted of bradypsychia, dysartria, limb rigidity with equine varus feets predominating on the right. The syndrome was aggravated when the patient was sitting with the sequential appereance over minutes of a typical parkinsonian levodopa resistant tremor starting on the right side, extending to the four limbs, followed with diplopia resulting from a left abducens nerve palsy followed by a left sided mydriasis. All the signs would recover within 1 hour or two after horizontalisation. It was correlated with an orthostatic progressive sinking of the skin flap, MRI and CT-Scan mesodiencephalic distortion without evidence of parenchymal lesion. Brain stem auditory evoked potential wave III latency increase, were observed on the right side upon verticalisation of the patient. EEG exploration excluded any epileptic activity. Symptoms were fully recovered within 2 days after cranioplasty was performed. The cranioplasty had to be removed twice due to infection. Bradypsychia, speech fluency, limb rigidity and tremor reappeared within the week after removal of the prosthesis. While waiting for sterilisation of the operative site, the symptoms could be successfully prevented by a custom-made transparent suction-cup helmet before completion of cranioplasty.
Acta Neurochirurgica, 1984
Forty patients with cranial bone defects after craniectomy underwent extensive cerebrospinal fluid (CSF) hydrodynamic investigations by means of a CSF infusion test before and after cranioplasty. The results of these investigations were related to the clinical signs of the patients before and after cranioplasty and to the size and location of the skull bone defect. Twenty-two patients were considered to have "the syndrome of the trephined" (ST). The remaining patients were either free of symptoms or had symptoms not related to ST. CSF hydrodynamic variables that were changed before and normalized after cranioplasty include the following: Resting pressure, sagittal sinus pressure, buffer volume, elastance at resting pressure and pulse variations at resting pressure. The changes were statistically significant mainly in ST patients who were also relieved of their symptoms after cranioplasty.
Unusual presentation in syndrome of trephined – A unique case observation
Surgical Neurology International
Background: Syndrome of trephined (SoT) is a well-recognized complication of decompressive craniectomy (DC). The understanding of SoT has improved more recently with the increasing utilization of DC for severely raised intracranial pressure. It usually presents after a period of weeks or months with a cluster of adverse neurological symptoms, most commonly with worsening of motor strength. Case Description: An elderly gentleman with traumatic brain injury underwent DC. He later developed a sinking flap and unexplained agitation which responded to cranioplasty by returning to a state of calm. His cognitive function further improved over a period of 6 months. This is an unusual observation reported in this case. Conclusion: Timely recognition of the cognitive complications of craniectomy that may respond to early cranioplasty promises to decrease the length of hospital stay and enhance rehabilitation in such patients.
Complications Associated with Decompressive Craniectomy A Systematic Review pdf
Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.
Medicina Intensiva, 2011
Second level therapeutic maneuvres for controlling intracranial hypertension (ICH) proposed by the European Brain Injury Consortium and the American Association of Neurological Surgeons include barbiturates, moderate hypothermia and more recently the decompressive craniectomy (DC).In most patients, ICP can be maintained below 25 mmHg after a DC. However, the exact effect of DC on brain oxygenation (PtiO2) still unclear. From our point of view the PtiO2 monitoring with the probe located in the healthy area of the most severely damaged cerebral hemisphere is not only a important tool for timing craniectomy in the future but also for evaluating the therapeutic effectivity of DC.