• Journal of Korean Neurosurgical Society
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• v.30 no.3
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• pp.295-306
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• 2001

Objectives : The management of massive brain swelling remains an unsolved problem in neurosurgical field. Despite newly developed medical and pharmacological therapy, the mortality and morbidity due to massive brain swelling remains high. According to many recent reports, surgical decompression with dura expansion is superior to medical management in patients with massive brain swelling. We performed surgical treatment on the first line of treatment, and followed medical management in case with refractory increased intracranial pressure(ICP). To show the quantitative effect of decompressive surgery on the intracranial pressure, we performed ventricular puncture and checked the ventricular ICP continuously during the decompressive surgery and postoperative period. Materials and Methods : Fifty-one patients with massive brain swelling, undergoing bilateral decompressive craniectomy with dura expansion, were studied in this study. In all patients, ventricular puncture was performed at Kocher's point on the opposite side of massive brain swelling. The ventricular pressure was monitored continuously, during the bilateral decompression procedures and postoperative period. Results : The initial ventricular ICP were varied from 13mmHg to 112mmHg. Immediately after the bilateral craniectomy, mean ventricular ICP decreased to $53.1{\pm}15.8%$ of the initial ICP(ranges from 5mmHg to 87mmHg). Dura opening decreased mean ICP by additional 36.7% and made the ventricular pressure $16.4{\pm}10.5%$ of the initial pressure (ranges from 0mmHg to 28mmHg). Postoperatively, ventricular pressure was lowered to $20.2{\pm}22.6%$(ranged from 0mmHg to 62.3mmHg) of the initial ICP. The ventricular ICP value during the first 24 hours after decompressive surgery was found to be an important prognostic factor. If ICP was over 35mmHg, the mortality was 100% instead of additional medical(barbiturate coma therapy and hypothermia) treatments. Conclusion : Bilateral decompression with dura expansion is considered an effective therapeutic modality in ICP control. To obtain favorable clinical outcome in patients with massive brain swelling, early decision making on surgical management and proper patient selection are mandatory.

• Journal of Korean Neurosurgical Society
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• v.30 no.3
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• pp.278-283
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• 2001

Objective : Massive cerebral infarction could be accompanied by severe brain swelling and death secondary to transtentorial herniation. Approximately 10% to 15% of middle cerebral artery infarctions are associated with this phenomenon. However, the effectiveness and timing of decompressive surgery are still controversial. In this study, we present our results on the effect of decompressive craniectomy in life threatening cerebral infarction. Method : We retrospectively analyzed 15 patients who underwent decompressive craniectomy for massive cerebral infarction from January 1997 to April 1999. Surgical indication was based on the clinical signs such as neurological deterioration, pupillary reflex, and radiological findings. Clinical outcome was assessed by Glasgow Outcome Scale (GOS). Results : All 15 patients(five men, ten women ; mean age, 52.3 years ; right 11, left 4) were treated with wide craniectomy and duroplasty. The average time interval between onset of symptom and surgical decompression was 2.9 days. Clinical signs of uncal herniation(anisocoria, or fixed and dilated pupils) were presented in 13 of 15 patients. Mean Glasgow coma scale(GCS) was 12.4 points on admission, 8.1 points on preoperative state and 11.8 points postoperatively. Overall outcomes were favorable in 5 cases(Glasgow outcome scale : GOS I, II), unfavorable in 6 cases(Glasgow outcome scale : GOS III, IV) and dead in 4 cases. Conclusion : Early decompressive craniectomy before brain stem compression is considered as an effective lifesaving procedure for massive cerebral infarction unresponsive to aggressive medical therapy.

• Journal of Trauma and Injury
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• v.26 no.3
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• pp.226-228
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• 2013

Elderly patients with acute subdural hematomas have higher mortality and lower functional recovery rates compared with those of other head-injured patients. Early and widely surgical decompression and active intensive care represent the best way to assist these patients. However, abrupt decompression of the hematoma can lead to brain disruption and secondary ischemia in the brain surrounding the craniectomy site. Acute brain swelling and brain extrusion, which take place shortly after decompression, can lead to a catastrophic situation during the operation due to the impossibility of appropriate closure of the dura and scalp. To avoid the deleterious consequences of disruption of brain tissue, we have adopted multiple fenestrations of the dura in a mesh-like fashion and gradual release of subdural clots through the small dural openings that are left open. This is especially important in cases in which there are massive amount of subdural hematomas with small parenchymal lesion and severe midline shifts in elderly patients. Further clinical experiences should be conducted in a more selected series patients to estimate the impact of this technique on morbidity and mortality rates.

• Journal of Korean Neurosurgical Society
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• v.64 no.2
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• pp.261-270
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• 2021

Objective : Decompressive craniectomy (DC) can partially remove the unyielding skull vault and make affordable space for the expansion of swelling brain contents. The objective of this study was to compare clinical outcome according to DC surface area (DC area) and side. Methods : A total of 324 patients underwent different surgical methods (unilateral DC, 212 cases and bilateral DC, 112 cases) were included in this retrospective analysis. Their mean age was 53.4±16.6 years (median, 54 years). Neurological outcome (Glasgow outcome scale), ventricular intracranial pressure (ICP), and midline shift change (preoperative minus postoperative) were compared according to surgical methods and total DC area, DC surface removal rate (DC%) and side. Results : DC surgery was effective for ICP decrease (32.3±16.7 mmHg vs. 19.2±13.4 mmHg, p<0.001) and midline shift change (12.5±7.6 mm vs. 7.8±6.9 mm, p<0.001). The bilateral DC group showed larger total DC area (125.1±27.8 ㎠ for unilateral vs. 198.2±43.0 ㎠ for bilateral, p<0.001). Clinical outcomes were nonsignificant according to surgical side (favorable outcome, p=0.173 and mortality, p=0.470), significantly better when total DC area was over 160 ㎠ and DC% was 46% (p=0.020 and p=0.037, respectively). Conclusion : DC surgery is effective in decrease the elevated ICP, decrease the midline shift and improve the clinical outcome in massive brain swelling patient. Total DC area and removal rate was larger in bilateral DC than unilateral DC but clinical outcome was not influenced by DC side. DC area more than 160 ㎠ and DC surface removal rate more than 46% were more important than DC side.

• Journal of Trauma and Injury
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• v.25 no.4
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• pp.247-253
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• 2012

Purpose: Hemorrhage is a main cause of death in trauma patients. The goal of this study is to describe the characteristics of trauma patients with massive bleeding and to evaluate the prognostic factors concerning their survival. Methods: This study was performed retrospectively and included trauma patients with massive bleeding who had been treated from March 2007 to August 2012. The inclusion criterion was patients who received more than 10 U of packed red blood cells within the first 24 hours after visiting the emergency department. Based on their medical records, we collected data in terms of demographic findings, mechanisms of injury, initial clinical and laboratory findings, methods for hemostasis (emergency surgery and/or angioembolization), transfusion, injury severity score (ISS), revised trauma score (RTS) and trauma and injury severity score (TRISS). We used the Mann-Whitney U test and Fisher's exact test to compare the variables between the patients that survived and those that did not. We performed a logistic regression analysis with the significant variables from the univariate test. Results: Thirty-two(32) patients were enrolled. The main mechanisms of injury were falls and motor vehicle accidents. The mean transfusion amount of packed red blood cells (PRBC) was 17.4 U. The mean elapsed time for the first hemostasis (surgery or embolization) was 3.5 hours. The initial technical success rates were 83.3%(15/18) in angioembolization and 66.7%(8/12) in surgery. The overall mortality rate was 34.4%(11/32). The causes of death were bleeding, brain swelling and multiple organ failure. The ISS(25.5 vs 46.3, p=0.000), TRISS(73.6 vs 45.1, p=0.034) and base excess(<-12 mmol/L, p=0.020) were significantly different between the patients who survived and those who did not. Conclusion: The ISS was a prognostic factor for trauma patients with massive bleeding.

• Journal of Korean Neurosurgical Society
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• v.29 no.8
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• pp.1126-1135
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• 2000

Objectives : The goal of surgical management of cerebral arteriovenous malformation(AVM) is elimination of the lesion without development of new neurological deficits. To improve the management results of cerebral AVMs in the future, this article discusses about surgical complications of the AVM and their management. Material and Methods : During the past 18 years, 116 patients with cerebral AVMs were managed by surgery. Among these cases, 7 cases died, 7 cases developed new neurological deficits, 11 cases residual AVM and 5 cases intracerebral hematoma(ICH) after surgery. The author analyzes the causes of those complications and investigates the methods to minimized those complications based on the review of the literatures. Results : One stage removal of AVM and ICH in the poor neurological state were performed in 5 of 7 death cases. Subtotal removal of ICH followed by delayed AVM surgery after recovery is regard as one method to improve the outcome of patient with large ICH. Postoperative new neurological deficits developed owing to normal perfusion pressure breakthrough(NPPB) in 3, judgement error in 2, preoperative embolization in 1 and cortical injury in 1 case(s). Proper management of NPPB, accurate anatomical knowledge and physiological monitoring during operation, and well trained skill for embolization are regard as methods to minimize those complications. Residual AVMs after surgery were noticed in 11 cases, in which unintended 6 cases due to inaccurate dissection of peripheral margin of AVM, and intended 3 cases due to massive brain swelling during operation, 1 cases due to diffuse type and 1 case due to multiple type of AVM. Accurate dissection of peripheral margin of AVM and mild hypotension during operation may help to avoid this complication. Postoperative hemorrhage occurred in 3 cases due to rupture of the residual AVM and in 2 cases due to oozing from the AVM bed. Complete resection of AVM, complete control of bleeding points at AVM bed and mild hypotension during early postoperative period are the methods to avoid this complication. Conclusion : A precise but flexible therapeutic strategy and refined skill for endovascular, radiosurgical and microsurgical techniques are required to successful treatment of cerebral AVM. Adequate timing of AVM resection, accurate anatomical knowledge, proper management of NPPB and accurate dissection of peripheral margin of AVM are the key points for avoiding complications of the AVM surgery.