الفهرس 
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Abstract
Brain oedema can develop after traumatic brain injury (TBI), ischaemic
stroke[2]. Due to the rigid nature of the skull, brain oedema leads to an
increase in intracranial pressure (ICP) which, in turn, causes reduction in
cerebral perfusion pressure (CPP; mean arterial blood pressure minus ICP),
cerebral blood flow (CBF) and brain oxygenation. These effects contribute to
development of additional brain oedema forming part of a ’vicious circle’ that,
if not interrupted, can lead to brain herniation and death[3].
Decompressive Craniectomy (DC) a procedure where part of the skull is
removed and the underlying dura is opened is attractive for management of
evolving brain oedema as it can provide additional space for the swollen brain,
thereby avoiding the risk of ICP elevation and herniation. [4].
We were aiming to determine the outcome of early decompressive
craniectomy in cases of rapidly increasing (evolving) parenchymatous
swelling due to trauma or MCA infarction.
This retrospective study was done in the Neurosurgery Department,
Menoufia University on patient admitted in the period from March 2013 to
November 2015, in case of severe rapidly increasing brain swelling due to
trauma or MCA infarction .This study was approved by the committee of the
Ethics and values of Menoufia University at the tenth session at 21/6/2015.
Inclusion criteria were:
Failure of other therapeutic measures (hyperventilation, deep sedation,
diuretics), Therapeutic measures are not suitable for the management (e.g. surgical
ASDH with rapid deterioration in the conscious level),
Diffuse bilateral or unilateral brain swelling on CT scan with clinical
deterioration (evaluation will depend on the picture of CT to reveal the
swelling, brain shift and effacement.
Worsening of Glascow Coma Scale (GCS) and/or dilation of pupil
unresponsive to light
Initial GCS 4 or higher with signs of herniation on the first day after head
trauma or MCA infarction.
Massive intraoperative brain swelling during evacuation of intracranial
heamatoma.
Exclusion criteria were:
Patient with severe primary brainstem damage (i.e., an initial and
persisting GCS score of 3 and/or bilateral fixed and dilated pupils). After
exclusion of postictal, toxicities conditions
Patients without radiological evidence of mass effect.
All patients were subjected to:
After admission to the hospital, primary resuscitation and stabilization.
Clinical evaluation:
- History taking, clinical examination, Investigations: Routine and CT brain.
Initially and 24 hours post-operative.
Surgical procedure:
Patients receive Decompressive Craniectomy, hematoma removal,
augmentative duraplasty or dural snips, and Decompressive lobectomy if
necessary. Decompressive Craniectomy is performed by removing a large portion of the fronto-tempro-parietal cranium (>12 cm) for lesions confined
to one cerebral hemisphere [47]. A fronto-tempro-parietal or bilateral
fronto-temporal Decompressive Craniectomy can also be performed for the
control of intracranial hypertension secondary to diffuse brain swelling
refractory to medical management. The operation increases intracranial
volume which reduces the ICP. Further ICP reduction can be achieved by
opening the dura, so some surgeons prefer to perform a durotomy and
duraplasty (covering the dural defect with synthetic dura or pericranium) as
part of the procedure. The bone is implanted in the subcutaneous tissue of
the abdominal wall until replacement at a later date. That Decompressive
Craniectomy decreases ICP is well accepted but its efficacy in terms of
improved morbidity and mortality is still unproven[48].
In this study; 20 cases managed by DC. The data collected from 20
cases in this study were evaluated .11 RTA, 6 MCA infarction and 3 fall.
All cases of bilaterally reactive pupil were clinically improved and only one
case of unilaterally reactive was improved after DC. All cases with
moderate GCS clinically improved after DC and 23% (3 out of 13) of
severe GCS affection were improved clinically. According to Glascow
Outcome Scale (GOS): Grade V as good recovery 3 cases; 15%, Grade IV
as moderate disability 6 cases; 30%, Grade I as death 11 cases; 55%.