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The pathophysiology of malignant intracranial hypertension is a deleterious cycle of increased intracranial pressure, decreased tissue perfusion, declining intracellular energy production, increasing cellular edema, and subsequent increasing intracranial pressure. The use of decompressive craniectomy as a treatment to interdict this cycle, thereby improving outcome, remains controversial. Decompressive craniectomy offers an effective treatment for intracranial hypertension that is refractory to standard medical treatment. In traumatic brain injury, 2 randomized-controlled trials are underway to compare decompressive craniectomy to maximal medical management. In malignant infarction, recent randomized-controlled trials have demonstrated improved clinical outcomes in patients who underwent a decompressive craniectomy, but information on the optimal time-point remains under investigation. Definitive answers as to who will benefit, when to operate, and how the procedure is best carried out, remain as yet to be determined. [ABSTRACT FROM AUTHOR] more...

Objective: To present four cases of life-threatening intracranial complications associated with temporal bone osteoradionecrosis., Study Design: This study was a retrospective case review of four patients combined with a literature review., Setting: All patients were treated at Loyola University Medical Center, which is a tertiary care facility., Patients: The four patients were retrospectively reviewed without demographic constraints., Interventions: All patients underwent preoperative radiographic assessment (magnetic resonance imaging/computed tomography scan), and three of the four patients underwent surgery., Main Outcome Measure: The role of surgical intervention in the management of advanced temporal bone osteoradionecrosis., Results: Three patients underwent mastoid surgery after medical treatment of intracranial complications associated with temporal bone osteoradionecrosis. All three patients had dry, epithelialized mastoid cavities. One patient died as a result of meningitis., Conclusions: Mastoid surgery should be used in the overall management of patients with advanced temporal bone osteoradionecrosis to prevent secondary intracranial complications. more...

Resection of skull base tumors may sometimes result in massive extirpation defects that are not amenable to local tissue closure. Closure of large basicranial defects can be performed with either a myocutaneous, a deepithelialized myocutaneous, or a simple muscle free flap designed from the ample rectus abdominis vascular territory. This free-tissue donor site has abundant and reliable well-vascularized tissue that can easily be customized to seal these tenuous areas. The rectus abdominis muscle and its vascularized territory were used in 18 of 19 consecutive patients at our center to close basicranial ablation defects. Of these, 6 were rectus abdominis muscle flaps, 5 were myocutaneous rectus abdominis flaps, and 7 were deepithelialized rectus abdominis muscle flaps. All free flaps survived. The intracranial space was sealed successfully in all but one patient. This patient underwent reconstruction with a muscle free flap and had a postoperative cerebrospinal fluid leak. This complication could have been avoided by using a deepithelialized myocutaneous flap to obliterate the central dead space with the vascularized subcutaneous fat. Two patients experienced minor wound infections, and one had a subdural abscess that was fully contained by a free flap placed over the duraplasty. One patient had a donor-site hernia. There was no incidence of meningitis. Knowledge of the anatomy of the vascular territory of the deep inferior epigastric vessels can be used judiciously to secure three-dimensional reconstruction of the skull base. The donor site supplies ample tissue for reconstruction and allows individual tailoring for obliteration of geometrically complex extirpation defects in and around the cranial base without the need to reposition the patient. more...