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Copyright of Gyermekgyógyászat is the property of Semmelweis Kiado and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Patients with cerebral venous sinus thrombosis (CVST) may die during the acute phase due to increased intracranial pressure and cerebral herniation. The purpose of this study was to assess the role of decompressive craniectomy in the treatment of patients with malignant CVST. Patients who underwent decompressive craniectomy and were consequently admitted to the Critical Care Unit, Department of Neurosurgery, at Capital Medical University Xuanwu Hospital from March 2010 to January 2021 were retrospectively examined with follow-up data at 12 months. In total, 14 cases were reviewed, including 9 female and 5 male patients, aged 23–63 years (42.7 ± 12.3 years). Prior to surgery, all patients had a GCS score <9. 6 patients had a unilateral dilated pupil, while 4 patients had bilateral dilated pupils. According to the head computed tomography (CT), all patients had hemorrhagic infarction, and the median midline shift was 9.5 mm before surgery. Thirteen patients underwent unilateral decompressive craniectomy, and 1 patient underwent bilateral decompressive craniectomy, among whom, 9 patients underwent hematoma evacuation. Within 3 weeks of surgery, 3 cases (21.43%) resulted in death, with 2 patients dying from progressive intracranial hypertension and 1 from acute respiratory distress syndrome (ARDS). Eleven patients (78.57%) survived after surgery, of whom 4 (28.57%) patients recovered without disability at 12-month follow-up (mRS 0–1), 2 (14.29%) patients had moderate disability (mRS 2–3), and 5 (35.71%) patients had severe disability (mRS 4–5). Emergent decompressive craniectomy may provide a chance for survival and enable patients with malignant CVST to achieve an acceptable quality of life (QOL). [ABSTRACT FROM AUTHOR]

Arachnoid cysts are usually asymptomatic, benign lesions commonly occurring in the middle cranial fossa. However, the cysts may rupture in rare cases causing intracystic or subdural hemorrhages with significant mass effect. We report two cases of middle cranial fossa arachnoid cyst with subdural hemorrhage with very different clinical course. The first case presented with significant mass effect with cerebral herniation and had significant neurological morbidity post-surgery. The second case had minimal symptoms and was managed conservatively with offer of elective surgery. The report underscores the importance of prompt diagnosis and appropriate surgical intervention in managing arachnoid cysts with hemorrhage, highlighting the potential for diverse clinical presentations and outcomes. [ABSTRACT FROM AUTHOR]

Acute brain injury is a significant cause of paediatric morbidity and mortality. Management should be tailored towards preventing sustained periods of elevated intracranial pressure (ICP) to limit secondary damage and prevent cerebral herniation. This article aims to promote recognition of children with raised ICP, explore the goals behind available management options and provide clinicians with concise management algorithms in order to promptly reduce ICP and improve patient outcome. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) is the leading cause of mortality and morbidity in children. Previous studies evaluated outcomes of adult patients; however, few assessed outcomes of pediatric TBI patients presenting with herniation. This study investigated outcome data in pediatric patients presenting with TBI and cerebral herniation and the interventional strategies used for each patient in a rural community. A dual-institution retrospective review of 50 pediatric patients presenting with TBI and cerebral herniation from January 2011 to December 2020 was conducted. Mechanism of injury; herniation based on radiology findings; admission, presurgery, and postsurgery Glasgow Coma Scale scores; intracranial pressure values; discharge Glasgow Outcome Scale scores; length of stay; intensive care unit length of stay; procedures performed; and 30-day mortality/morbidity were collected for each patient. Although a nonsurgical approach led to better outcomes (29.4% vs. 48.4% mortality rate), early intervention with decompressive craniectomy improved morbidity in patients with severe TBI and cerebral herniation. Male patients presenting with TBI complicated by herniation were more likely to have a fatal outcome compared with female patients (51.6% vs. 26.3%). Behavior and age at injury may play a role in these differences. TBI remains a serious concern in the pediatric population with no clear guidelines on the optimal treatment. This study highlights the advantage of integrating more aggressive surgical intervention, such as decompressive craniectomy, in rural communities earlier in the hospital course. Future studies should explore additional factors that could contribute to outcomes in this patient population. [ABSTRACT FROM AUTHOR]

Acute intraoperative cerebral herniation is catastrophic in craniotomy and seriously affects the outcomes of surgery and the prognosis of the patient. Although the probability of its occurrence is low, it can lead to severe disability and high mortality. We describe a rare case of intraoperative cerebral herniation that occurred in a syphilis-positive patient. The patient was diagnosed with both glioma and syphilis. When the glioma was completely removed under the surgical microscope, acute cerebral herniation occurred. An urgent intervention in cerebral herniation identified a collection of colorless, transparent, and proteinrich gelatinous substances rather than a hematoma, which is a more commonly reported cause of intraoperative cerebral herniation in the literature. We have found no previous descriptions of such cerebral herniation during craniotomy in a patient with syphilis and glioma. We suspected that the occurrence of intraoperative cerebral hernia might be related to the patient's infection with syphilis. We considered the likelihood of an intraoperative cerebral herniation to be elevated when a patient had a disease similar to syphilis that could cause increased vascular permeability. [ABSTRACT FROM AUTHOR]

Background: Conventionally, open surgery (OS), including standard craniotomy (SC) and decompressive craniectomy (DC) with hematoma evacuation, is adopted to treat life-threatening large spontaneous supratentorial intracerebral hemorrhage (ICH). Recently, endoscopic surgery (ES), a minimally invasive surgical treatment, has gained increased popularity. However, the safety and efficacy of ES for life-threatening large ICH is uncertain. Aim: The aim of this study was to evaluate the effectiveness and safety of ES for life-threatening large ICH and compare it with traditional OS. Methods: We retrospectively analyzed the clinical and imaging data of consecutive supratentorial ICH patients with preoperative Glasgow Coma Scale (GCS) score ⩽ 8, who underwent ES or OS between May 2015 and October 2021. To minimize bias in case selection, propensity score matching was performed (ratio 1:2, caliper o.2). The primary outcome was a prognosis-based dichotomized (favorable or unfavorable) outcome of the 5-point Glasgow Outcome Scale (GOS) at 6 months. Favorable outcome was defined as a GOS score of 4 to 5 at 6 months. Sensitivity analysis was also performed to ensure the robustness of the findings. Results: Of 695 patients who underwent surgical treatment for spontaneous ICH, 191 patients were identified to be eligible, with 58 patients in the ES group and 133 patients in the OS group. Propensity score matching improved covariate balance and generated a comparable cohort (53 ES and 106 OS) for all analyses. The ES group had a higher incidence of the primary outcome of favorable outcome at 6 months (ES 20/53 (37.7%) vs. OS 22/106 (20.8%); propensity score–matched relative risk (RR) (95% CI) = 1.74 (1.13–2.68); p = 0.013). Sensitivity analysis showed the result was stable. Conclusion: ES is a safe treatment for life-threatening large spontaneous supratentorial ICH patients and may achieve better outcomes than OS. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical–surgical consultation. [ABSTRACT FROM AUTHOR]

Purpose: To establish an ensemble machine learning (ML) model for predicting the risk of futile recanalization, malignant cerebral edema (MCE), and cerebral herniation (CH) in patients with acute ischemic stroke (AIS) who underwent mechanical thrombectomy (MT) and recanalization. Methods: This prospective study included 110 patients with premorbid mRS < 2 who met the inclusion criteria. Futile recanalization was defined as a 90day modified Rankin Scale score >2. Clinical and imaging data were used to construct five ML models that were fused into a logistic regression algorithm using the stacking method (LR-Stacking). We added the Shapley Additive Explanation method to display crucial factors and explain the decision process of models for each patient. Prediction performances were compared using area under the receiver operating characteristic curve (AUC), F1-score, and decision curve analysis (DCA). Results: A total of 61 patients (55.5%) experienced futile recanalization, and 34 (30.9%) and 22 (20.0%) patients developed MCE and CH, respectively. In test set, the AUCs for the LR-Stacking model were 0.949, 0.885, and 0.904 for the three outcomes mentioned above. The F1-scores were 0.882, 0.895, and 0.909, respectively. The DCA showed that the LR-Stacking model provided more net benefits for predicting MCE and CH. The most important factors were the hypodensity volume and proportion in the corresponding vascular supply area. Conclusion: Using the ensemble ML model to analyze the clinical and imaging data of AIS patients with successful recanalization at admission and within 24 h after MT allowed for accurately predicting the risks of futile recanalization, MCE, and CH. [ABSTRACT FROM AUTHOR]

Background: International guidelines exist for obtaining a head computed tomography (CT) scan before a lumbar puncture (LP) in adults with suspected meningitis but there are no studies comparing them in their ability to identify intracranial abnormalities. Methods: A retrospective study of 202 cases of adults with community-acquired bacterial meningitis at 16 hospitals in Houston from December 2004 until May 2019 to compare the 4 guidelines' ability in identifying minor and major intracranial findings, cases in which CT findings changed management, and patients who suffered cerebral herniation. Results: Minor and major intracranial findings were seen in 69 (34.1%) and in 24 (11.8%) of the patients, respectively. A total of nine (37.5%) of the major intracranial findings prompted a neurosurgical intervention. A total of four (1.9%) patients had cerebral herniation. The Infectious Diseases of America (IDSA), the United Kingdom (UK), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), and the Swedish guidelines for cranial imaging were met in 92.1%, 54%, 41.6%, and in 23.3% of the patients, respectively. The IDSA, UK, European, and the Swedish guidelines missed 0%, 20.8%, 41.7%, and 70.8% of the major intracranial findings and 0, 1, 3 and 4 of the 9 patients that prompted a neurosurgical intervention, respectively. All four patients with cerebral herniation met the criteria for all four guidelines. Conclusion: Out of the four international guidelines, only the IDSA recommendations for cranial imaging did not miss any major intracranial abnormality or any finding that prompted a neurosurgical intervention but all guidelines identified herniation. [ABSTRACT FROM AUTHOR]

ABSTRACT Background: Cadaveric studies on humans have shown anatomical variabilities in the morphometric characteristics of the tentorial notch. These anatomical variations could influence the worsening of neurocritical patients. Objectives: 1) To investigate the morphometric characteristics of the tentorial notch in neurocritical patients using computed tomography (CT); 2) To investigate the correlation between tentorial notch measurements by CT and by magnetic resonance imaging (MRI); and 3) To analyze the individual variability of the tentorial notch anatomy seen in neurocritical patients. Methods: Prospective series of neurocritical patients was examined. An imaging protocol for measurements was designed for CT and MRI. The level of the agreement of the measurements from CT and MR images was established. According to the measurements found, patients were divided into different types of tentorial notch. Results: We studied 34 neurocritical patients by CT and MRI. Measurements of the tentorial notch via CT and MRI showed significant agreement: concordance correlation coefficient of 0.96 for notch length and 0.85 for maximum width of tentorial notch. Classification of tentorial notch measurements according to the criteria established by Adler and Milhorat, we found the following: 15 patients (58%) corresponded to a "short" subtype; 7 (21%) to "small"; 3 (9%) to "narrow"; 2 (6%) to "wide"; 2 (6%) to “large”; 1 (3%) to “long”; and 4 (12%) to "typical". Conclusions: The anatomical variability of the tentorial notch could be detected in vivo by means of CT scan and MRI. Good agreement between the measurements made using these two imaging methods was found.

Abstract Background Continuous electroencephalography (cEEG) is an important neuromonitoring tool in brain injured patients. It is commonly used for detection of seizure but can also be used to monitor changes in cerebral blood flow. One such event that can cause a change in cerebral blood flow is imminent, cerebral herniation. cEEG monitoring and quantitative electroencephalography (QEEG) can be used as neurotelemetry to detect cerebral herniation prior to onset of clinical signs. Case presentation We discuss two cases highlighting the use of cEEG in cerebral herniation accompanied by clinical examination changes. The first case is a patient with multiorgan failure and intracerebral hemorrhage (ICH). Given his coagulopathy status, his ICH expanded. The second case is a patient with intraventricular hemorrhage and worsening obstructive hydrocephalus. In both cases, the cEEG showed increasing regional/lateralized slowing. The Quantitative electroencephalography (QEEG) showed a decrease in frequencies, worsening asymmetry, decreasing amplitude and increasing burst suppression ratio corresponding with the ongoing herniation. Clinically, these changes on cEEG preceded the bedside neurological changes by up to 1 h. Conclusions The use of cEEG to monitor patients at high risk for herniation syndromes may identify changes earlier than bedside clinical exam. This earlier identification may allow for an earlier opportunity to intervene.

Introduction: Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical–surgical consultation.

Copyright of Arquivos de Neuro-Psiquiatria is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract Background A large craniotomy is usually the first choice for removal of traumatic acute subdural hematoma (TASDH). To date, few studies have reported that TASDH could be successfully treated by twist drill craniostomy (TDC) alone or combined with instillation of urokinase. We aimed to define the TDC for the elderly with TASDH and performed literature review. Case presentation A total of 7 TASDH patients, who were presented and treated by TDC in this retrospective study between January 2009 and May 2017, consisted of 5 men and 2 women, ranging in age from 65 to 89 (average, 78.9) years. The patients’ baseline characteristics, including age, sex, medical history, received ventriculoperitoneal shunt for hydrocephalus or not, reason for avoiding or refusing large craniotomy, preoperative Glasgow Coma Scale (GCS), suffered from cerebral herniation or not, the location of TASDH, imaging characteristics of TASDH in CT scan, injury/surgery time interval, midline shift, preoperative neurologic deficit, operation time, and infusions of urokinase or not, were collected. The postoperative GCS, postoperative neurologic deficit, rebleeding or not, intracranial infection, and modified Rankin Scale (mRS) at 6 months after surgery were analyzed to access the safety and efficacy of evacuation with TDC. The results showed that the mean time interval from injury to TDC was 68.6 min (30–120 min). The mean distance of midline shift was 14.6 mm (10–20 mm). The preoperative GCS in all patients ranged from 4 to 13(median, 9). The mean duration of the operation was 14.4 min (6–19 min). Postoperative CT scan showed that hematoma evacuation rate was more than 70% in all cases. There were no cases of acute rebleeding and intracranial infection after TDC. No cases presented with chronic SDH at the ipsilateral side within 6 months after being treated by TDC alone or combined with instillation of urokinase. Favorable outcomes were shown in all cases (mRS scores 0–2) at 6 months after surgery. Conclusions TASDH in the elderly could be safely and effectively treated by TDC alone or combined with instillation of urokinase, which was a possible alternative for the elderly.

Massive cerebral infarction (MCI) is a life-threatening disease and may lead to cerebral herniation. Neutrophil degranulation contributes to ischemic injury in the early stage. To investigate whether neutrophil degranulating factors can predict cerebral herniation and the long-term prognosis of patients with MCI and to investigate the relationship between neutrophil degranulation and blood brain barrier (BBB) damage. In this case-control study of 14 MCI patients, we divided the patients into a cerebral hernia group and no cerebral hernia group according to whether they developed cerebral herniation within 5 days. The prognosis of MCI patients was assessed using the Modified Rankin Scale (mRS) score at 6 months, which was the primary end point. The composition of white blood cells (WBC) and degranulating factors for neutrophils in the plasma of MCI patients was determined on days 2 and 4. Baseline characteristics were comparable in both groups. The neurological functional scores and long-term prognosis showed no difference between patients with or without cerebral herniation, while the mortality rate of the cerebral hernia group in the short term was higher (P < 0.05). The WBC count, neutrophil to lymphocyte ratio (NLR) and plasma myeloperoxidase (MPO) levels of patients with cerebral hernia were significantly higher than those of patients without cerebral hernia (all P < 0.05). MPO is a better predictor of cerebral herniation, and the NLR showed superior predictive value in the prognosis of MCI patients. neutrophil degranulation may play an important role in malignant cerebral hernia during MCI. These data suggest that, MPO and the NLR might be predictive factors for cerebral herniation and the prognosis of MCI patients. [ABSTRACT FROM AUTHOR]

Objectives: This study was performed to evaluate retrospectively the clinical signs, complications and postoperative outcomes of feline intracranial meningioma (IM) with concurrent cingulate, transtentorial and foramen magnum herniations. Methods: The medical records and MRI scans of cats with IM and cerebral herniation were reviewed. Cases involving concurrent cingulate, transtentorial and foramen magnum herniations were included. Owners were contacted to obtain long-term follow-up information. Results: Seven cats (four castrated males and three spayed females) met the inclusion criteria. Median age was 13.0 years (range 9.9–16.1 years) and median duration of clinical signs was 35 days (range 21–163 days). The clinical signs of cats with cerebral herniation included visual impairment (n = 5 [71.4%]), ataxia (n = 4 [57.1%]), impaired consciousness (n = 2 [28.6%]), head pressing (n = 2 [28.6%]), paresis (n = 1 [14.3%]), torticollis (n = 1 [14.3%]) and personality changes (n = 1 [14.3%]). Median tumour volume, cranial cavity volume and tumour volume:intracranial volume ratio before surgery were 3.37 cm3 (range 3.23–11.5 cm3), 32.6 cm3 (range 29.8–78.3 cm3) and 10.4% (range 5.3–35.3%), respectively. Median overall tumour excision rate was 90.6%. Preoperative intracranial pressure (ICP) ranged from 15 to 32 mmHg (median 29 mmHg). In all cases, the ICP dropped to 0 mmHg immediately after tumour removal. No adjuvant therapy was required after surgery. The median survival period was 612 days (range 55–1453 days). Conclusions and relevance: The results of this study indicate that surgical treatment of rostrotentorial IM is effective and allows prolonged survival, even in cats with concurrent cingulate, transtentorial and foramen magnum herniations. [ABSTRACT FROM AUTHOR]

Abstract Intracranial mass lesions can lead to transtentorial uncal herniation, and pupillary asymmetry is a well-recognized sign of impending cerebral herniation. Impending uncal herniation can lead to ipsilateral, bilateral, or uncommonly the contralateral pupillary dilatation. We report a case of a 22-year old, who had contralateral pupillary dilatation due to expanding intracranial mass lesion and recovered well after neurosurgical intervention. This case illustrates contralateral pupillary dilatation (“false-localizing” sign) in a sub-group of patients, and if untreated and ICP continues to rise, this is followed by ipsilateral pupil dilatation.

Symmetric peripheral gangrene is a rare but devastating complication, scarcely reported after brain surgery. We present a case of symmetric peripheral gangrene shortly after brain surgery of intracranial hematoma removal and aneurysm clipping. [ABSTRACT FROM AUTHOR]

Highlights from the article: Hyperammonemia is a known cause of cerebral edema through multiple mechanistic pathways that ultimately converge on intracellular edema and toxic neuronal dysfunction [[1]-[3]]. While the presence of cerebral herniation has been reported to carry an overall unpropitious neurological prognosis, even with appropriate management, we present a case of severe hyperammonemia with cerebral edema and herniation where rapid and aggressive medical therapy resulted in complete neurological recovery, both clinically and radiographically [[9]]. The sulcal effacement, loss of ventricular size, and bilateral medialization of the uncus indicative of impeding herniation, secondary to cerebral edema in the initial scan (a) are completely reversed after successful treatment of the patient's elevated intracranial pressure and hyperammonemia (b) Furthermore, CVVHD is a rapid and safe bridging measure to effectively control hyperammonemia, and it should be initiated early and preferred in cases refractory to medical treatment with brain edema.

Objective To investigate the clinical benefits of emergent single burr hole evacuation technology in traumatic acute subdural hematoma (ASDH) with cerebral herniation cases. Methods We conducted a review comparing patients with ASDH with cerebral herniation who underwent single burr hole evacuation followed by decompressive craniectomy and intracranial hematoma removal surgery (n = 45, group A) and those who underwent decompressive craniectomy and intracranial hematoma removal surgery after rapid infusion of mannitol 250 mL (n = 53, group B) in our institution. Pre- and postoperative assessments included Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), activities of daily living (ADLs), and common complication incidences. Results At 1 and 6 months after operation, the median GCS score of group A was significantly higher than group B (P = 0.04 and P = 0.03, respectively). After 6 months, the GOS score and ADLs between the 2 groups had significant differences (P < 0.05). There were no differences between the 2 groups in the common complication incidences. Conclusions Emergent single burr hole evacuation in combination with decompressive craniectomy surgery is a useful treatment for ASDH with cerebral herniation, which can achieve reduction of intracranial pressure as soon as possible and improve the prognosis. Highlights • No reports have described the efficacy of emergent single burr hole evacuation for ASDH with cerebral herniation. • We studied a series of patients with ASDH with cerebral herniation. • Single burr hole evacuation is an effective and safe treatment for traumatic ASDH with cerebral herniation. • It can reduce intracranial pressure rapidly and relieve cerebral hernia. [ABSTRACT FROM AUTHOR]

Spontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation. We reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up. Of 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r 2 = 0.90). Data from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families. [ABSTRACT FROM AUTHOR]

Victoria Cui,1 Timur Kouliev2 1Washington University School of Medicine, St Louis, MO, USA; 2Emergency Department, Beijing United Family Hospital, Beijing, China Abstract: Acute subdural hematoma (SDH) resulting from head trauma is a potentially life-threatening condition that requires expedient diagnosis and intervention to ensure optimal patient outcomes. Rapidly expanding or large hematomas, elevated intracranial pressure, and associated complications of brain herniation are associated with high mortality rates and poor recovery of neurological function. However, smaller bleeds (clot thickness

Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.

Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter. [ABSTRACT FROM AUTHOR]

Background It is unclear how often lumbar puncture (LP) is complicated by cerebral herniation in patients with bacterial meningitis and whether cranial computed tomography (CT) can be used to identify patients at risk for herniation. Methods We performed a nationwide prospective cohort study of patients with community-acquired bacterial meningitis from 2006 to 2014 and identified patients with clinical deterioration possibly caused by LP. For systematic evaluation of contraindications for LP on cranial CT, these patients were matched to patients in the cohort without deterioration. Four experts, blinded for outcome, scored cranial CT results for contraindications for LP. A Fleiss’ generalized κ for this assessment was determined. Results Of 1533 episodes, 47 (3.1%) had deterioration possibly caused by LP. Two patients deteriorated within 1 hour after LP (0.1%). In 43 of 47 patients with deterioration, cranial CT was performed prior to LP, so CT results were matched with 43 patients without deterioration. The interrater reliability of assessment of contraindications for LP on cranial CT was moderate (Fleiss’ generalized κ = 0.47). A contraindication for LP was reported by all 4 raters in 6 patients with deterioration (14%) and in 5 without deterioration (11%). Conclusions LP can be performed safely in the large majority of patients with bacterial meningitis, as it is only very rarely complicated by cerebral herniation. Cranial CT can be considered a screening method for contraindications for LP, but the interrater reliability of this assessment is moderate. [ABSTRACT FROM AUTHOR]

Objectives To explore the association, if any, between the relationship between cardiac troponin and cerebral herniation after intracerebral hemorrhage ( ICH). Methods Six hundred and eighty-seven consecutive ICH patients admitted to West China Hospital from May 1, 2014 to September 1, 2015 were retrospectively reviewed. Data on demographics, etiology, laboratory examinations at admission including serum cardiac troponin, computed tomography ( CT) scans at admission and follow-up, and clinical outcomes were obtained. Using multiple logistic regression to identify the relationship of troponin and herniation. The association between troponin and hematoma volume was assessed using bivariate correlation and linear regression. Results Among 188 (27.4%) patients who underwent the test of serum cardiac troponin at admission, 16 (8.5%) demonstrated cerebral herniation. The median time from symptom onset to CT at admission and follow-up was 4 and 30.25 hr, respectively. In multivariate analysis, elevated troponin was independently associated with cerebral herniation (adjusted odds ratio [ OR] 5.19; 95% confidence interval [ CI], 1.08-24.93). And those with elevated troponin had larger hematoma volume at follow-up in bivariate correlation (correlation coefficient, .375, p = .003) and linear regression (β, .370, 95% CI, 0.062-0.320, p = .005), higher National Institutes of Health Stroke Scale score (adjusted OR 2.06; 95% CI, 1.06-4.01, p = .033) and lower Glasgow Coma Scale score (adjusted OR 2.34; 95% CI, 1.17-4.68, p = .016) than those without. Conclusions Elevated cardiac troponin was associated with an almost five-fold increased risk of cerebral herniation, but not in-hospital mortality. The possibility of cerebral herniation should be considered when ICH patients with large hematoma volume and elevated troponin. [ABSTRACT FROM AUTHOR]