Sudden cerebral edema after uncomplicated bilateral cranioplasty. Clinical observation and literature review

A.Yu. Lubnin, A.A. Potapov, I.V. Nikitenkova, I.A. Savin, K.A. Popugaev, A.V. Oshorov

FGAU "National Medical Research Center of Neurosurgery named after. acad. N.N. Burdenko" of the Ministry of Health of Russia, Moscow, Russia

For correspondence: Lubnin Andrey Yurievich - Dr. med. Sciences, Professor, Head of the Department of Anesthesiology, Resuscitation and Intensive Care of the Federal State Institution "National Medical Research Center of Neurosurgery named after. acad. N.N. Burdenko" of the Ministry of Health of Russia, Moscow; e-mail

For citation: Lubnin A.Yu., Potapov A.A., Nikitenkova I.V., Savin I.A., Popugaev K.A., Oshorov A.V. Sudden cerebral edema after uncomplicated bilateral cranioplasty. Clinical observation and literature review. Bulletin of Intensive Care named after. A.I. Saltanova. 2020;2:137–145. DOI: 10.21320/1818-474X-2020-2-137-145

Essay

The paper describes a clinical observation of the acute development of cerebral edema after uncomplicated bilateral cranioplasty. The discussion and review of the literature examines the mechanisms of development of cerebral edema that occurs after the closure of extensive bone defects of the skull, especially large and bilateral ones, as well as the possible role of subgaleal drainages.

Key words: cranioplasty, complications, acute cerebral edema

Received: 03.03.2020

Accepted for publication: 02.06.2020

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Statistics Plumx Russian

Methods for plastic surgery of a bone defect of the skull

A bone defect in the skull is a hole in it that forms after neurosurgical intervention on the organs of the central nervous system or as a result of trauma.
Let's talk in more detail about skull defects in medical practice. After removing a section of bone and creating a hole in the skull, patients experience not only psychological discomfort, but also the so-called “trepanned skull syndrome.” In both cases, the hole must be closed with an implant. And now about everything in more detail.

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Consequences of skull defects

The bones of the skull not only protect the brain from mechanical damage. The absence of one area can cause a lot of unpleasant symptoms or complications for the patient. It is their presence that serves as a direct indication for surgical plastic surgery.

It could be:

• Headache. It occurs not only at the site of the defect, but also affects other areas. Most often, the symptom intensifies or occurs when there is a change in atmospheric pressure and air temperature. The so-called meteosensitivity appears.
• "Astheno-neurotic syndrome." These include complaints of absent-mindedness, decreased concentration, difficulties in solving intellectual problems, frequent mood swings, decreased ability to withstand stress and tolerance to alcohol.
• Protrusion of the contents of the skull outward. When coughing or sneezing, physical stress or exertion, part of the brain substance can protrude through an opening in the skull, under the skin. This leads to traumatization of internal tissues at the edges of the bone defect.
• Symptomatic epilepsy.
• Mental disorders.

Features of the operation

Surgical intervention should not be started when inflammatory processes are detected in the cranial cavity, in the meninges or brain. Contraindications also include noticeable mental abnormalities of the patient, the presence of a piece of bone tissue or a foreign object in the cranial cavity, and bulging of the brain in the problem area. If visual examination and diagnosis do not reveal any of the listed points, surgery is prescribed.

Skull plastic surgery after trephination and other similar manipulations are called cranioplasty. It is aimed at restoring the integrity of the skull after decompression and stabilization operations, gunshot wounds, falls from a height, and mechanical damage. The choice of intervention technology depends on the timing of the plastic surgery, and it can be primary (1-2 days after injury), primary delayed (up to 2 weeks), early (up to 8 weeks), late (more than 2 months).

There are several rules that must be followed during any type of cranioplasty surgery:

• maximum possible preservation of bone tissue elements;
• use of separated fragments as an autograft;
• strict correspondence between the plate size and the size of the closure area;
• absence of sharp and too thin parts of the skull.

Elimination of a skull defect is a rather complex and responsible operation, the first step of which will be excision of the meningeal scar. All manipulations are performed as carefully as possible to avoid trauma to the brain tissue. For good adhesion of the skull bones and the implant, the edges of the entire problem area are exposed, and the material is necessarily installed “flush” with the skull bones. To prevent such a negative phenomenon as graft displacement, reliable fixation is carried out. Conventional soft tissue suturing is not enough.

Cranioplasty

This is the name of the operation to restore the tightness of the skull. It is designed to restore the brain’s protection from external influences, normalize blood and lymph flow, eliminate the above symptoms, cosmetic defects and relieve psychological discomfort.

The essence of the procedure is to close the hole in the skull with an implant. A competent neurosurgeon will help you understand the great variety of implants offered by medicine today and choose the best one. Fill out an application on the website or call us to get advice from a leading specialist to choose the right implant and discuss the features of the upcoming operation.

We will tell you what types of cranioplasty implants there are and how the operation to install them is performed.

How is rehabilitation after brain surgery?

First, the patient is examined by doctors from the rehabilitation team, then, based on the results of the examinations, a rehabilitation program is collectively formed. Next, a physical therapy instructor, an ergotherapist, a neuropsychologist, a speech therapist begin to work with the patient, and physiotherapy and massage procedures are carried out. Doctors of the rehabilitation team examine the patient during the implementation of the program, assess the dynamics of the patient’s condition and, if necessary, adjust the objectives of rehabilitation measures. At the conclusion of the rehabilitation program, a final examination of the doctors of the rehabilitation team is carried out and recommendations are formulated for the patient.

Occupational therapy

Bobath therapy

What is the PNF technique?

Hirudotherapy

Amplipulse (SMT therapy)

Vacuum therapy

Implants

There is a list of mandatory qualities that they must have:

• sufficient strength;
• biocompatibility;
• ease;
• plastic;
• do not cause infectious complications;
• do not have a carcinogenic effect.

Implants can be made from the patient's own bone (autografts) or artificial (xenografts).

Autografts

This is bone that has been temporarily removed to access the patient's brain tissue. If the bone needs to be preserved to close a skull defect later, it is placed under the skin of the patient's abdomen or anterior outer thigh. If such preservation is not possible, other techniques using the person’s own bone tissue are used. And if it is impossible to replace the defect with autografts, they resort to materials replacing them.

Xenografts

The so-called “artificial bones” are made of metal (aluminum or titanium), using methyl methacrylate or hydroxyapatite.

Each of the mentioned implants has its own advantages and disadvantages. For example, hydroxyapatite can be used for defects up to 30 square centimeters. This material is completely biocompatible. And it is able to turn into its own bone tissue after 18 months with small defects. And the risk of infectious complications for this type of implant is the lowest among similar ones.

Titanium is the least likely to cause local inflammatory reactions. And from it it is possible to recreate lost fragments of the facial skeleton, the base of the skull, the vault and the walls of the orbit. This is done using simulation and neuronavigation in the preoperative period.

The doctor will help you understand the variety of implants, as well as find out what the latest medical developments in the field of implantology are, during an in-person consultation. Fill out an application on our website and we will make an appointment with a leading specialist in the field of neurosurgery.

In each specific case, it is important to take into account not only the direct benefits for a person, but also the aesthetic and psychological aspects. As well as restrictions imposed on the patient in connection with the choice (for example, a metal implant does not allow the patient to subsequently resort to MRI examination).

Indications for trepanation

The reasons for the operation are conditions, diseases in which the functioning of the brain and blood circulation are disrupted due to pathologies that compress the brain structures and blood vessels:

• traumatic brain injuries;
• inflammatory processes;
• increased intracranial pressure;
• blood clots, emboli, aneurysm of cerebral vessels;
• hemorrhages;
• abnormalities of the skull;
• tumors;
• cavities with blood clots and other fluid.

Preparation

During an emergency operation, there is no time for a full examination; they are limited only to cito (emergency) blood tests, which include determining the blood group, Rh factor, determining the level of hemoglobin, red blood cells, leukocytes, and indicators of the coagulation system. From instrumental studies - X-ray of the skull or CT. For a planned operation - a complete laboratory analysis of urine, blood, MRI, consultation with a cardiologist, therapist, ophthalmologist and other specialists.

The day before surgery, the last meal is no later than 6 pm. Avoid fatty, salty, spicy foods and alcohol. Stop taking medications that affect blood clotting and alcohol for 7 days. On the day of manipulation, it is forbidden to drink, eat, or smoke. The hair in the incision area is shaved off. The choice of anesthesia depends on the type of trepanation, often general, less often local, if it is necessary to control the patient’s reactions during manipulations.

The patient's position on the operating table depends on three requirements: anesthetic, local, general. The first requirements are that the patient’s position should not impede the movement of the chest; in case of cardiac or respiratory arrest, the position should not interfere with emergency resuscitation measures. Local requirements are optimal exposure of brain structures, a convenient approach for the neurosurgeon to the patient. General – the position should not provoke a deterioration in the patient’s condition or complications.

When trepanning the frontal lobes to gain access to the cranial fossa, the person's chiasmata are placed on their back. When manipulating the temporal, occipital, parietal zones, position on the side or back of the head with the body turned in the opposite direction from the area of ​​​​operation.