Disorders of the Central Nervous System – Postoperative Complications of Craniotomy

Disorders of the Central Nervous System – Postoperative Complications of Craniotomy

A craniotomy is associated with trephine syndrome, paradoxical herniation, external brain tamponade, and extracranial herniation as complications. Some of the conditions that can result from craniotomies include bone flap infections, strain pneumocephalus, soft tissue infections, hemorrhage, and extradural abscesses.

Extracranial brain herniation is the herniation of the brain tissues that are external to the calvaria due to defects in the skull bone (Hanko et al., 2020). External brain herniation can occur after trauma or after surgery. A craniotomy is one of the surgical procedures that can cause extracranial herniation (Hanko et al., 2020). A craniotomy can be done to decompress the intracranial contents in individuals who have intracranial hypertension after the failure of management by medications (Ignatavicius et al., 2017). This brain herniation is different from encephaloceles since it is not surrounded by meninges. The brain tissue that is herniated needs a surgical operation to reduce it since the patient is at risk of developing venous infarction and ischemia from occluded cortical veins.

Decompressive craniectomy is effective in controlling intractable elevated intracranial pressure. However, there is hygroma after the surgical process, which is subgaleal or subdural fluid collecting at the bone defect site (Motoyama et al., 2021). In most patients, the post-surgical hygroma disappears spontaneously with no symptoms (Motoyama et al., 2021). However, in rare cases, the hygroma can develop into a mass with neurological deterioration. This term is known as external brain tamponade. Its causative mechanisms and pathologies are not precise.

Syndrome of the trephined is a rare complication that happens after decompressive craniectomy. It is commonly referred to as the “sinking skin flap syndrome.” It involves the sinking of the scalp on the decompressed site deep beyond the bone defect’s age (Hiruta et al., 2019). It is rare, but it can lead to paradoxical brain herniation, which is herniation to the decompressed area on the contralateral side, leading to serious neurological deterioration, which includes anisocoria, comatose state, and decerebrate rigidity (Hiruta et al., 2019). Lower intracranial pressure rather than extracranial pressure is implicated in these phenomena (Hiruta et al., 2019). Most patients have brained swelling at the decompressed side in the acute trauma phase due to brain edema (Hiruta et al., 2019). Thus, these complications occur several weeks after the injury during the decline in the intracranial pressure in the chronic traumatic phase (Hiruta et al., 2019).

The “Motor Trephine Syndrome (MTS)” commonly referred to as the “Sunken Brain and Scalp Flap Syndrome” or the “Sinking Skin Flap Syndrome (SSFS)” or the “Syndrome of the Trephined,” is an uncommon syndrome that occurs after the removal of the large skull none flap leading to neurological dysfunction. In craniotomies that are too close to the midline, the sagittal sinus is more likely to be collapsed by the atmospheric pressure, leading to the loss of sagittal sinus to cerebrospinal fluid gradient, resulting in the poor absorption of CSF, increasing the ventriculomegaly (Gu et al., 2020).

References

Gu, G. T., Wong, S. B., & Ho, C. L. (2020). Postoperative motor trephine syndrome and delayed tension pneumocephalus. British Journal of Hospital Medicine, 81(10), 1-4. https://doi.org/10.12968/hmed.2020.0046

Hanko, M., Soršák, J., Snopko, P., Opšenák, R., Zeleňák, K., & Kolarovszki, B. (2020). Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: A 5-year experience. European Journal of Trauma and Emergency Surgery. https://doi.org/10.1007/s00068-020-01367-4

Hiruta, R., Jinguji, S., Sato, T., Murakami, Y., Bakhit, M., Kuromi, Y., & Saito, K. (2019). Acute paradoxical brain herniation after decompressive craniectomy for severe traumatic brain injury: A case report. Surgical Neurology International, 10, 79. https://doi.org/10.25259/sni-235-2019

Ignatavicius, D. D., Workman, M. L., & Rebar, C. (2017). Medical-surgical nursing – E-book: Concepts for interprofessional collaborative care. Elsevier Health Sciences.

Motoyama, Y., Kogeichi, Y., Matsuoka, R., Takamura, Y., Takeshima, Y., Matsuda, R., & Nakase, H. (2021). External brain tamponade paradoxically induced by cerebrospinal fluid Hypovolemia after decompressive craniectomy: A retrospective cohort study. Neurosurgery Open, 2(1). https://doi.org/10.1093/neuopn/okaa023

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Disorders of the Central Nervous System – Postoperative Complications of Craniotomy

You are preparing to work as a nurse in the neurology unit. The preceptor informs you to be prepared to discuss the following topics as they are commonly seen in the unit. In order to prepare, choose one of the following topics of interest for your initial discussion post. Use this course’s resources and one evidence-based article to explore the topic of your choice.

1. How do you assess a client when the nurse suspects the onset of CVA?
2. Provide discharge information for a client with mild TBI.
3. Discuss surgical management of brain tumors.
4. Describe postoperative complications of a craniotomy.

When responding to the initial posting, provide an evidence-based article to support your response.