Dural-stabs after wide craniectomy to decompress acute subdural hematoma with severe traumatic brain edema - An alternative technique to open dural flap

Abstract

The Department of Neurosurgery Sher-i-Kashmir Institute of Medical Sciences (SKIMS) Srinagar, a single neurosurgical centre in Kashmir valley, assessed prospectively, under a uniform protocol, 120 patients of severe traumatic brain edema with acute subdural hematoma by wide decompressive craniectomy with dural-stabs in 60(cases) patients as against conventional dural opening (open dural flap) and removal of acute subdural hematoma in 60(controls) patients during a period of 3 years (June 2006 to June 2009). A free bone flap was elevated and preserved. All patients had GCS (Glassgow Coma Scale) score of 8 and less. The elective ventilation and ICP monitoring was carried out in all patients. Most patients were young and males with a mean age of 30 years in both groups. The overall survival of the dural-stab group (case-study) was 78.3% with good recovery in 43.3% and a mortality of 21.6% (13/60) as compared to 40% survival in open dural flap (control) group with 11.6% good recovery and a mortality of 60% (36/60). The conventional (open dural flap) procedure to remove the clot proved dangerous in a traumatic “vent-searching” and edematous brain, restricted in a rigid cranial vault. This midway-approach, known in SKIMS as “dural-stabs”, between the only decompressive craniectomy and removal of acute subdural clot by open dural flap (conventional) method, proved much effective in increasing survival of low GCS and severe traumatic brain edema with acute subdural hematoma. In conclusion decompressive craniectomy alone is not sufficient and open dural flap is full of risk in such patients.

Keywords

acute subdural hematoma - dural-stabs - low gcs score - outcome - severe brain edema

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