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Decompressive craniectomy (DC) at the non-injured side of the brain has the potential to improve patient outcome as measured with computational simulation

  • Clinical Article - Neurosurgical Techniques
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Abstract

Objective

Decompressive craniectomy (DC) is efficient in reducing the intracranial pressure in several complicated disorders such as traumatic brain injury (TBI) and stroke. The neurosurgical procedure has indeed reduced the number of deaths. However, parallel with the reduced fatal cases, the number of vegetative patients has increased significantly. Mechanical stretching in axonal fibers has been suggested to contribute to the unfavorable outcome. Thus, there is a need for improving treatment procedures that allow both reduced fatal and vegetative outcomes. The hypothesis is that by performing the DC at the non-injured side of the head, stretching of axonal fibers at the injured brain tissue can be reduced, thereby having the potential to improve patient outcome.

Methods

Six patients, one with TBI and five with stroke, were treated with DC and where each patient’s pre- and postoperative computerized tomography (CT) were analyzed and transferred to a finite element (FE) model of the human head and brain to simulate DC both at the injured and non-injured sides of the head. Poroelastic material was used to simulate brain tissue.

Results

The computational simulation showed slightly to substantially increased axonal strain levels over 40 % on the injured side where the actual DC had been performed in the six patients. However, when the simulation DC was performed on the opposite, non-injured side, there was a substantial reduction in axonal strain levels at the injured side of brain tissue. Also, at the opposite, non-injured side, the axonal strain level was substantially lower in the brain tissue. The reduced axonal strain level could be verified by analyzing a number of coronal sections in each patient. Further analysis of axial slices showed that falx may tentatively explain part of the different axonal strain levels between the DC performances at injured and opposite, non-injured sides of the head.

Conclusions

By using a FE method it is possible to optimize the DC procedure to a non-injured area of the head thereby having the potential to reduce axonal stretching at the injured brain tissue. The postoperative DC stretching of axonal fibers may be influenced by different anatomical structures including falx. It is suggested that including computational FE simulation images may offer guidance to reduce axonal strain level tailoring the anatomical location of DC performance in each patient.

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Acknowledgments

The present study was supported by the research foundations at Karolinska University Hospital, Stockholm County, and division of Neuronic engineering at KTH, Sweden

Conflict of interest

None.

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Authors and Affiliations

  1. Division of Neuronic Engineering, School of Technology and Health, Royal Institute of Technology (KTH), Stockholm, Sweden

    Hans von Holst & Xiaogai Li

  2. Section of Neurosurgery, Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

    Hans von Holst

Authors
  1. Hans von Holst
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  2. Xiaogai Li
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Corresponding author

Correspondence to Hans von Holst.

Additional information

Comment

The authors present an interesting study using the finite elements to determine the correlation between the strain level and axonal function in traumatic brain injury or stroke. From the computational simulation in the present study it was found that by performing decompressive craniectomy at the opposite, non-injured side, the axonal strain level decreased not only at the injured side but also on the opposite, non-injured side. This study represents a significant step in introducing the finite-elements thinking in the neurosurgical community. This method is of interest for the development of new innovative ways in neurosurgery.

A. Alfieri,

Neuruppin, Germany

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von Holst, H., Li, X. Decompressive craniectomy (DC) at the non-injured side of the brain has the potential to improve patient outcome as measured with computational simulation. Acta Neurochir 156, 1961–1967 (2014). https://doi.org/10.1007/s00701-014-2195-5

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  • DOI: https://doi.org/10.1007/s00701-014-2195-5

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