Simultaneous Cranioplasty and External Ventricular Drain Implantation in Patients with Hydrocephalus: Case Series and Literature Review

Abstract

Introduction The increase in intracranial pressure (ICP) is a neurological complication resulting from numerous pathologies that affect the brain and its compartments. Therefore, decompressive craniectomy (DC) is an alternative adopted to reduce ICP in emergencies, especially in cases refractory to clinical therapies, in favor of patient survival. However, DC is associated with several complications, including hydrocephalus (HC). The present study presents the results of an unusual intervention to this complication: the implantation of an external ventricular drain (EVD) in the intraoperative period of cranioplasty (CP).

Methods Patients of both genders who presented with HC and externalization of the brain through the cranial vault after decompressive hemicraniectomy and underwent EVD implantation, to allow the CP procedure, in the same surgical procedure, were included.

Results Five patients underwent DC due to a refractory increase in ICP, due to automobile accidents, firearm projectiles, falls from stairs, and ischemic strokes. All evolved with HC. There was no uniform time interval between DC and CP. The cerebrospinal fluid (CSF) was drained according to the need for correction of cerebral herniation in each patient, before undergoing cranioplasty. All patients progressed well, without neurological deficits in the immediate postoperative period.

Conclusion There are still several uncertainties about the management of HC resulting from DC. In this context, other CP strategies simultaneous to the drainage of CSF, not necessarily related to ventriculoperitoneal shunt (VPS), should be considered and evaluated more deeply, in view of the verification of efficacy in procedures of this scope, such as the EVD addressed in this study.

Resumo

Introdução O aumento da pressão intracraniana (PIC) decorre de inúmeras patologias que acometem o encéfalo e seus envoltórios. Diante disso, a craniectomia descompressiva (CD) é uma alternativa adotada para redução da PIC nas emergências, especialmente em casos refratários a terapias clínicas, em prol da sobrevida dos pacientes. Entretanto, existem diversas complicações associadas à CD, entre as quais está a hidrocefalia (HC). O presente estudo apresenta resultados de uma intervenção incomum para essa complicação: o implante de derivação ventricular externa (DVE) no intraoperatório de cranioplastia (CP).

Métodos Foram incluídos pacientes de ambos os gêneros que apresentaram HC e exteriorização encefálica da abóbada craniana após hemicraniectomia descompressiva e foram submetidos a implante de DVE, para possibilitar a CP, no mesmo ato operatório.

Resultados Cinco pacientes foram submetidos a CD pelo aumento refratário da PIC, decorrente de acidentes automobilísticos, projéteis de arma de fogo, quedas de escada e acidentes vasculares cerebrais isquêmicos. Todos evoluíram com HC. Não houve uniformidade de intervalo de tempo entre a CD e a CP. O líquido cerebroespinal (LCE) foi drenado de acordo com a necessidade de correção da herniação cerebral em cada paciente, antes da CP. Todos os pacientes evoluíram bem, sem déficits neurológicos no pós-operatório imediato.

Conclusão Ainda existem inúmeras incertezas sobre o manejo da HC consequente de CD. Assim, outras estratégias de CP simultânea à drenagem de LCE, não necessariamente relacionadas à derivação ventriculoperitoneal, devem ser consideradas e avaliadas mais profundamente, tendo em vista a constatação de eficácia em procedimentos desse âmbito, como a DVE abordada no presente estudo.

Keywords

cranioplasty - external ventricular drain - post-traumatic hydrocephalus - neurosurgery

Palavras-chave

cranioplastia - dreno ventricular externo - hidrocefalia pós-traumática - neurocirurgia

Publication History

Received: 18 October 2020

Accepted: 00 January 2021

Article published online:
29 July 2021

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