Transfalcine Contusion Evacuation in Bifrontal Contusion

Abstract

Traumatic bifrontal contusions have an unpredictable course with often rapid deterioration, requiring an aggressive approach. However, integral to an individual's personality, frontal lobe surgeries demand a maximally effective approach but with minimal invasiveness. The author explores the feasibility of a transfalcine corridor for the effectiveness of contusion evacuation in asymmetric bifrontal contusion cases, with one side extensive and the other moderate size, aiming minimal invasiveness on the less affected side without compromising the surgical efficacy. The authors have evaluated the role of transfalcine brain surgeries in the selected cases of bifrontal contusions, and here, they report the experiences of their first two cases performed using this corridor between January 2024 and April 2024 at their institution. Two cases of bifrontal contusions were operated on, with a sizeable contusion on one side and a relatively smaller basifrontal contusion on the other. The craniotomy was focused on the side with the larger contusion. After the contusion was evacuated from that side, the contralateral side was approached through a corridor made in the intervening falx cerebri, and the contralateral frontal contusion was evacuated under the microscope. Both patients showed significant clinical and radiological improvement in their postoperative period with early recovery. Transfalcine bifrontal contusion evacuation is a good option, especially in selected cases with one side larger and relatively smaller contralateral inferior-medial frontal contusion locations.

Keywords

transfalcine - bifrontal - basifrontal - contusion - frontal

Introduction

The frontal lobe contusion is notorious for unpredictable behavior, with often rapid deterioration in conservatively managed cases.[1] While an aggressive surgical approach remains counterproductive to one's personality, this is the first time the authors have described the role of transfalcine surgeries in bifrontal contusions to obtain a balance between aggression and conservation in cases with surgical dilemmas.

Materials and Methods

Following ethical approval from our institutional ethical committee, patients with an asymmetric contusion, i.e., a sizeable contusion on one side with mass effect and a moderate frontal contusion on the opposite side, were selected for this study to evaluate transfalcine surgery's role. The authors report their experiences of the first two cases performed after appropriate consent using this corridor between January 2024 and April 2024 at our institution.

Surgical Technique

The initial surgical steps, namely a standard unilateral frontal craniotomy, a single trapdoor-fashion superior sagittal sinus (SSS)-based dural flap flush with the SSS, and ipsilateral contusion evacuation, are the same as those for the conventional frontal contusion evacuation. Following ipsilateral contusion removal, the falx cerebri becomes exposed to a variable length (depending on contusion extension), allowing for the creation of a window in it. With a 15# surgical blade, the falx is incised inferior and parallel to the SSS with its vertical cut until its free inferior margin and the window is extended to the desired anteroposterior extent under the microscope. Next, the contralateral frontal contusion evacuation followed the exposed surface corticectomy. Given the intervening SSS, the superolateral surface contusion, not in direct vision, remains unlikely to be evacuated using this corridor. Finally, a dural and a routine closure are required only on the ipsilateral side.

Case Illustration

Case 1

A 45-year-old female with a history of fall 5 days back presented in a Glasgow Coma Scale (GCS) score of E1V1M5, with bilateral normal pupil size and reactions. A head computed tomography (CT) scan revealed a bifrontal contusion (left > right) with mass effect from the left side ([Fig. 1A]).

Fig. 1 (A) Computed tomography (CT) scan head showing bifrontal (left > right) contusion (black arrow), perilesional, and diffuse cerebral edema with effaced left frontal horn. (B) Postop day 14th CT scan.

She underwent an emergency bifrontal craniotomy with left frontal and trans-falcine right frontal contusion evacuation. During surgery, after the left frontal contusion evacuation, the falx was incised, a corticectomy was performed over the exposed right medial basifrontal cortex, and the underlying contusion was evacuated ([Fig. 2A–C]). Finally, a standard closure was done.

Fig. 2 Surgical photograph showing (A) contralateral basifrontal and contused medial surface through falx cerebri corridor. (B) Basifrontal contusion evacuation. (C) Hemostasis after contusion removal. FC, falx cerebri.

The postoperative CT scan revealed a completely evacuated contusion ([Fig. 1B]). Finally, on the 17th day, an improved patient with GCS E4VtM6 was discharged.

Case 2

A 34-year-old female with a history of a road traffic accident 1 day back presented with altered sensorium and vomiting in GCS E3V1M5 with bilateral normal pupillary size and reactions. Her head CT scan revealed left frontotemporal and right basifrontal contusions, with mass effect from the left side ([Fig. 3A]).

Fig. 3 (A) CT scan head showing left frontotemporal and right basifrontal contusion (black arrow). (B) Postop day 10th CT scan. CT, computed tomography.

First, she underwent a left frontotemporal craniotomy and ipsilateral contusion evacuation. Next, the anterior falx was incised, a posterior-based falcine dural flap was created, and right basifrontal contusion evacuation was done ([Fig. 4A–C]). After hemostasis and left dural closure, a standard closure followed.

Fig. 4 Surgical photo showing (A) falcine dural flap. (B) Transfalcine contralateral basifrontal contusion evacuation. (C) Falcine defect showing evacuated contusion.

The postoperative CT scan revealed an evacuated contusion and mass effect resolution. Finally, the patient was discharged in GCS 15 on the 10th day ([Fig. 3B]).

Discussion

Approximately 30% of cerebral contusions occupy the frontal lobes, mainly in the basifrontal region.[2] Clinically, a late deterioration has often been observed in conservatively managed bifrontal contusion cases. Senapati and Das mentioned more clinical and radiological deterioration, delayed surgery, and even higher mortality in bilateral basifrontal contusion patients managed conservatively.[3]

Traditionally, frontal contusions with surgical indications require frontal craniotomy and contusion evacuation.[4] Recently, new minimally invasive approaches have been introduced for frontal contusion surgeries, such as the endoscopic supraorbital approach,[5] microscopic supraorbital keyhole approach,[6] and endoscope-assisted falx incision.[7] Furthermore, to reduce future cognitive disturbances, Huang et al suggested decompressive craniectomies without hematoma evacuation, allowing the hematomas to resolve in due course without increasing the intracranial pressure.[8]

Extensive bifrontal contusions invariably require a bifrontal craniotomy or decompressive craniectomy and contusion removal.[4] However, surgical decision-making becomes challenging in cases with a bifrontal contusion, more extensive on one side than the other, creating a dilemma of whether to remove both sides of the contusion or only one side. The available options in asymmetric bifrontal contusion cases are as follows.

• Unilateral craniotomy with contusion removal on the side with a significant mass effect and conservative management on the contralateral side. However, in the presence of moderate-size contralateral contusions, it may prove undertreatment, requiring a second surgery in due course.

• Bifrontal craniotomy, removal of both sides' contusions, which may be overtreatment, with more cognitive impairment in convalescence.

To overcome this dilemma, the author used an interhemispheric transfalcine approach to remove both sides' contusions without much collateral damage. This is not novel and rather a well-described technique for parafalcine lesions like meningiomas,[9] gliomas,[10] and arteriovenous malformations; however, it has never been used in trauma cases before.

The pathology and uniqueness of their locations, i.e., anterior frontal pole, do not require extra planning like CT/magnetic resonance venography, positioning for gravity retraction, and cerebrospinal fluid drainage for brain relaxation before dural opening, like other elective indications. Additionally, unlike other elective transfalcine surgeries, here, the contralateral surgery remains accessible for the surgeon after contusion evacuation from the ipsilateral side, as no arachnoid dissection or brain retraction will be required to expose the falx.

The surgery invariably results in less blood loss than routine bifrontal contusion surgeries, and hemostasis is also easily achievable by simple conventional maneuvers. Finally, the dural closure is less time-consuming, only on one side.

Significant brain edema, a contraindication for other previously described minimally invasive approaches, could not be a contraindication of this approach; hence, our work is the next step in the minimally invasive neurosurgical armamentarium, and the successful outcome of our cases instills optimism about the potential of this new approach.

Conclusion

Transfalcine bifrontal contusion surgeries allow only traumatic hematoma evacuation and help preserve the normal brain in the relatively less affected frontal lobe.

Conflict of Interest

None declared.

Note

The work should be Attributed to Department of Neurosurgery, Lifeline Hospital & Research Centre, Azamgarh, Uttar Pradesh, India.

Patients' Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

• References

• 1 Statham PF, Johnston RA, Macpherson P. Delayed deterioration in patients with traumatic frontal contusions. J Neurol Neurosurg Psychiatry 1989; 52 (03) 351-354
• 2 Winn MD, Richard H. Structural imaging of traumatic brain injury. In: Winn HR. ed. Youmans and Winn Neurological Surgery. Philadelphia, PA: Elsevier; 2017
• 3 Senapati SB, Das D. Treatment strategy & outcome in basifrontal contusion- analysis of 76 cases. IJAR 2017; 7 (09) 236-238
• 4 Singh AK. Traumatic brain contusion and hematoma. In: Surgical Nuances of Head Injury. In: Singh AK. ed. Delhi: Thieme Delhi; 2023: 239-257
• 5 Yang Q, Cui M, Xiong W. et al. Surgical treatment of traumatic frontal hematoma: comparison of the endoscopic supraorbital approach with frontotemporal approach. Front Neurol 2023; 14: 1234009
• 6 Zhang S, Qian C, Sun G, Li X. Clinical application of the supraorbital key-hole approach to the treatment of unilateral-dominant bilateral frontal contusions. Oncotarget 2017; 8 (29) 48343-48349
• 7 Ji-Rong D, Qin-Yi X, Xue-Jian C. et al. Endoscopy-assisted cerebral falx incision via unilateral approach in treatment of dissymmetric bilateral frontal contusion. J Craniofac Surg 2012; 23 (06) 1819-1821
• 8 Huang AP, Tu YK, Tsai YH. et al. Decompressive craniectomy as the primary surgical intervention for hemorrhagic contusion. J Neurotrauma 2008; 25 (11) 1347-1354
• 9 Boissonneau S, Beucler N, Graillon T, Farah K, Fuentes S, Dufour H. Transfalcine approach for the resection of a bilateral falx meningioma: Technical nuances and review of literature. Asian J Neurosurg 2021; 16 (04) 821-823
• 10 Goel A. Transfalcine approach to a contralateral hemispheric tumour. Acta Neurochir (Wien) 1995; 135 (3–4): 210-212

Publication History

Article published online:
25 March 2025