Mandell Melanie, Grassia Fabio, Riaz Muhammad
Doctor of Medicine Training Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
Department of Neurosurgery, Denver Health Hospital Authority, Denver, CO, USA.
Am J Case Rep. 2025 Jan 8;26:e946230. doi: 10.12659/AJCR.946230.
BACKGROUND Decompressive craniectomy is a common life-saving intervention in the setting of elevated intracranial pressure. Cranioplasty restores the calvarium and intracranial physiology once swelling recedes. Cranioplasty is often thought of as a low-risk intervention. However, numerous reports indicate that malignant cerebral edema (MCE) is an often-fatal complication of an otherwise uneventful cranioplasty. A careful review of the literature is needed to better understand this devastating condition. CASE REPORT A 41-year-old man presented after suffering a gunshot wound to the right frontal lobe. Upon initial evaluation, the patient had grossly visible brain matter, left-sided hemiparesis with a Glascow Coma Score (GCS) of 11, and vital signs concerning for elevated intracranial pressure. Computed tomography (CT) showed right-sided intraparenchymal and subarachnoid hemorrhage with a 5 mm leftward midline shift. The patient was taken to the operating room (OR) for right fronto-parietal craniectomy. Over the next 3 months, he recovered steadily and underwent PEEK cranioplasty on post-operative day 83. Pre-operative CT showed sunken skin flap syndrome with an 8-mm midline shift. Following an uneventful cranioplasty, he failed to regain consciousness. Examination revealed absent brainstem reflexes. CT showed global diffuse cerebral edema. The patient was declared brain dead. CONCLUSIONS Continued research is needed to better understand the pathophysiology of malignant cerebral edema so that future incidences may be prevented. A combination of negative-pressure suction drainage, sunken skin flap syndrome, and delayed time to cranioplasty likely play a significant role in the evolution of MCE. We urge neurosurgeons to consider the likelihood of MCE and adapt surgical planning accordingly.
减压性颅骨切除术是颅内压升高情况下常见的挽救生命的干预措施。颅骨成形术可在肿胀消退后恢复颅骨和颅内生理功能。颅骨成形术通常被认为是一种低风险的干预措施。然而，大量报告表明，恶性脑水肿（MCE）是原本顺利的颅骨成形术常见的致命并发症。需要仔细回顾文献以更好地了解这种毁灭性疾病。病例报告：一名41岁男性因右额叶枪伤就诊。初步评估时，患者可见明显的脑组织、左侧偏瘫，格拉斯哥昏迷评分（GCS）为11分，生命体征提示颅内压升高。计算机断层扫描（CT）显示右侧脑实质内和蛛网膜下腔出血，中线向左移位5mm。患者被送往手术室（OR）行右额顶颅骨切除术。在接下来的3个月里，他恢复稳定，并在术后第83天行聚醚醚酮（PEEK）颅骨成形术。术前CT显示皮瓣下陷综合征，中线移位8mm。颅骨成形术顺利完成后，他未能恢复意识。检查发现脑干反射消失。CT显示全脑弥漫性脑水肿。患者被宣布脑死亡。结论：需要继续研究以更好地了解恶性脑水肿的病理生理学，以便预防未来的发病情况。负压吸引引流、皮瓣下陷综合征和延迟颅骨成形术时间的综合作用可能在MCE的发展中起重要作用。我们敦促神经外科医生考虑MCE的可能性并相应调整手术计划。
