title: Emergency decompressive craniectomy after removal of convexity meningiomas.
abstract: BACKGROUND
  Convexity meningiomas are benign brain tumors that are amenable to complete surgical resection and are associated with a low complication rate. The aim of this study was to identify factors that result in acute postoperative neurological worsening after the removal of convexity meningiomas.
  
  
  METHODS
  Clinical evaluation and neuroradiological analysis of patients who underwent removal of a supratentorial convexity meningioma were reviewed. Patients were selected when their postoperative course was complicated by acute neurological deterioration requiring decompressive craniectomy.
  
  
  RESULTS
  Six patients (mean age: 43.3 years) underwent surgical removal of a supratentorial convexity meningioma. Brain shift (mean: 9.9 mm) was evident on preoperative imaging due to lesions of varying size and perilesional edema. At various times postoperatively, patient consciousness worsened (up to decerebrate posture) with contralateral paresis and pupillary anisocoria. Computed tomography revealed no postoperative hematoma, however, did indicate increased brain edema and ventricular shift (mean: 12 mm). Emergency decompressive craniectomy and brief ventilator assistance were performed in all patients. Ischemia of the ipsilateral posterior cerebral artery occurred in 3 patients and hydrocephalus occurred in 2 patients. Outcome was good in 2, fair in 2, 1 patient had severe disability, and 1 patient died after 8 months.
  
  
  CONCLUSIONS
  Brain shift on preoperative imaging is a substantial risk factor for postoperative neurological worsening in young adult patients after the removal of convexity meningiomas. Emergency decompressive craniectomy must be considered because it is effective in most cases. Other than consciousness impairment, there is no reliable clinical landmark to guide the decision to perform decompressive craniectomy; however, brain ischemia may have already occurred.
authors.affiliation: Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Missori
authors.affiliation: Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Domenicucci
authors.affiliation: IRCCS Neuromed-Pozzilli, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Sergio
authors.initials: S
authors.lastname: Paolini
authors.affiliation: Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Mancarella
authors.affiliation: IRCCS Neuromed-Pozzilli, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Serena
authors.initials: S
authors.lastname: Tola
authors.affiliation: Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: D'Elia
authors.affiliation: Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Marotta
authors.affiliation: University Hospital Center Mother Theresa, Tirana, Albania.
authors.forename: Arsen
authors.initials: A
authors.lastname: Seferi
authors.affiliation: IRCCS Neuromed-Pozzilli, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Esposito
keywords: Brain; craniectomy; meningioma; shift; ventricular system