Saturday News

Contents of This Week Saturday News:

• Headline - Decompressive Craniectomy

Decompressive craniectomy (crani- + -ectomy) is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury and stroke. Use of the surgery is controversial. A definition from Wikipedia and video clips from YouTube / Vimeo.

• Eclectic - Many articles from many Guest Bloggers about Stroke
• Putting the Possibility in Disability
• Hemicraniectomy for Massive Middle Cerebral Artery Infarction: A Review
• Cranio-What?
• Craniotomy vs. Craniectomy
• Six Top Clinical Trials in Traumatic Brain Injury (TBI)
• In the Limelight, Part 2
• My Upcoming Surgery for Foot Drop, aka My 50/50 Gamble
• Don't Worry, Therapists...
• Emotions and Attitude, Complexities of #50shades of Emotions
• Technology & #Strokerecovery Tweetchat – Your Views!
• Singing and Speaking Aphasia Speech Therapy
• The Stress of Aphasia and Recovery
• PoNS Inspired Therapy
• Blog for April 14 Stroke Recovery Tweet Chat: Patient Engagement
• What is an Engaged Patient?
• Weekly Columnists
• Musing: Severe Brain Injury Warrants Bold Moves
• Sunday Stroke Survival: Holes in Your Head? Brains Leaking Out
• Caregiver: Home Again, Home Again, Jiggity Jig!
• Jackie The Jester: Fossil Fuel Divestment Protester
• TED Talks - Henry Markram: A Brain in a Supercomputer
• Rick Mercer Report: Rick and Trapshooting
• Laid-Back Administration: Just a Minor Updated (Again!)
• Daily Comics: FB Or FW, Dilbert, Mayes, Doonesbury

Definition: Decompressive Craniectomy

Decompressive Craniectomy
      From Wikipedia, the free encyclopedia

A large decompressive craniectomy
is removed and the dura is opened
to allow the brain to expand.

Decompressive craniectomy (crani- + -ectomy) is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury and stroke. Use of the surgery is controversial.

The procedure evolved from a primitive form of surgery known as trephining or trepanning. The older procedure, while common in prehistoric times, was deprecated in favor of other, less invasive treatments as they were developed; although it was still performed with some frequency prior to the twentieth century, its resurgence in modern form became possible only upon the development of precision cutting tools and sophisticated post-operative care such as antibiotics.

Results of Clinical Trials

Reduction of Intracranial Pressure

Though the procedure is considered a last resort, some evidence suggests that it does improve outcomes by lowering intracranial pressure (ICP), the pressure within the skull. Raised intracranial pressure is very often debilitating or fatal because it causes compression of the brain and restricts cerebral blood flow. The aim of decompressive craniectomy is to reduce this pressure. The part of the skull that is removed is called a bone flap. A study has shown that the larger the removed bone flap is, the more ICP is reduced.

DECRA Trial

Video: Decompressive Craniectomy

Craniotomy and Craniectomy

Published on Jan 7, 2014 

 View more NUCLEUS medical animations at http://www.nucleuslibrary.com.

If you like this animation, LIKE us on Facebook: http://www.nucleusinc.com/facebook.

http://www.nucleusinc.com/medical-animations This 3D medical animation depicts two operations, called craniotomy and craniectomy, in which the skull is opened to access the brain. The normal anatomy of the skull and tissues surrounding the brain are shown, including arteries and veins. The animation lists the common reasons for these procedures, and briefly introduces intracranial pressure.

Transcript:

• Your doctor may recommend a craniotomy or a craniectomy procedure to treat a number of different brain diseases, injuries, or conditions.
• Your skull is made of bone and serves as a hard, protective covering for your brain.
• Just inside your skull, three layers of tissue, called meninges, surround your brain. 
• The thick, outermost layer is the dura mater.
• The middle tissue layer is the arachnoid mater and the innermost layer is the pia mater.
• Between the arachnoid mater and the pia mater is the subarachnoid space, which contains blood vessels and a clear fluid called cerebrospinal fluid.
• Blood vessels, called bridging veins, connect the surface of your brain with the dura mater.
• Other blood vessels, called cerebral arteries, bring blood to your brain.
• Inside your skull, normal brain function requires a delicate balance of pressure between the blood in your blood vessels, ... the cerebrospinal fluid that surrounds your brain, ... and your brain tissue.
• This is called normal intracranial pressure.
• Increased intracranial pressure may result from:
• brain tumours, 
• head injuries, 
• problems with your blood vessels, 
• or infections in your brain or spinal cord. 
• These conditions put pressure on your brain and may cause it to swell or change shape inside your skull, which can lead to serious brain injury.
• Your doctor may recommend a craniotomy to remove:
• abnormal brain tissue, such as a brain tumor,
• a sample of tissue by biopsy,
• a blood clot, called a hematoma, 
• excess cerebrospinal fluid, 
• or pus from an infection, called an abscess. 
• A craniotomy may also be done to: 
• relieve brain swelling, 
• stop bleeding, called a hemorrhage, 
• repair abnormal blood vessels, 
• repair skull fractures, 
• or repair damaged meninges. 
• Finally, a craniotomy may also be done to: 
• treat brain conditions, such as epilepsy, 
• deliver medication to your brain, 
• or implant a medical device, such as a deep brain stimulator. 
• The most common reason for a craniotomy is to remove a brain tumor.

Standard YouTube License @ Nucleus Medical Media

Eclectic Stuff

Definition: Eclectic(noun) a person who derives ideas, style, or taste from a broad and diverse range of sources.

Putting the Possibility in Disability

Jackie Poff
Stroke Survivors Tattler

Friday, November 11, 2011

SSTattler: Re-published Nov/11 2011 -- Thanks Jackie for a
                   great article!

by Jackie Poff

Some stroke survivors remember vividly their strokes and the events leading up to and around their strokes. I personally remember very little about my stroke – thankfully!

It has been three and one half years since my stroke, which took place on a very cold morning in January 2008. But here is what I do know about that day. On January 22nd (the day before my stroke) I was taking advantage of my lunch hour at work by taking with me my daughter, Nicole, who I had had the great pleasure of hiring onto my staff. We headed out to start apartment hunting for her. I received a phone from my mother informing me that my grandfather, Jack, who I was named after, had passed away at ninety years old.

That evening our family gathered at grandpa’s house in Tofield to discuss his passing. We arrived back home on our acreage near Spruce Grove much later than we intended. We all crawled into bed exhausted and I, as always, slept like a log.

I did remember to set my alarm for 6:30 in order to give Michelle, our youngest daughter, then thirteen, a ride to school for an early morning handball practice. When the alarm went off, I stumbled out of bed and went to the bathroom to run a brush through my hair. My husband Larry, a light sleeper, followed me and asked me why I was up so early. As he questioned me, suddenly my words became gibberish and I started to fall over. Larry, wondering what the heck was going on, caught me and rushed me to our bed. I was not responding. Nothing I did or said made any sense.

Larry recognized that I must be having a stroke. He managed to call our families and yell to the kids. He threw me in the car and got me to the nearest hospital, the Sturgeon Hospital in St. Albert.

There a CT scan confirmed I was having a massive MCA Stroke. TPA was administered within the 3 hour window. However, the TPA did not work and I was rapidly losing function.

Hemicraniectomy for Massive Middle Cerebral Artery Infarction: A Review

Jackie Poff
Stroke Survivors Tattler

Can. J. Neurol. Sci. 2008

Dulka Manawadu, Ahmed Quateen, J. Max Findlay

ABSTRACT: Hemicraniectomy and opening underlying dura mater permits the expansion of infarcted, swollen brain outwards, reversing dangerous intracranial pressure elevations and the risk of fatal transtentorial temporal lobe or diencephalic herniation. Recently published randomized controlled trials have proven this procedure a powerful life-saving measure in the setting of malignant middle cerebral artery infarction and allayed concerns that a reduction in mortality is accompanied by an unacceptable increase in patients suffering severe neurological impairments. Appropriate patients are relatively young, in the first five decades of life, suffering infarction of a majority of the middle cerebral artery (MCA) territory in either hemisphere, and decompression should be performed prior to progression to coma or two dilated, fixed pupils. Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider and discuss surgical intervention. Families and, when possible, patients themselves, should be informed of the certainty of at least moderate to mild permanent deficits, and the possibility of worse. To be successful decompression must be extensive, targeting a bone flap measuring 14 cm from front to back, and extending 1 to 2 cms lateral to the midline sagittal suture to the floor of the middle cranial fossa at the level of the coronal suture. An augmentation duraplasty is mandatory.



See the full article:
      Hemicraniectomy for Massive Middle Cerebral Artery Infarction: A Review

Cranio-What?

Grace Carpenter
My Happy Stroke

Monday, September 13, 2010

One of the specialists we saw last week was looking over the notes about my stroke and said, "I see you had a craniotomy."

Craniotomy?

I know that I had brain surgery, but I didn't realize that it's called a craniotomy. The image that comes to mind for me is a slightly unbalanced Victorian surgeon, indulging his curiosity by drilling holes willy-nilly in his patient's skull (apologies to the fabulous Dr. Tierney).

I'm sure this procedure has come a long way since the Victorian times, especially at MGH. Still, I'm glad that I wasn't awake during the operation.

See the original article:

Cranio-What?

in

My Happy Stroke

Craniotomy vs. Craniectomy

Amy Shissler
My Cerebellar Stroke Recovery

November 21, 2012

Recently I was asked about my brain surgery.  I had a craniectomy.  Actually my surgery was called a Decompressive Craniectomy.  But I said the word ‘craniotomy’ when I was asked about it.  I figure I got it mixed up, so I bet other people do too.  Otomy means opening.  Ectomy means removal.  So they open the skull in a craniotomy, and remove a part of the skull in a craniectomy.  It’s basically the same surgery, the end is just different.  A piece of skull is removed to allow access to the brain.  The difference is that in a craniotomy the doctors do what they need to do and then that piece of bone is replaced.  In a craniectomy, that bone is not replaced because of all of the swelling.  Sometimes in a craniectomy that bone is replaced later on, but not in my case.  That bone will never be replaced.  I used to be really, really freaked out by this.  I thought it meant my brain was just exposed.  It’s not.  They did the craniectomy in a spot where the muscle covering my brain is like an inch thick.  It’s still weird, but I’m not freaked out by it anymore.  Sometimes however, it hurts when people give me a hug in the wrong spot and squeeze.  If I hug someone our arms have to be low, it’s weird, I hate hugging like a normal person.  I always say to my friend Mandy, well “back when I was normal…..”  This makes her laugh.  I do what I can.  I’m not sure what this means and I’m not sure I want to know.  I don’t know why it hurts sometimes and have never asked anyone.  I don’t want to hear something like “because your brain has pressure on it.”  I’m better off not knowing the reason.  I have read that craniectomies are often the source of more headaches because the theory is that those muscles are working a lot harder since there is no longer bone there.  I’m not sure if I really believe this is the reason for more headaches, but whatever.  Good thing I know what I know about posture and headaches.

Related articles:

• Doctors Store Skull In Woman’s Stomach For 42 Days Following Brain Surgery (seattle.cbslocal.com)

See the original article:

Craniotomy vs. Craniectomy

in

My Cerebellar Stroke Recovery

Six Top Clinical Trials in Traumatic Brain Injury (TBI)

Bill Yates
Brain Posts

10th July 2014

This month topic is traumatic brain injury (TBI). I have reviewed some recent research manuscript related to the epidemiology and brain imaging issues of TBI.

Today I am posting links to clinical trials recently completed in the treatment of TBI.

I was surprised at the low number of high-quality clinical trials in TBI.

Given the public health burden of TBI, more rigorous randomized controlled trial efforts need to funded.

After reviewing about 100 PubMed abstracts, these five stand out to me as important additions to our knowledge base. Clicking on the heading will take you to the full abstract.

Hyperbaric oxygen therapy following blast-related traumatic brain injury in veterans
U.S. Navy veterans with blast-related TBI and post concussion syndrome were randomized to receive a trial of 40 sixty minute treatments with hyperbaric oxygen therapy. There was no evidence of improvement over three months with hyperbaric oxygen in this cohort.

In the Limelight, Part 2

Pamela Hsieh
Rehab Revolution

15 September 2010

After my interview, they struck down the set and we moved to another place in the same building, I think, to lunch together before my neurosurgeon, Dr. Yamini, was due for photographs with me (unplanned ones, but the marketing rep was certainly quick to seize the opportunity!) and filming.

The catering was rather tasty, and as everyone ate, I got to further expound on stuff I hadn’t been asked about during interview to sate other crew workers’ curiosity. And tangentially, I learned a bit more about the film production process.

Dr. Yamini was brought in shortly after lunch. I was invited out into a more picturesque part of the bridgelike hallway and photographed very, very close to my doctor. (I had never seen him this up close before, but I think for him this was among the least invasive ways he’s viewed me, as this is the man who’s literally rearranged the inside of my head before.)

It might be worth mentioning that this was also how we were reintroduced. I hadn’t seen him in ages, for natural reasons like no longer needing follow-up appointments, living away at school or being abroad, and also because I never seem to be able to get ahold of him whenever I try to visit randomly. I imagine his workday being ever so slightly more demanding than my own (I spent most of my day today in my kitchen). Ha!

My Upcoming Surgery for Foot Drop, aka My 50/50 Gamble

Joyce Hoffman
The Tales of a Stroke Patient

Jun 22, 2014

This may be my last post until my surgery on July 14th. Or maybe not. Anyway, I'll update you as soon as I can on the surgery. As usual, here's some background on the operation.

Ever since the stroke, I developed foot drop (or drop foot--I've heard it both ways), meaning the muscles and tendons that pull the foot and toes up are no longer working substantially. I walk on the side of my foot and the toes are not flat on the ground.

The American Orthopedic Foot and Ankle Society (AOFAS) says, "The surgical procedure for a foot drop is called a tendon transfer. In general, a tendon transfer is a procedure in which a tendon (and attached muscle) that is still working is taken from one part of the foot and moved to another part of the foot to try to replace the muscle function that is missing. The most common tendon transferred is the posterior tibial tendon."

Don't Worry, Therapists...

Peter G. Levine
Stronger After Stroke

Saturday, March 14, 2015

I was doing a series of talks - on stroke recovery, natch - in Georgia last week. Someone brought up a concern about my talk that I also heard last time I did a series of talks. Here's a paraphrasing of that concern:

"You're saying that a lot of what we do in the clinic is shown to be ineffective in research. Payers (insurance/Medicare/Medicaid) are going to hear about this and then... I'm afraid we're going to get paid less and have fewer treatment options."

And I laughed. On the inside because out loud would have been rude. But: How silly! To think that insurance companies are listening to researchers about what is and is not effective! Insurance cares about shareholders and Medi"care" cares about keeping costs as low as possible. One thing they care little about: the science.

Therapists, fret not. Things that research indicates are ineffective are still paid for. Consider splinting. These are the rigid pieces of plastic that keep a joint in a certain position.  They are believed to reduce muscle shortening in patients that poster in a flexed potion.

So people like this:

Get one of these...

Emotions and Attitude, Complexities of #50shades of Emotions

Sas Freeman

March 9, 2015

Like many other aspects of stroke emotions attached along the way are also complex, not only for us as the stroke survivor but for the main carer and the whole family.

As the survivors we tend to experience regular pattern of emotions, possibly at different times and often for different lengths of time but the pattern remains pretty much the same. Initially we are in denial, what me? No I haven’t had a stroke and we go through the many reasons in our head why we haven’t had a stroke, none of them obviously valid. Having come out the other side of this one we find ourselves dealing with the WHY, why me and we go through the 50 reasons plus why we shouldn’t be in this position before moving onto the anger stage. I have possibly touched on these in such a way, that it has almost made light of them, but they are heavy emotions that take time to work through, often needing help to come out the other side.

We are then left with what I term as a fortunate situation, and yes I did say fortunate. There are many conditions where we can only rely on medics and medication. The rest is completely out of our hands. Stroke on the other hand is very much down to us too. Almost a partnership between the medical professional and ourselves, our own efforts.

Technology & #Strokerecovery Tweetchat – Your Views!

Kate Allatt
Stroke Recovery Tips

March 1, 2015

What an amazing tweetchat! Our engagement with you doubled from last month, we all wrote 559 tweets, had 50 participants, received 726,202 impressions, with key influencers were @fightingstrokes, @stroketattler, @dailycaring & @sissstroke.  No wonder my fingers were on fire!  Thank you v much, it was fun and informative.  We were absolutely delighted to receive a tweet from the @natlstrokeassoc (see below)   So here’s what I gleaned from our #strokerecovery & technology tweetchat tonight but feel free to study the symplur #strokerecovery transcript if you like. We asked you:

T1. What technology do you use/offer in #strokerecovery therapy? You said:

• Electrical stimulation albeit it was offered tom slowly in the community at 11 months
• Scheduling apps to coordinate family visits
• Apps to help with aphasia and alarms to take medication
• Wii gaming technology for rehabilitation which also involved your children, though it doesn’t work for everyone.
• Blogging in itself helped keep the brain active and was used in #strokerecovery
• @natlstrokeassoc – ‘Wii, Constraint Therapy, Bioness, WalkAid, Mobile apps for aphasia, Myopro, sling supported treadmills.

Singing and Speaking Aphasia Speech Therapy

March 18 / 2015

Many have asked me about the relationship between speaking and singing and what my opinion was regarding the use of Music therapy as an adjunct to or replacement for speech and language therapy.  

Many have invested a great deal into the process of music therapy and singing and hoping it will have a positive influence on the ability to speak.  Having worked with people who have had brain injury and aphasia, I have explored the use of singing as an adjunct to speech therapy and have found it to be an enjoyable activity that helps build confidence in uttering lyrics from songs once learned, rhythm and melody can also help facilitate some production of words.

Singing is dependent on rote memory that occurs due to the repetition of a given group of words over and over again throughout ones childhood and lifetime. Sometimes the words do not even make sense like many of the songs we grew up with as teenagers, but it did not matter since it was the "melody" that we liked so much.  Being able to repeat a song, or catchy jingle develops through rote repetition.  Singing helps reinforce and stabilize the learning of a song.  It seems like a miracle, doesn't it, when one who is unable to construct a thought with words can sing the words normally?  

Whereas speech is a very different process.  One must gather a thought in the mind, (develop and construct), then go to the brain depository where all the words are (lexicon), and select, in order, the words one wishes to say in a split second and at a "conscious" level with appropriate grammatical structure also.

The Stress of Aphasia and Recovery

Jeff Porter
Stroke of Faith

Thursday, March 12, 2015

When my stroke happened, I couldn't talk. I slowly recovered that ability, but not without some stress, worries and frustration. And, as this story (link below) reminds everyone, aphasia doesn't reduce intelligence.

Check out this story about someone who speaks volumes of stroke rehab - by not saying much at all:

▶ The stroke survivor has spent the last six years learning to speak again, thanks to aphasia, a condition that can range from trouble finding words to losing the ability to speak, read, or write.
▶ It does not affect intelligence. Tom understands exactly what you've said, and in his mind knows what he wants to say - but the message gets scrambled when he opens his mouth to articulate a thought.
▶ "Before...smoke, smoke, smoke," Tom said in describing what likely led to the stroke at just 49. "But now - quit."

See the original article:

The Stress of Aphasia and Recovery

in

Stroke of Faith

PoNS Inspired Therapy

Rebecca Dutton
Home After a Stroke

March 15, 2015

I read about a device called PoNS that delivers mild electric stimulation to the tongue (1).  Thousands of sensory receptors on the tongue send information to the brainstem.  This got my attention because I had a brainstem stroke.  Brain scans and EEG studies found that milliseconds after using PoNS all parts of the brain start to fire.  Brain damaged subjects who used PoNS during therapy got better (e.g. while walking on a treadmill).

I have been aspirating pills into my lungs lately so I decided to gently stroke my tongue with an extra soft toothbrush.  The hemiplegic side of my tongue was numb while the sound side was hypersensitive.  Tongue stimulation produced saliva only when I brushed the sound side.  I turned the toothbrush over to the smooth side and pressed down on my tongue.  The sound side arched up into a hump, but the hemiplegic side stayed flat unless I concentrated fiercely.  I have been blaming my epiglottis for not completely covering the opening to my lungs  - the flap that covers the opening to my lungs when I swallow.  Trying to move food to my throat with a tongue that is numb and floppy on one side cannot be good.

Before I take my morning pills I do tongue stimulation and then sing or read out loud to warm up my tongue and throat muscles.  The 1st time I did tongue stroking I felt a weird sensation on the affected side of my tongue for several hours.  For several days I have safely swallowed numerous pills in the morning.  However, this positive outcome fades by lunch time.  I will continue brushing and pressing down on my tongue to see where this leads.  Gently using an extra soft toothbrush is cheaper than driving 900 miles to Wisconsin where Dr. Yuri Danolov has a PoNS clinic.  My past recovery has confirmed the research on neuroplasticity, so it is worth a try.

1. Doidge N. The Brain's Way of Healing Itself. New York, NY: Penguin Books; 2015.

See the original article:

PoNS Inspired Therapy

in

Home After a Stroke

Blog for April 14 Stroke Recovery Tweet Chat: Patient Engagement

Sharon D. Anderson
Stroke Survivors Tattler

March 16 / 2015

Carolyn Thomas (2013) charges that it’s a stressful time to be a patient these days.  Patients are expected to be empowered and engaged in managing our own health.  Word at some patient engagement conferences is that patients are apathetic: “If only patients were more engaged, more knowledgeable, more compliant, more trusting, more prepared, ask more questions, etc” patients and the health systems would be healthier (Wilkins, 2013).

Never mind that you have just had a stroke and have  been discharged home with several vials of medication,  a cane or walker,  and perhaps a few pamphlets or fact sheets with your diet and  exercise regimes on them.  Moreover, you were likely discharged home earlier than you expected to be.  The notion is that stroke survivors and their care partners need more education and more support to be engaged patients.

Wilkins (2013) also suggests that patients need to be taught to engage. Below is a graphic of the link between teaching patients to communicate and outcomes.  Certainly, these are the outcomes that stroke survivors, care partners, and health professionals want.

What is an Engaged Patient?

Sharon D. Anderson
Stroke Survivors Tattler

March 16 / 2015

What is an engaged patient?

• Patient understands the disease process, and assumes role as the daily self-manager,
• Family and caregivers are engaged in/supportive of patient’s self-management. 

Why are we talking about patient engagement? 

Patient engagement is seen as strategy to:

1. help patients prevent and effectively self-manage  their health (stroke, diabetes,  and other chronic conditions),
2. Improve the patient’s experience with health professionals and their health,
3. Improve the quality of care,
4. Promote population health,  and
5. Contain burgeoning health costs.  

See the Canadian Foundation for Healthcare Improvement Brochure: Patient and Family Engagement: Putting Patients at the Centre of Care.

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