Decompressive hemicraniectomy for malignant middle cerebral artery infarction including patients with additional involvement of the anterior and/or posterior cerebral artery territory—outcome analysis and definition of prognostic factors

Kürten, Sven; Munoz, Christopher; Beseoglu, Kerim; Fischer, Igor; Perrin, Jason; Steiger, Hans‐Jakob

doi:10.1007/s00701-017-3329-3

Cited by 25 publications

(17 citation statements)

References 16 publications

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“…In Kürten and colleague's trial [18], 22.8% of patients recovered to moderate disability (mRS 3) at 3-month follow-up, 44.6% remained with moderate-severe disability (mRS 4), and 32.6% suffered a poor outcome (mRS 5).…”

Section: Discussionmentioning

confidence: 98%

Decompressive craniectomy in malignant hemispheric infarction: favorable outcome and disability

Elsayed

2019

Egypt J Neurol Psychiatry Neurosurg

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Context: Patients with malignant middle cerebral artery (MCA) infarction are prone to a mortality rate of 70-80%. Decompressive craniectomy (DC) has been used as an important treatment modality to control refractory intracranial hypertension. Aim: In this study, we aimed to evaluate the impact of DC in reducing mortality rate and improving the functional outcome in the patients who underwent DC surgery for malignant MCA infarction Settings and design: The prospective clinical case study included 24 patients with refractory intracranial hypertension due to malignant MCA infarction Patients and methods: All patients enrolled in the study have refractory intracranial hypertension due to malignant MCA infarction; they were allocated to undergo decompressive craniectomy between 2014 and 2017. Each patient was evaluated clinically using the Glasgow Coma Scale (GCS) and the modified Rankin Scale (mRS). Results: All patients on admission have the GCS of 5-12 score (mean 8). Fourteen patients underwent DC in the first 48 h while 10 patients were operated upon after 48 h. Postoperatively, two patients (9%) had a score of 3 on the modified Rankin Scale, six patients (25%) had a score of 4, and eight patients (33%) had a score of 5. Mortality occurred in eight patients (33%) with the worst score of 6. Similar unfavorable outcome was reported at 6-and 12-month follow-up with different degrees of disability. Conclusion: Decompressive craniectomy for malignant MCA infarction has an effective role in decreasing the mean intracranial pressure, reducing the mortality rate, and increasing the number of patients with a favorable outcome.

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Section: Discussionmentioning

confidence: 98%

Decompressive craniectomy in malignant hemispheric infarction: favorable outcome and disability

Elsayed

2019

Egypt J Neurol Psychiatry Neurosurg

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“…The therapeutic consequences of elevated ICP can be variable: Paldor and co-workers reported frequent episodes of intracranial hypertension after DC, which were treated with intensive care measures such as drainage of cerebrospinal fluid, modification of sedation, hyperosmotic therapy, cooling, head elevation, and moderate hyperventilation [43]. In the studies of Schwake and co-workers as well as Kürten and co-workers raised ICP after DC even triggered secondary debridement of infarcted tissue, and this intervention was found to at least reduce case fatality rates [44, 45].…”

Section: Supratentorial Malignant Ischemic Stroke In Adultsmentioning

confidence: 99%

Decompressive craniectomy for acute ischemic stroke

et al. 2019

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Malignant stroke occurs in a subgroup of patients suffering from ischemic cerebral infarction and is characterized by neurological deterioration due to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique aiming to open the “closed box” represented by the non-expandable skull in cases of refractory intracranial hypertension. It is a valuable modality in the armamentarium to treat patients with malignant stroke: the life-saving effect has been proven for both supratentorial and infratentorial DC in virtually all age groups. This leaves physicians with the difficult task to decide who will require early or preemptive surgery and who might benefit from postponing surgery until clear evidence of deterioration evolves. Together with the patient’s relatives, physicians also have to ascertain whether the patient will have acceptable disability and quality of life in his or her presumed perception, based on preoperative predictions. This complex decision-making process can only be managed with interdisciplinary efforts and should be supported by continued research in the age of personalized medicine.

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“…[21,29,31,37] Some elements of strokectomy are already used such as supratentorial resection of infarcted brain tissue including the temporal pole as an adjuvant procedure following hemicraniectomy either to control ICP intraoperatively or when there is a refractory rise in ICP. [20,[23][24][25]35] Strokectomy as a primary surgical procedure where the bone flap is replaced has been described in small series. [20,22,38] Our technique is slightly different and craniotomies in our strokectomy group were significantly smaller when compared to those who underwent hemicraniectomy.…”

Section: Discussionmentioning

confidence: 99%

“…2). In the remaining eight, full texts were assessed for eligibility and 5 were excluded because they did not include strokectomy as a primary procedure for the treatment of malignant MCA infarction [5,[23][24][25]35]. We included three studies [20,22,38] with a total of 37 patients.…”

Section: Systematic Review and Meta-analysismentioning

confidence: 99%

Strokectomy for malignant middle cerebral artery infarction: experience and meta-analysis of current evidence

et al. 2020

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Strokectomy means surgical excision of infarcted brain tissue post-stroke with preservation of skull integrity, distinguishing it from decompressive hemicraniectomy. Both can mitigate malignant middle cerebral artery (MCA) syndrome but evidence regarding strokectomy is sparse. Here, we report our data and meta-analysis of strokectomy compared to hemicraniectomy for malignant MCA infarction. All malignant MCA stroke cases requiring surgical intervention in a large tertiary centre (January 2012–December 2017, N = 24) were analysed for craniotomy diameter, complications, length of follow-up and outcome measured using the modified Rankin score (mRS). Good outcome was defined as mRS 0–3 at 12 months. In a meta-analysis, outcome from strokectomy (pooled from our cohort and published strokectomy studies) was compared with hemicraniectomy (our cohort pooled with published DECIMAL, DESTINY and HAMLET clinical trial data). In our series (N = 24, 12/12 F/M; mean age: 45.83 ± 8.91, range 29–63 years), 4 patients underwent strokectomy (SC) and 20 hemicraniectomy (HC). Among SC patients, craniotomy diameter was smaller, relative to HC patients (86 ± 13.10 mm, 120 ± 4.10 mm, respectively; p = 0.003), complications were less common (25%, 55%) and poor outcomes were less common (25%, 70%). In the pooled data (N = 41 SC, 71 HC), strokectomy tended towards good outcome more than hemicraniectomy (OR 2.2, 95% CI 0.99–4.7; p = 0.051). In conclusion, strokectomy may be non-inferior, lower risk and cost saving relative to hemicraniectomy sufficiently to be worthy of further investigation and maybe a randomised trial.

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Decompressive hemicraniectomy for malignant middle cerebral artery infarction including patients with additional involvement of the anterior and/or posterior cerebral artery territory—outcome analysis and definition of prognostic factors

Cited by 25 publications

References 16 publications

Decompressive craniectomy in malignant hemispheric infarction: favorable outcome and disability

Decompressive craniectomy in malignant hemispheric infarction: favorable outcome and disability

Decompressive craniectomy for acute ischemic stroke

Strokectomy for malignant middle cerebral artery infarction: experience and meta-analysis of current evidence

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