Decompressive surgery in space-occupying hemispheric infarction

Rieke, K.; Schwab, Stefan; Krieger, Derk; Kummer, Rüdiger von; Aschoff, A.; Schuchardt, V.; Hacke, Werner

doi:10.1097/00003246-199509000-00019

Cited by 324 publications

(262 citation statements)

References 31 publications

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“…Only 4 of these 31 patients had signs of uncal haerniation with a unilaterally fixed and dilated pupil. The results compared favourably with those attained in patients previously studied by the same group and operated later (mean 39 hours, range 6 to 112 hours), who exhibited a 34.4% mortality rate 13 . Also, functional evolution (Barthel index and Rankin scale) was better and lenght of stay in the intensive care unit was shorter in the earlyoperation group.…”

supporting

confidence: 50%

Temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report

André

Niemeyer-Filho

2003

Arq. Neuro-Psiquiatr.

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-Objective: To call attention to an unusual complication of decompressive haemicraniectomy in the treatment of malignant haemispheric infarction. Method: We describe a case in which partial decompression occurred despite large craniectomy. Complete decompression followed resection of the temporal muscle. Pertinent literature is briefly reviewed. Case description: A 55-year old woman developed massive right middle cerebral artery infarction evolving to cerebral haerniation in 40 hours. Decompressive haemicraniectomy without cortical excision was unable to revert coma and decerebrate posturing because of a massive temporal muscle haemorrhage with persistent contralateral deviation of midline structures. Muscle resection was followed by adequate external haerniation of the affected haemisphere and fast recovery. Cranioplasty was succesfully performed 22 days later, following gradual regression of cerebral oedema. Conclusion: There is an increasing perception of the need to operate patients with massive middle cerebral or internal carotid artery territory infarctions before the development of coma and cerebral haerniation. The most common factor leading to inadequate surgical decompression is small size craniectomy. The case reported calls attention to temporal muscle bleeding as an additional complication of craniectomy.KEY WORDS: ischaemic stroke, acute cerebral infarct, craniectomy. Hematoma de músculo temporal como causa de inadequada descompressão após hemicraniectomia descompressiva: relato de casoRESUMO -Objetivo: Alertar para o risco de descompressão cirúrgica subótima após hemicraniectomia descompressiva. Método: Revisão da literatura pertinente após descrição de caso clínico exemplificador. Resultados -Descrição do caso: Mulher de 55 anos, com instalação rápida de infarto cerebral no território da artéria cerebral média à direita. Evolução em 40 horas para coma e síndrome de herniação uncal. Tratada com salina hipertônica, hiperventilação e hemicraniectomia descompressiva (sem excisão de tecido cerebral), mantendo, porém, coma e decerebração persistentes. Exame de controle demonstrando volumoso hematoma de músculo temporal, levando a persistente desvio contralateral do segmento anterior do hemisfério afetado. Reoperação após 72 horas (exérese de músculo temporal), com rápida recuperação do nível de consciência e extubação. Controles neurorradiológicos mostrando adequada herniação externa do hemisfério, seguida de lenta regressão do edema cerebral, permitindo cranioplastia após 22 dias da primeira cirurgia. Conclusão: Progressivamente torna-se clara a importância potencial da cirurgia descompressiva. Estudos recentes sugerem maior benefício em casos de cirurgia precoce (de preferência antes da instalação de herniação cerebral) e de grandes craniectomias com descompressão completa para a evolução favorável de pacientes com infarto cerebral maciço. Hematoma de músculo temporal pode constituir causa não rara de descompressão incompleta. PALAVRAS-CHAVE: acidente vascular cerebral agudo, craniectomia de...

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supporting

confidence: 50%

Temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report

André

Niemeyer-Filho

2003

Arq. Neuro-Psiquiatr.

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“…Si se espera la aparición de signos clínicos de una hernia cerebral, la mortalidad es de 35% 22 . Si se realiza antes de las 24 h, basándose en la clínica y la TC, desciende a 16% 21 .…”

Section: Tabla 2 Tratamiento Médico Del Imacmunclassified

Hemicraniectomía descompresiva en dos pacientes con infarto maligno de la arteria cerebral media

et al. 2005

Rev. méd. Chile

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Malignant middle cerebral territory infarction represents 5 to 10% of all brain infarctions. Its mortality is 80%, due to brain herniation and it is not reduced byL a enfermedad cerebrovascular es la tercera causa de muerte y la etiología más frecuente de invalidez en el mundo 1 . El 80% corresponde a infartos encefálicos. En las últimas décadas se ha logrado un gran avance en el tratamiento del infarto encefálico, fundamentalmente con la creación de unidades especializadas en su tratamiento (unidades de stroke) y la trombólisis intravenosa 2 . El infarto maligno de la arteria cerebral media (IMACM), debido a su extensión y a la aparición de edema secundario, produce hernias cerebrales que pueden provocar la muerte en hasta 80% de los casos 3,4 . En los últimos años, esta elevada mortalidad ha sido reducida con el uso de técnicas quirúrgicas precoces y, lo que es más importante, con una morbilidad menor a la esperada.A continuación presentamos dos pacientes con IMACM del hemisferio no dominante, que fueron sometidos a una hemicraniectomía descompresiva (HD). Ambos sobrevivieron y a los dos años realizan una vida autovalente en sus domicilios.

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“…These patients usually show a rapid decline in consciousness and develop signs of herniation 2-4 days after the onset of symptoms. Outcome is fatal in the majority of these patients, with a mortality of about 80% with standard treatment 150,151 .…”

Section: Ischemic Brain Edemamentioning

confidence: 99%

“…More than 80% of these patients die despite maximal conservative treatment. In selected cases, hemicraniectomy may be lifesaving and may improve outcome 150,151 .…”

Section: Malignant Middle Cerebral Artery (Mca) Infarctionmentioning

confidence: 99%

“…This mortality is due to the development of occlusive hydrocephalus or direct brainstem compression. In these patients, decompressive surgery of the posterior fossa is significantly superior to ventriculostomy 151,152 . It should be noted that these are the results of open small-or medium-sized case series, so data from a controlled, randomized trial are needed.…”

Section: Cerebellar Infarctionmentioning

confidence: 99%

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Recommendations for Stroke Management

Demarin¹,

Lovrenčić-Huzjan²,

Šerić³

et al. 2000

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Decompressive surgery in space-occupying hemispheric infarction

Abstract: Hemicraniotomy may improve survival in massive hemispheric stroke victims, decreasing mortality rates to < 35%. The disability rate remains high (24%), although some patients seem to benefit significantly.

Cited by 324 publications

References 31 publications

Temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report

Temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report

Hemicraniectomía descompresiva en dos pacientes con infarto maligno de la arteria cerebral media

Recommendations for Stroke Management

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