Early Hemicraniectomy in Patients With Complete Middle Cerebral Artery Infarction

Abstract

Background and Purpose-Malignant, space-occupying supratentorial ischemic stroke is characterized by a mortality rate of up to 80%. Several reports indicate a beneficial effect of hemicraniectomy in this situation. However, whether and when decompressive surgery is indicated in these patients is still a matter of debate. Methods-In an open, prospective trial we performed hemicraniectomy in 63 patients with acute complete middle cerebral artery infarction. Initial clinical presentation was assessed by the Scandinavian Stroke Scale (SSS) and the Glasgow Coma Scale (GCS). All survivors were reexamined 3 months after surgical decompression, with the clinical evaluation graded according to the Rankin Scale (RS) and Barthel Index (BI). We analyzed the influence of early decompressive surgery (Ͻ24 hours after symptom onset, based on clinical status at admission and initial CT findings) versus late surgery (Ͼ24 hours after first reversible signs of herniation) on mortality, functional outcome, and the length of time of critical care therapy was needed. Results-In total, 46 patients (73%) survived. Despite complete hemispheric infarction, no survivor suffered from complete hemiplegia or was permanently wheelchair bound. In patients with speech-dominant hemispheric infarction (nϭ11), only mild to moderate aphasia was present. The mean BI score was 65, and RS score revealed severe handicap in 13% of the patients. In 31 patients with early decompressive surgery, mortality was 16% and BI score 68.8. Early hemicraniectomy led to a significant reduction in the length of time critical care therapy was needed (7.4 versus 13.3 days, PϽ0.05). Conclusions-In general, the outcome of patients treated with craniectomy in severe ischemic hemispheric infarction was surprisingly good. In addition, early decompressive surgery may further improve outcome in these patients. (Stroke. 1998;29:1888-1893.)

Novel Treatment Targets for Cerebral Edema

“…Historically, there has been reluctance to perform this operation because of a high rate of mortality and profound morbidity in survivors. Until recently, only case series and nonrandomized case-control studies suggested any benefit of decompressive craniectomy [39][40][41][42][43]. Several recent randomized controlled trials have demonstrated improved survival after decompressive craniectomy in certain stroke populations [6,[44][45][46].…”

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

“…The technique for decompressive haemicraniectomy is already well established 10,11 . It includes the A B remotion of a large (≥ 12 cm) bone flap with a circular or oval shape including the frontal, parietal, temporal and parts of the occipital squamae (with special care to avoid producing sharp bone edges); fixation of the dura at the edge of the craniectomy to prevent epidural bleeding; opening of the dura (usually one longitudinal and three radial incisions almost reaching the osseous rim) and placement of a dural patch made of lyophilised cadaver dura or more recently microporic poliester-uretane (Neuro-Patch ® ) in the incision.…”

“…In an open study 11 of 63 patients with complete MCA territoy strokes -with or without additional anterior or posterior artery territory infarction -those operated early (mean time from onset 21 hours, range 8 to 42 hours), had a 16%mortality rate. Only 4 of these 31 patients had signs of uncal haerniation with a unilaterally fixed and dilated pupil.…”

Protein microarray analysis identifies key cytokines associated with malignant middle cerebral artery infarction

“…A previous work has suggested that early craniectomy may be more effective since a reduction in mortality from 27% to 16% can be caused by stepwise reduction in time from 39 to 21 hours between surgery and stroke onset (Schwab, 1998).…”