External decompressive craniectomy including resection of temporal muscle and fascia in malignant hemispheric infarction

Park, Jaechan; Kim, Ealmaan; Kim, Gyoung Ju; Hur, Yun Kyung; Guthikonda, Murali

doi:10.3171/2008.4.17540

Cited by 42 publications

(42 citation statements)

References 3 publications

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“…20% of the operated patients died. Although 60% of the survivors showed an mRS <4, 20% remained severely disabled and dependent (mRS ≥4) in a 6 months follow-up assessment [45]. …”

Section: Surgical Treatmentmentioning

confidence: 99%

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Zweckberger¹,

Jüettler

Bösel

et al. 2014

Cerebrovasc Dis

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Background: Space-occupying malignant stroke of the middle cerebral artery (MCA) is associated with a high mortality rate of up to 80% under conservative treatment. Although there is convincing evidence that decompression craniectomy can significantly reduce mortality rate and improve neurological outcome in young patients (<60 years), many surgeons are still hesitant to recommend hemicraniectomy for stroke patients. Summary: This review addresses some major issues that appear to be an obstacle to decompression craniectomy, in particular, indicating surgery for patients >60 years or with infarcts of the dominant hemisphere. Furthermore, it emphasizes technical issues such as timing and size of the craniectomy, additional temporal lobectomy, and resection of the temporal muscle, as well as duraplasty and cranioplasty. According to the current literature, decompression craniectomy in older patients can increase survival without most severe disabilities, although, most survivors need assistance in most bodily needs. Involvement of the dominant hemisphere results in aphasia that might partly recover in younger patients, although, considering the neuropsychological deficits caused by infarctions of the nondominant hemisphere, involvement of the dominant hemisphere does not pose as a contraindication for decompression craniectomy. Furthermore, there is convincing evidence that surgery should be performed within 48 h after the onset of symptoms and the size of the craniectomy should be at least 12 cm as a minimum. An additional lobectomy or the resection of the temporal muscle, however, can only be part of individual treatment options. Conceding the weak evidence, it is recommended to close the dura by some form of a duraplasty avoiding cerebrospinal fluid leakages or scarring between the cortex and the scalp leading to injuries during reimplantation of the bone-flap. Complications associated with decompression surgery (hemorrhages, infections, ‘sinking skin-flap syndrome', cerebrospinal fluid leakages, hydrocephalus, seizures), with the infarction itself, or with those that occur during the ICU course (cardiac and pulmonary complications) appear acceptable and are mostly treatable, especially considering the fatal course of conservative treatment. Key Message: This review summarizes the current state of the literature about decompression craniectomy of patients with malignant stroke addressing, in particular, critical surgical issues, and thus, help surgeons to make decisions confidently for/or against performing surgery.

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“…20% of the operated patients died. Although 60% of the survivors showed an mRS <4, 20% remained severely disabled and dependent (mRS ≥4) in a 6 months follow-up assessment [45]. …”

Section: Surgical Treatmentmentioning

confidence: 99%

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Zweckberger¹,

Jüettler

Bösel

et al. 2014

Cerebrovasc Dis

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“…In another attempt to control ICP, Park et al 11) thought that the temporal muscle and fascia were significant limiting factors that contributed to the external herniation of the edematous brain. Therefore, they performed a decompressive craniectomy and expansive duroplasty combined with resection of the temporal muscle and fascia for patients with a malignant hemispheric infarction.…”

Section: Discussionmentioning

confidence: 99%

“…This procedure is intended to increase the volume of space to accommodate brain swelling 2,16) . Although the outcomes of decompressive craniectomy have been improving, there are several problems associated with decompressive craniectomy, such as the need for secondary cranioplasty, storage of the bone flap, compression due to temporal muscle swelling, and complications related to the absence of a bone flap 6,11,13) . For cranioplasty with an autologus bone flap or resin, neurosurgeons must dissect the previous operation field very carefully, which is very troublesome.…”

Section: Introductionmentioning

confidence: 99%

In Situ Floating Resin Cranioplasty for Cerebral Decompression

Ahn

Kim

Kang

2009

J Korean Neurosurg Soc

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J Korean Neurosurg Soc 46 : [417][418][419][420] 2009 The purpose of this report is to describe our surgical experiences in the treatment of cerebral decompression with in situ floating resin cranioplasty. We included in this retrospective study 7 patients who underwent in situ floating resin cranioplasty for cerebral decompression between December 2006 and March 2008. Of these patients, 3 patients had traumatic brain injury, 3 cerebral infarction, and one subarachnoid hemorrhage due to aneurysmal rupture. In situ floating resin cranioplasty for cerebral decompression can reduce complications related to the absence of a bone flap and allow reconstruction by secondary cranioplasty without difficulty. Furthermore, it provides cerebral protection and selectively eliminates the need for secondary cranioplasty in elderly patients or patients who have experienced unfavorable outcome.

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“…The concept and surgical technique used to achieve this maximal external decompression were previously reported as a technical note by the current authors. 16 The hemicraniectomy involved the removal of a large fronto-temporo-parietal bone flap with an anteroposterior diameter of > 14 cm. In addition, the temporalis muscle and fascia were resected at the level of the zygomatic arch.…”

Section: Maximal and Timely Surgical Decompressionmentioning

confidence: 99%