Large Size Hemicraniectomy Reduces Early Herniation in Malignant Middle Cerebral Artery Infarction

Abstract

Background: Decompressive hemicraniectomy (DHC) reduces mortality and improves outcome after malignant middle cerebral artery infarction (MMI) but early in-hospital mortality remains high between 22 and 33%. Possibly, this circumstance is driven by cerebral herniation due to space-occupying brain swelling despite decompressive surgery. As the size of the removed bone flap may vary considerably between surgeons, a size too small could foster herniation. Here, we investigated the effect of the additional volume created by an extended DHC (eDHC) on early in-hospital mortality in patients suffering from MMI. Methods: We performed a retrospective single-center cohort study of 97 patients with MMI that were treated either with eDHC (n = 40) or standard DHC (sDHC; n = 57) between January 2006 and June 2012. The primary study end point was defined as in-hospital mortality due to transtentorial herniation. Results: In-hospital mortality due to transtentorial herniation was significantly lower after eDHC (0 vs. 11%; p = 0.04), which was paralleled by a significantly larger volume of the craniectomy (p < 0.001) and less cerebral swelling (eDHC 21% vs. sDHC 25%; p = 0.03). No statistically significant differences were found in surgical or non-surgical complications and postoperative intensive care treatment. Conclusion: Despite a more aggressive surgical approach, eDHC may reduce early in-hospital mortality and limit transtentorial herniation. Prospective studies are warranted to confirm our results and assess general safety of eDHC.

Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke

“…DHC was performed in a standardized fashion and is described elsewhere in detail. 4,[7][8][9] Anesthesia was maintained with propofol and remifentanil. Mean arterial blood pressure was targeted between 70 and 80 mmHg.…”

“…So far, only few recent reports exist regarding outcome after DHC for treatment of MHS and most have rather focused on early or general mortality and not on longterm neurological disability as a primary outcome measure. 7,[12][13][14] Due to the far-reaching consequences of MHS, however, we believe that the decision to perform DHC should not just be based on the patient's chance to merely survive, but rather on the chance to reach an individually acceptable long-term outcome. 15 Since the purpose of our present study was not to confirm or reject the general indication for surgery like in the RCTs on MHS but rather to retrospectively identify non-modifiable risk factors for a higher degree of long-term neurological disability following DHC, we selected an mRS cut-off between 3 and 4, which according to recent surveys, most patients and physicians would consider acceptable.…”

“…Naturally, one would therefore expect that the size of an MHS would also influence long-term outcome in patients undergoing DHC, since the amount of volume created through the bone flap appears to be directly associated with the risk of transtentorial herniation due to the space-occupying effect of edema. 7 However, the link between the volume of an MHS and clinical outcome following DHC has not yet been investigated. Interestingly, we found that only thalamic involvement by itself and not categorical involvement of additional vascular territories was an independent predictor of unfavorable outcome, which is most likely explained by the decreased level of consciousness and marked motor dysfunction of interhemispheric connectivity and dementia reported in thalamic stroke.…”

Clinical Significance of Decompressive Craniectomy Surface Area and Side

“…Many studies have reported benefits and limitations of DC and compared surgical effects according to causative diseases 15,24,39) . Some reports insist that DC should be as large as possible or bone fragment to be removed should be at least 12×15 cm in size or have a diameter of 15 cm 8,29,31) .…”

Złośliwy obrzęk mózgu leczony kompleksowo i skutecznie – opis dwóch przypadków

“…Dowiedziono związku pomiędzy średnicą wykonanej kraniektomii a objętością uzyskiwaną poprzez jej przeprowadzenie dla obrzękniętego mózgu oraz efektami leczenia. Wykazano ponadto, że wraz ze wzrostem średnicy kraniektomii, przy mniejszej wysokości wstawiania się mózgowia uzyskuje się większe, dodatkowe objętości [43,44,45]. Efekt ten ma niebagatelne znaczenie w przeciwdziałaniu powstawania miejscowych uszkodzeń kory na granicy otwarcia kostnego [46].…”