Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful?

Poca, María A.; Benejam, Bessy; Sahuquillo, Juan; Riveiro, Manuel; Frascheri, Laura; Merino, Maria; Delgado, Pilar; Alvarez-Sabin, José

doi:10.3171/2009.7.jns081677

Cited by 97 publications

(64 citation statements)

References 36 publications

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“…While many physicians on neuro intensive care units support ICP monitoring in unconscious patients, it is still debatable whether an ICP-targeted therapy might improve outcome of stroke patients. Poca et al could not prove any advantage of ICP monitoring in comparison to clinical examinations and CT scanning [15]. Medical treatment of cerebral edema mainly consists of osmotherapy with mannitol or hypertonic saline, sedation, and eventually hyperventilation, buffers, or hypothermia [16,17].…”

Section: Conservative 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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Section: Conservative Treatmentmentioning

confidence: 99%

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Zweckberger¹,

Jüettler

Bösel

et al. 2014

Cerebrovasc Dis

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“…The clinical deterioration from tissue shifts precedes increased global ICP level. Therefore, monitoring has little utility in early selection of patients for surgical decompression [68,69]. Similarly, tissue shifts can be clinically significant and may not display concomitant elevation in ICP [67][68][69], limiting its use for driving osmotic therapy.…”

Section: Neurocritical Care Of MMImentioning

confidence: 96%

“…Similarly, tissue shifts can be clinically significant and may not display concomitant elevation in ICP [67][68][69], limiting its use for driving osmotic therapy. Though counterintuitive, ICP spikes are not uniformly present in all patients who suffered MMI despite the fact that ICP spikes (which can be present in up to ¾ of surgically decompressed patient) have been correlated with poor outcomes [67][68][69][70]. Prospective studies are needed to clarify the significance of ICP spikes and ICP targeted interventions in this patient population.…”

Section: Neurocritical Care Of MMImentioning

confidence: 97%

Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions

Maciel

Sheth

2015

Curr Atheroscler Rep

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Despite a decline over the past decade in overall stroke mortality, hemispheric strokes retain a strikingly high mortality due to their potential for malignant edema and herniation. The pathogenesis of ischemic cerebral edema is steered by disruption of ionic homeostasis in the neurogliovascular unit. Significant effort has been made to identify potential medical therapies targeting edema formation with promising results. To date, decompressive craniectomy remains the therapy with the most robust impact on mortality. Historically, patient selection for surgical treatment of malignant supratentorial strokes has focused on a strict age cutoff and hemispheric dominance. Recent evidence supports a significant mortality benefit in elderly population, although the impact in morbidity is modest. Careful patient selection for surgical treatment in conjunction with comprehensive neurocritical care and inclusion of family in the educated decision making process remain the mainstay of care for such shattering disease.

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“…However, ICP readings can be misleading in the setting of MMI and there is insufficient evidence at this time as to how this may affect outcome. 29 …”

Section: Post-operative Decompressionmentioning

confidence: 97%