Newly Suggested Surgical Method of Decompressive Craniectomy for Patients With Middle Cerebral Artery Infarction

Chung, Joonho; Bang, Oh Young; Lim, Yong Cheol; Park, Soo Young; Shin, Yong Sam

doi:10.1097/nrl.0b013e3181f4ec88

Cited by 27 publications

(19 citation statements)

References 18 publications

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“…Furthermore, perioperative blood loss, postoperative infections, duration of intubation and time to rehabilitation did not differ between groups, which is in line with a previous report on 60 patients who were treated with sDHC in 2001 and a recent publication from 2011 on 25 patients with large craniectomies, where surgical revision was necessary in only 1 patient because of an epidural hematoma [12,28] . In contrast to our protocol, however, in both these studies, DHC was performed as a rescue treatment at a time when signs of herniation were already present.…”

Section: Discussionsupporting

confidence: 88%

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

Neugebauer

Fiss²,

Pinczolits³

et al. 2016

Cerebrovasc Dis

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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.

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Section: Discussionsupporting

confidence: 88%

“…More than the technique of DHC, the dimensions of the removed bone flap are considered crucial, since they define the amount of additionally created volume for the swollen brain to occupy [10][11][12][13][14]. Using mathematical formulas, this volume can be estimated.…”

Section: Introductionmentioning

confidence: 99%

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

Neugebauer

Fiss²,

Pinczolits³

et al. 2016

Cerebrovasc Dis

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“…Likewise, these results are supported by a prospective study of Kilincer et al identifying sings of herniation as a prognostic factor for poor outcome [31], and by several retrospective trials [32,33,34]. Furthermore, in the studies of Skoglund et al (n = 18) and Chung et al (n = 24) 67 and 100% of patients, respectively, showed signs of herniation, leading to worse neurological outcomes compared to the results of the DECIMAL and DESTINY trials [8,9,35,36]. …”

Section: Surgical Treatmentmentioning

confidence: 99%

“…In a recently published study, Chung et al could demonstrate that a maximal size of decompression craniectomy (>14-16 cm or >399 cm 2 ) versus a large size (>12 cm or 308 cm 2 ) increases the ratio of a favorable outcome 3 months after stroke (mRS ≤3) and decreases the ratio of poor outcomes or deceased patients [36]. …”

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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“…Decompressive craniectomy (DC) is an important method to decreased ICP,9) and DC is widely performed throughout the world 10). This surgical procedure is performed by any neurosurgeons or even residents under training, so it should achieve enough decompression without interoperator differences, but textbook only commented that "the bone flap should not be just as large as possible" 3). The authors considered that the skin incision could interfere the size of enough decompression area, and considered new skin incision technique what we called the "n-shaped skin incision".…”

Section: Introductionmentioning

confidence: 99%

A Faster and Wider Skin Incision Technique for Decompressive Craniectomy: n-Shaped Incision for Decompressive Craniectomy

Yang

Hyun

Oh³

et al. 2016

Korean J Neurotrauma

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ObjectiveDecompressive craniectomy (DC) is a useful surgical method to achieve adequate decompression in hypertensive intracranial patients. This study suggested a new skin incision for DC, and analyzed its efficacy and safety.MethodsIn the retrograde reviews, 15 patients underwent a newly suggested surgical approach using n-shape skin incision technique (Group A) and 23 patients were treated with conventional question mark skin incision technique (Group B). Two groups were compared in the terms of the decompressed area of the craniectomy, protruded brain volume out of the skull layer, the operation time from skin incision to bone flap removal, and modified Rankin Scale (mRS) which was evaluated for 3 months after surgery.ResultsThe decompressed area of craniectomy (389.1 cm2 vs. 318.7 cm2, p=0.041) and the protruded brain volume (151.8 cm3 vs. 116.2 cm3, p=0.045) were significantly larger in Group A compared to the area and the volume in Group B. The time interval between skin incision and bone flap removal was much shorter in Group A (23.3 minutes vs. 29.5 minutes, p=0.013). But, the clinical results were similar between 2 groups. Group A showed more favorable outcome proportion (mRS 0-3, 6/15 patients vs. 5/23 patients, p=0.225) and lesser mortality cases proportion 1/15 patients vs. 4/23 patients, but these differences were not significantly observed (p=0.225 and 0.339).ConclusionDC using n-shaped skin incision was a feasible and safe surgical technique. It may be an easier and faster method for the purpose of training neurosurgeons.

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Newly Suggested Surgical Method of Decompressive Craniectomy for Patients With Middle Cerebral Artery Infarction

Cited by 27 publications

References 18 publications

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

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

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

A Faster and Wider Skin Incision Technique for Decompressive Craniectomy: n-Shaped Incision for Decompressive Craniectomy

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