Outcome after External Decompression for Massive Cerebral Infarction

Abstract

Acute ischemic stroke involving the entire vascular distribution of a carotid or middle cerebral artery can cause massive cerebral edema. This study evaluated external decompression for the treatment of massive stroke and analyzed possible prognostic factors. Twenty-four patients with acute massive cerebral infarction, which had progressed to tentorial herniation and impending death, underwent ex ternal decompression after medical therapy failed to achieve an effective response. The neurological outcome 2 months after surgery using the Glasgow Outcome Scale was severe disability in 14 patients, vegetative state in two, and death in eight. The overall mortality was 33%. Various characteristics (age, sex, etiology, side of hemispheric infarction, pupillary asymmetry, Japan Coma Scale, distribution of in farction, hemorrhagic infarction, midline shift, tentorial herniation) were evaluated to determine the factors associated with high mortality after surgical intervention. There was no statistically significant relationship between any variable and mortality. Mortality was especially high in the patients with preoperative consciousness level of 200, anterior, middle, and posterior cerebral artery territory infarc tion, and stage III of tentorial herniation. Postoperatively, all patients with severe disability returned to a clear level of consciousness.Six patients with dominant hemisphere stroke had some measure of communicative skills in spite of aphasia. External decompression is a life-saving treatment for pa tients with massive cerebral infarction and can provide a reasonable quality of life even for those with dominant hemisphere strokes. Decompressive surgery should be considered and performed as soon as possible if computed tomography demonstrates signs of descending tentorial herniation.

Guidelines for the Early Management of Adults With Ischemic Stroke

“…465,466 Decompressive surgery, including hemicraniectomy and durotomy with temporal lobe resection, remains the most attractive option for ischemic brain swelling. [692][693][694][695][696][697][698][699][700][701] Timing of surgery is poorly defined, with some opting for early (within 24 hours) intervention. 702 Recent studies have found that decompressive craniectomy may have a less favorable outcome than suggested.…”

Hemicraniectomy for Massive Middle Cerebral Artery Territory Infarction

“…4 Since that time, several case series or case reports have reported improved survival of patients after craniectomy, but no definitive conclusion has been reached as to any benefit in functional outcomes. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] The largest case series 5 suggested that early decompression (ie, Ͻ24 hours) reduces mortality and may provide improved outcomes by avoiding the consequences of brainstem compression from transtentorial herniation. Patients who underwent early hemicraniectomy had a mortality rate of 16% compared with 34% for delayed surgery.…”

Coma scales: a historical review

“…Various other scales have been developed, some of which are seldom used outside their country of origin 14 . Examples of these are the Innsbruck coma scale 6 and the Japanese scale 15 . They all generally involve assessing the patient and awarding a score that gives an overall idea of their level of consciousness.…”