Space-expanding flap in decompressive hemicraniectomy for stroke

Abstract

OBJECTIVE Decompressive hemicraniectomy (DCE) is the standard of care for space-occupying malignant infarction of the medial cerebral artery in suitable patients. After DCE, the brain is susceptible to trauma and at risk for the syndrome of the trephined. This study aimed to assess the feasibility of using temporary space-expanding flaps, implanted during DCE, to shield the brain from these risks while permitting the injured brain to expand. METHODS The authors performed a prospective feasibility study to analyze the safety of space-expanding flaps in 10 patients undergoing DCE and evaluated clinical and radiological outcomes. RESULTS The relatives of 1 patient withdrew consent, leaving 9 patients in the final analysis. No patients required removal of the space-expanding flap because of uncontrolled increase of intracranial pressure or infection. One patient required additional external ventricular drainage and 1 received mannitol. The mean (range) midline shift decreased from 6.67 (3–12) mm to 1.26 (0–2.6) mm after DCE with the space-expanding flap. The authors observed no cases of sinking skin flap syndrome, other complications, or deaths. One patient underwent further treatment due to infection of the reimplanted autologous bone flap. Two patients later refused cranioplasty, preferring to keep the space-expanding flap and thus avoid the potential risks of cranioplasty. CONCLUSIONS This feasibility study showed that the concurrent use of space-expanding flaps appeared to be safe in patients who underwent DCE for malignant infarction of the medial cerebral artery. Moreover, space-expanding flaps may permit patients to avoid a second surgery for reimplantation of the autologous bone flap and the risks inherent to this procedure.

How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling single-stage surgery

“…In our view though the potential upsides of only having one surgical procedure as well as protection of the brain from outside influences are worth to be further explored. In a small series of patients ( Schucht et al., 2022 ) on a single stage procedure with a space-expanding flap implanted to protect the brain no complications that would not also be expected in two-stage procedures were observed, though this will have to be confirmed in larger cohorts.…”

“…Several novel single-stage surgical strategies using hinge-craniotomies, ladder-fixation, and overlaying titanium meshes provide brain protection and some degree of additional space for the brain to swell ( Hsu et al., 2019 ; Stoner et al., 2016 ; Wong and Wong, 2021 ; Layard Horsfall et al., 2020 ). Most recently, a refined single-stage strategy using a custom-made, overlying Palacos® flap has been proposed ( Schucht et al., 2022 ). All these strategies share the goal of providing sufficient space for the injured brain to expand safely, while avoiding the risk of trauma, the syndrome of the trephined, and the inconvenience and side effects of a second surgery.…”