Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Abstract

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.

Decompressive Hemicraniectomy in Malignant Middle Cerebral Artery Infarction: The ‘Real World' Beyond Studies

“…Moreover, Zweckberger et al [24] summarize that complications after DHC in MMI have never been systematically assessed. We found that patients with MMI who have undergone DHC are prone to a high rate of complications in the acute as well as in the recovery phase.…”

Study on the behavioral changes of a post-stroke depression rat model

“…The rate of stroke-induced disabilities can reach as high as 80% (15). Stroke-induced disabilities can have a serious effect on the daily life of the patient, bring great suffering and place a heavy burden on the family and society (16).…”

Decompressive Craniotomy in the Treatment of Malignant Ischemic Stroke of Cerebral Hemispheres (Review)

“…The most optimal time for subsequent cranioplasty is 1.5-6 months after DC [17,18,89]. In addition, the number of complications reaches 26%: epileptic attacks 15.6%, superficial wound infections 3.1%, hydrocephaly 3.1%, transient neurological impairments 3.1%, and osteomyelitis 2.1% [90].…”

“…The main DC complications in MIS are the following: postoperative epidural hematoma, meningitis, wound infection, parenchymatous brain injury, liquorrhea, hygroma, hemorrhagic conversion of the infarction zone, cosmetic defects [24, 89,98]. All these complications deteriorate MIC course and prognosis, and in some cases can determine the severity of an underlying disease.…”

“…The main causes of death of such patients are the following: pneumonia, deep venous thrombosis of lower extremities, thromboembolia of the pulmonary artery, sepsis, multiple-organ-failure syndrome [89,100].…”