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Seraj FQM, Najafi S, Pahlavan H, Organji H, Baharvahdat H. Unilateral Oculomotor Nerve Palsy as a Rare Manifestation of Isolated Pre-Communicating Segment of Posterior Cerebral Artery Thrombosis. Neurointervention 2023; 18:195-199. [PMID: 37604592 PMCID: PMC10626041 DOI: 10.5469/neuroint.2023.00283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/05/2023] [Accepted: 08/05/2023] [Indexed: 08/23/2023] Open
Abstract
Ipsilateral mydriasis (IM) is usually not acute. However, the acute occurrence of unilateral dilated pupil may result in acute ischemic stroke. Herein, we present 3 patients with IM, lateral eye deviation, ptosis, and contralateral hemiparesis due to isolated occlusion of the pre-communicating segment of the posterior cerebral artery with preservation of the posterior communicating artery, which was successfully treated by emergent mechanical thrombectomy. In a 3-month follow-up, all patients were independent without any neurological deficits.
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Affiliation(s)
- Farid Qoorchi Moheb Seraj
- Section of Endovascular Neurosurgery, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajjad Najafi
- Section of Endovascular Neurosurgery, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Neurosurgery, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hashem Pahlavan
- Section of Endovascular Neurosurgery, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Organji
- Section of Endovascular Neurosurgery, Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Humain Baharvahdat
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
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Lehrieder D, Müller HP, Kassubek J, Hecht N, Thomalla G, Michalski D, Gattringer T, Wartenberg KE, Schultze-Amberger J, Huttner H, Kuramatsu JB, Wunderlich S, Steiner HH, Weissenborn K, Heck S, Günther A, Schneider H, Poli S, Dohmen C, Woitzik J, Jüttler E, Neugebauer H. Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction. J Neurol 2023:10.1007/s00415-023-11766-3. [PMID: 37162579 DOI: 10.1007/s00415-023-11766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION In malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14). METHODS Patients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses. RESULTS Among 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses. CONCLUSION In this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy. CLINICAL TRIAL REGISTRATION INFORMATION German Clinical Trials Register (URL: https://www.drks.de ; Unique Identifier: DRKS00000624).
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Affiliation(s)
- Dominik Lehrieder
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
| | | | - Jan Kassubek
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | | | - Katja E Wartenberg
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
- Department of Neurology, University of Halle-Wittenberg, Halle/Saale, Germany
| | | | - Hagen Huttner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Silke Wunderlich
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Suzette Heck
- Department of Neurology, University of Munich, Ludwig Maximilian University, Munich, Germany
| | - Albrecht Günther
- Department of Neurology, University Hospital Jena, Jena, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, Eberhard-Karls University Tuebingen, Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christian Dohmen
- Department of Neurology, University Hospital Cologne, Cologne, Germany
- Department for Neurology and Neurological Intensive Care, LVR Clinic Bonn, Bonn, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, University Hospital Oldenburg, Oldenburg, Germany
| | - Eric Jüttler
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
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Rodrigues TP, Rodrigues MAS, Bocca LF, Chaddad-Neto FE, Cavalheiro S, Junior EA, Silva GS, Suriano IC, Centeno RS. Decompressive craniectomy index: Does the size of decompressive craniectomy matter in malignant middle cerebral artery infarction? Surg Neurol Int 2022; 13:580. [PMID: 36600778 PMCID: PMC9805638 DOI: 10.25259/sni_895_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Background Malignant middle cerebral artery (MCA) infarction is associated with high mortality, mainly due to intracranial hypertension. This malignant course develops when two-thirds or more of MCA territory is infarcted. Randomized clinical trials demonstrated that in patients with malignant MCA infarction, decompressive craniectomy (DC) is associated with better prognosis. In these patients, some prognostic predictors are already known, including age and time between stroke and DC. The size of bone flap was not associated with long-term prognosis in the previous studies. Therefore, this paper aims to further expand the analysis of the bone removal toward a more precise quantification and verify the prognosis implication of the bone flap area/whole supratentorial hemicranium relation in patients treated with DC for malignant middle cerebral infarcts. Methods This study included 45 patients operated between 2015 and 2020. All patients had been diagnosed with a malignant MCA infarction and were submitted to DC to treat the ischemic event. The primary endpoint was dichotomized modified Rankin scale (mRS) 1 year after surgery (mRS≤4 or mRS>4). Results Patients with bad prognosis (mRS 5-6) were on average: older and with a smaller decompressive craniectomy index (DCI). In multivariate analysis, with adjustments for "age" and "time" from symptoms onset to DC, the association between DCI and prognosis remained. Conclusion In our series, the relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings.
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Affiliation(s)
- Thiago Pereira Rodrigues
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil.,Corresponding author: Thiago Pereira Rodrigues, Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil.
| | | | - Leonardo Favi Bocca
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil
| | | | - Sergio Cavalheiro
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil
| | | | | | - Italo Capraro Suriano
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil
| | - Ricardo Silva Centeno
- Department of Neurology and Neurosurgery, Federal University of Sao Paulo, São Paulo, Brazil
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Sehweil SMM, Goncharova ZA. How I do it: decompressive hemicraniectomy supplemented with resection of the temporal pole and tentoriotomy for malignant ischemic infarction in the territory supplied by the middle cerebral artery. Acta Neurochir (Wien) 2022; 164:1653-1657. [PMID: 35171374 PMCID: PMC9160119 DOI: 10.1007/s00701-022-05152-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/03/2022] [Indexed: 01/28/2023]
Abstract
Abstract Malignant ischemic infarction in the territory supplied by the middle cerebral artery is an extremely severe form of ischemic stroke associated with development of massive uncontrollable postischemic edema of the affected cerebral hemisphere; the end result of which is development of transtentorial herniation and death. Method The surgical technique of performance of decompressive hemicraniectomy involves removal of an extensive bone flap in the fronto-temporo-parieto-occipital zone with resection of the temporal squama and of the greater wing of the sphenoid bone to visualize the level of entrance of the middle meningeal artery to the cranial cavity, which, in its turn, allows resection of the upright margin of the middle cranial fossa. Decompressive hemicraniectomy is supplemented with resection of the temporal pole and tentoriotomy. Conclusion Performance of decompressive hemicraniectomy in combination with resection of the resection of the temporal pole and tentoriotomy is an effective surgical method of treatment of malignant ischemic stroke in the territory supplied by the middle cerebral artery, capable of reducing the lethality rate during the postoperative period. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05152-7.
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Lu W, Jia D, Qin Y. Decompressive craniectomy combined with temporal pole resection in the treatment of massive cerebral infarction. BMC Neurol 2022; 22:167. [PMID: 35501820 PMCID: PMC9063210 DOI: 10.1186/s12883-022-02688-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and prognosis of decompressive craniectomy combined with temporal pole resection in the treatment of massive cerebral infarction, in order to provide basis for treatment selection. METHODS The clinical data of the patient with massive cerebral infarction treated in our hospital from January 2015 to December 2018 were analyzed retrospectively. According to the surgical methods, the patients were divided into control group (decompressive craniectomy) and study group (decompressive craniectomy + temporal pole resection). Intracranial pressure monitoring devices were placed in both groups. The NIHSS scores of the two groups before and 14 days after operation, the changes of intracranial pressure, length of hospital stay, length of NICU, mortality and modified Rankin scale before and after treatment were compared between the two groups. RESULTS The NIHSS score of the two groups after operation was lower than that before operation, and the NIHSS score of the study group was significantly lower than that of the control group (P < 0.05); The intracranial pressure in the study group was significantly lower than that in the control group (P < 0.05); One month after operation, the mortality of the study group (13.0%) was lower than that of the control group (27.8%). After one year of follow-up, the mortality of the study group (21.7%) was significantly lower than that of the control group (38.8%) (P < 0.05); The scores of mRS in the two groups were significantly improved compared with those before treatment (P < 0.05), and the scores of mRS in the study group were better than those in the control group (P < 0.05). CONCLUSION Decompressive craniectomy combined with temporal pole resection has a better effect in the treatment of patients with massive cerebral infarction. It has good decompression effect, the postoperative intracranial pressure is well controlled, and significantly reduced the mortality. So it has better clinical application value.
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Affiliation(s)
- Wenchao Lu
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China
| | - Dong Jia
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China
| | - Yanchang Qin
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China.
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Moughal S, Trippier S, Al-Mousa A, Hainsworth AH, Pereira AC, Minhas PS, Shtaya A. Strokectomy for malignant middle cerebral artery infarction: experience and meta-analysis of current evidence. J Neurol 2022; 269:149-158. [PMID: 33340332 PMCID: PMC8739160 DOI: 10.1007/s00415-020-10358-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/25/2020] [Accepted: 12/04/2020] [Indexed: 11/05/2022]
Abstract
Strokectomy means surgical excision of infarcted brain tissue post-stroke with preservation of skull integrity, distinguishing it from decompressive hemicraniectomy. Both can mitigate malignant middle cerebral artery (MCA) syndrome but evidence regarding strokectomy is sparse. Here, we report our data and meta-analysis of strokectomy compared to hemicraniectomy for malignant MCA infarction. All malignant MCA stroke cases requiring surgical intervention in a large tertiary centre (January 2012-December 2017, N = 24) were analysed for craniotomy diameter, complications, length of follow-up and outcome measured using the modified Rankin score (mRS). Good outcome was defined as mRS 0-3 at 12 months. In a meta-analysis, outcome from strokectomy (pooled from our cohort and published strokectomy studies) was compared with hemicraniectomy (our cohort pooled with published DECIMAL, DESTINY and HAMLET clinical trial data). In our series (N = 24, 12/12 F/M; mean age: 45.83 ± 8.91, range 29-63 years), 4 patients underwent strokectomy (SC) and 20 hemicraniectomy (HC). Among SC patients, craniotomy diameter was smaller, relative to HC patients (86 ± 13.10 mm, 120 ± 4.10 mm, respectively; p = 0.003), complications were less common (25%, 55%) and poor outcomes were less common (25%, 70%). In the pooled data (N = 41 SC, 71 HC), strokectomy tended towards good outcome more than hemicraniectomy (OR 2.2, 95% CI 0.99-4.7; p = 0.051). In conclusion, strokectomy may be non-inferior, lower risk and cost saving relative to hemicraniectomy sufficiently to be worthy of further investigation and maybe a randomised trial.
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Affiliation(s)
- Saad Moughal
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, SW17 0RE, UK
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sarah Trippier
- Neurology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Alaa Al-Mousa
- Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Atticus H Hainsworth
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, SW17 0RE, UK
- Neurology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anthony C Pereira
- Neurology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Pawanjit S Minhas
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anan Shtaya
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, SW17 0RE, UK.
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK.
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Bruno A, Paletta N, Verma U, Grabowska ME, Haughey HM, Batchala PP, Abay S, Donahue J, Vender J, Sethuraman S, Nichols FT. Predicting Functional Outcome After Decompressive Craniectomy for Malignant Hemispheric Infarction: Clinical and Novel Imaging Factors. World Neurosurg 2021; 158:e1017-e1021. [PMID: 34906752 DOI: 10.1016/j.wneu.2021.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is an established optional treatment for malignant hemispheric infarction (MHI). We analyzed relevant clinical factors and computed tomography (CT) measurements in patients with DC for MHI to identify predictors of functional outcome 3-6 months after stroke. METHODS This study was performed at 2 comprehensive stroke centers. The inclusion criteria required DC for MHI, no additional intraoperative procedures (strokectomy or cerebral ventricular drain placement), and documented functional status 3-6 months after the stroke. We classified functional outcome as acceptable if the modified Rankin Scale score was <5, or as unacceptable if it was 5 or 6 (bedbound and totally dependent on others or death). Multiple logistic regression analyzed relevant clinical factors and multiple perioperative CT measurements to identify predictors of acceptable functional outcome. RESULTS Of 87 identified consecutive patients, 66 met the inclusion criteria. Acceptable functional outcome occurred in 35 of 66 (53%) patients. Likelihood of acceptable functional outcome decreased significantly with increasing age (OR 0.92, 95% CI 0.82-0.97, P = 0.004) and with increasing post-DC midline brain shift (OR 0.78, 95% CI 0.64-0.96, P = 0.016), and decreased non-significantly with left-sided stroke (OR 0.30, 95% CI 0.08-1.10, P = 0.069) and with increasing craniectomy barrier thickness (OR 0.92, 95% CI 0.85-1.01, P = 0.076). CONCLUSIONS Patient age and the post-DC midline shift may be useful in prognosticating functional outcome after DC for MHI. Stroke side and craniectomy barrier thickness merit further ideally prospective outcome prediction testing.
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Affiliation(s)
- Askiel Bruno
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA.
| | - Nina Paletta
- Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Uttam Verma
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Monika E Grabowska
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Heather M Haughey
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Prem P Batchala
- Department of Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Solomon Abay
- Department of Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Joseph Donahue
- Department of Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - John Vender
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | | | - Fenwick T Nichols
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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Karasin B, Grzelak M, Rizzo G, Hardinge T, Eskuchen L, Boyce M, Watkinson J. Decompressive Hemicraniectomy for Middle Cerebral Artery Stroke: Indications and Perioperative Care. AORN J 2021; 114:34-46. [PMID: 34181258 DOI: 10.1002/aorn.13430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/15/2020] [Indexed: 11/05/2022]
Abstract
Decompressive hemicraniectomy (DHC) is a procedure performed in the setting of malignant cerebral edema after a large middle cerebral artery stroke. The decision to proceed with surgical decompression is one that must be made judiciously and rapidly. Although this can be a life-saving surgery, it does not necessarily improve the patient's quality of life. The neurosurgical team must thoroughly discuss the patient's comorbidities, age, dominant versus nondominant hemispheric injury, and neurological expectations, and the procedure itself (ie, risks, benefits, expected postoperative course, goals of care) with the patient and his or her family before DHC. This article briefly reviews the anatomy of the brain and stroke presentation and provides an overview of DHC and the perioperative course. The article concludes with a case study of a patient with a medical history of hypertension and prediabetes who presents to the emergency department after a fall and undergoes an emergent DHC.
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Abecassis IJ, Young CC, Caldwell DJ, Feroze AH, Williams JR, Meyer RM, Kellogg RT, Bonow RH, Chesnut RM. The Kempe incision for decompressive craniectomy, craniotomy, and cranioplasty in traumatic brain injury and stroke. J Neurosurg 2021; 135:1807-1816. [PMID: 34020415 DOI: 10.3171/2020.11.jns203567] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is an effective, lifesaving option for reducing intracranial pressure (ICP) in traumatic brain injury (TBI), stroke, and other pathologies with elevated ICP. Most DCs are performed via a standard trauma flap shaped like a reverse question mark (RQM), which requires sacrificing the occipital and posterior auricular arteries and can be complicated by wound dehiscence and infections. The Ludwig Kempe hemispherectomy incision (Kempe) entails a T-shaped incision, one limb from the midline behind the hairline to the inion and the other limb from the root of the zygoma to the coronal suture. The authors' objective in this study was to define their implementation of the Kempe incision for DC and craniotomy, report clinical outcomes, and quantify the volume of bone removed compared with the RQM incision. METHODS A retrospective review of a single-surgeon experience with DC in TBI and stroke was performed. Patient demographics, imaging, and outcomes were collected for all DCs from 2015 to 2020, and the incisions were categorized as either Kempe or RQM. Preoperative and postoperative CT scans were obtained and processed using a combination of automatic segmentation (in Python and SimpleITK) with manual cleanup and further subselection in ITK-SNAP. The volume of bone removed was quantified, and the primary outcome was percentage of hemicranium removed. Postoperative surgical wound infections, estimated blood loss (EBL), and length of surgery were compared between the two groups as secondary outcomes. Cranioplasty data were collected. RESULTS One hundred thirty-six patients were included in the analysis; there were 57 patients in the craniotomy group (44 patients with RQM incisions and 13 with Kempe incisions) and 79 in the craniectomy group (41 patients with RQM incisions and 38 Kempe incisions). The mean follow-up for the entire cohort was 251 ± 368 days. There was a difference in the amount of decompression between approaches in multivariate modeling (39% ± 11% of the hemicranium was removed via the Kempe incision vs 34% ± 10% via the RQM incision, p = 0.047), although this did not achieve significance in multivariate modeling. Wound infection rates, EBL, and length of surgery were comparable between the two incision types. No wound infections in either cohort were due to wound dehiscence. Cranioplasty outcomes were comparable between the two incision types. CONCLUSIONS The Kempe incision for craniectomy or craniotomy is a safe, feasible, and effective alternative to the RQM. The authors advocate the Kempe incision in cases in which contralateral operative pathology or subsequent craniofacial/skull base repair is anticipated.
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Affiliation(s)
| | | | | | | | | | | | - Ryan T Kellogg
- 2Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert H Bonow
- 1Department of Neurological Surgery and
- 3Harborview Injury Prevention Research Center, University of Washington, Seattle, Washington; and
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Bruno A, Paletta N, Verma U, Grabowska ME, Batchala PP, Abay S, Haughey HM, Donahue J, Vender J, Sethuraman S, Nichols FT. Limiting Brain Shift in Malignant Hemispheric Infarction by Decompressive Craniectomy. J Stroke Cerebrovasc Dis 2021; 30:105830. [PMID: 33945955 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/15/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Decompressive craniectomy (DC) improves functional outcomes in selected patients with malignant hemispheric infarction (MHI), but variability in the surgical technique and occasional complications may be limiting the effectiveness of this procedure. Our aim was to evaluate predefined perioperative CT measurements for association with post-DC midline brain shift in patients with MHI. METHODS At two medical centers we identified 87 consecutive patients with MHI and DC between January 2007 and December 2019. We used our previously tested methods to measure the craniectomy surface area, extent of transcalvarial brain herniation, thickness of tissues overlying the craniectomy, diameter of the cerebral ventricle atrium contralateral to the stroke, extension of infarction beyond the craniectomy edges, and the pre and post-DC midline brain shifts. To avoid potential confounding from medical treatments and additional surgical procedures, we excluded patients with the first CT delayed >30 hours post-DC, resection of infarcted brain, or insertion of an external ventricular drain during DC. The primary outcome in multiple linear regression analysis was the postoperative midline brain shift. RESULTS We analyzed 72 qualified patients. The average midline brain shift decreased from 8.7 mm pre-DC to 5.4 post-DC. The only factors significantly associated with post-DC midline brain shift at the p<0.01 level were preoperative midline shift (coefficient 0.32, standard error 0.10, p=0.002) and extent of transcalvarial brain herniation (coefficient -0.20, standard error 0.05, p <0.001). CONCLUSIONS In patients with MHI and DC, smaller post-DC midline shift is associated with smaller pre-DC midline brain shift and greater transcalvarial brain herniation. This knowledge may prove helpful in assessing DC candidacy and surgical success. Additional studies to enhance the surgical success of DC are warranted.
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Affiliation(s)
- Askiel Bruno
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, 1120 15th Street BI3076, GA, United States.
| | - Nina Paletta
- Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Uttam Verma
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, 1120 15th Street BI3076, GA, United States
| | - Monika E Grabowska
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Prem P Batchala
- Department of Radiology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Solomon Abay
- Department of Radiology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Heather M Haughey
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Joseph Donahue
- Department of Radiology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - John Vender
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Sankara Sethuraman
- Department of Mathematics, Augusta University, Augusta, GA, United States
| | - Fenwick T Nichols
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, 1120 15th Street BI3076, GA, United States
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Fixed Positioning for Decompressive Hemicraniectomy Provides a Larger Diameter Flap than Nonfixed Positioning: A Single-Institution Experience. World Neurosurg 2020; 139:e293-e296. [DOI: 10.1016/j.wneu.2020.03.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 11/23/2022]
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Casolla B, Kyheng M, Kuchcinski G, Lejeune JP, Hanafi R, Bodenant M, Leys D, Labreuche J, Allart E, Jourdain M, Cordonnier C, Henon H. Predictors of outcome in 1-month survivors of large middle cerebral artery infarcts treated by decompressive hemicraniectomy. J Neurol Neurosurg Psychiatry 2020; 91:469-474. [PMID: 32165377 DOI: 10.1136/jnnp-2019-322280] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/04/2019] [Accepted: 01/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Decompressive hemicraniectomy (DH) increases survival without severe dependency in patients with large middle cerebral artery (LMCA) infarcts. The objective was to identify predictors of 1-year outcome after DH for LMCA infarct. METHODS We conducted this study in consecutive patients who underwent DH for LMCA infarcts, in a tertiary stroke centre. Using multivariable logistic regression analyses, we evaluated predictors of (1) 30-day mortality and (2) poor outcome after 1 year (defined as a modified Rankin Scale score of 4-6) in 30-day survivors. RESULTS Of 212 patients (133 men, 63%; median age 51 years), 35 (16.5%) died within 30 days. Independent predictors of mortality were infarct volume before DH (OR 1.10 per 10 mL increase, 95% CI 1.04 to 1.16), delay between symptom onset and DH (OR 0.41, 95% CI 0.23 to 0.73 per 12 hours increase) and midline shift after DH (OR 2.59, 95% CI 1.09 to 6.14). The optimal infarct volume cut-off to predict death was 210 mL or more. Among the 177 survivors, 77 (43.5%) had a poor outcome at 1 year. Independent predictors of poor outcome were age (OR 1.08 per 1 year increase, 95% CI 1.03 to 1.12) and weekly alcohol consumption of 300 g or more (OR 5.30, 95% CI 2.20 to 12.76), but not infarct volume. CONCLUSION In patients with LMCA infarcts treated by DH, stroke characteristics (infarct volume before DH, midline shift after DH and early DH) predict 30-day mortality, while patients' characteristics (age and excessive alcohol intake) predict 1-year outcome survivors.
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Affiliation(s)
- Barbara Casolla
- Neurology, Stroke Unit, CHU Lille, Inserm U1171, Lille, France
| | | | | | | | | | | | - Didier Leys
- Neurology, Stroke Unit, CHU Lille, Inserm U1171, Lille, France
| | | | | | | | | | - Hilde Henon
- Neurology, Stroke Unit, CHU Lille, Inserm U1171, Lille, France
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New CT measurements to assess decompression after hemicraniectomy: A two-center reliability study. Clin Neurol Neurosurg 2020; 188:105601. [DOI: 10.1016/j.clineuro.2019.105601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/24/2019] [Accepted: 11/11/2019] [Indexed: 11/18/2022]
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Lyon KA, Patel NP, Zhang Y, Huang JH, Feng D. Novel Hemicraniectomy Technique for Malignant Middle Cerebral Artery Infarction: Technical Note. Oper Neurosurg (Hagerstown) 2019; 17:273-276. [DOI: 10.1093/ons/opy399] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/08/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
Decompressive hemicraniectomy (DH) is the mainstay of treatment for malignant middle cerebral artery infarction (MMI). Although this operation significantly reduces mortality and improves functional outcomes, the conventional technique involves a reverse question mark incision starting anterior to the tragus that can injure the scalp's major blood supply, the superficial temporal artery (STA), which increases the risk of postoperative complications.
CLINICAL PRESENTATION
We developed a modified DH technique to reduce surgical morbidity associated with injury to the STA, accommodate a large bone window for effective decompression, and improve operative speed. After performing hospital chart review, a total of 34 patients were found who underwent this DH technique for MMI. Of these, 22 patients had this performed for right-sided MMI and 12 patients had this performed for left-sided MMI.
CONCLUSION
In each case, our approach preserved the STA and thereby minimized the risk for ischemic necrosis of the scalp flap. Since our technique avoids dissection of the preauricular temporalis muscle, we believe operative times can be decreased while still accommodating a large bone window to allow for effective decompression of the infarcted brain parenchyma.
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Affiliation(s)
- Kristopher A Lyon
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas
- Department of Surgery, Texas A&M University College of Medicine, Temple, Texas
| | - Nitesh P Patel
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas
- Department of Surgery, Texas A&M University College of Medicine, Temple, Texas
| | - Yilu Zhang
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas
- Department of Surgery, Texas A&M University College of Medicine, Temple, Texas
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas
- Department of Surgery, Texas A&M University College of Medicine, Temple, Texas
| | - Dongxia Feng
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas
- Department of Surgery, Texas A&M University College of Medicine, Temple, Texas
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