Decompressive hemicraniectomy after malignant middle cerebral artery infarction: rationale and controversies

Decompressive Hemicraniectomy and Favorable Outcome in a Pediatric Patient with Malignant Middle Cerebral Artery Infarction

We report a rare case of middle cerebral artery (MCA) stroke in a teenage girl with initial improvement, followed by progression to malignant MCA infarction, requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement in all areas, including language, comprehension, and motor skills at discharge and the 4-month follow-up. This rare presentation highlights the importance of monitoring the neurological status of a patient with an MCA infarct for progression to a life-threatening malignant MCA infarct. This case report also highlights the importance of consideration of DHC for a favorable outcome of the MMCA infarction.

Role of decompressive craniectomy in the management of poor-grade aneurysmal subarachnoid hemorrhage: short- and long-term outcomes in a matched-pair study

OBJECTIVE

To evaluate the short- and long-term therapeutic effect and possibility of decompressive craniectomy (DC) for patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Patients suffering from aSAH (Hunt-Hess grades IV, V) who underwent DC from January 2008 to April 2016 were enrolled in this study, and a sample-matched control group was set up. Information regarding participants' demography, clinical characteristics, and neuroimaging findings was systematically established. The outcome of a 6-month to 3-year follow-up was assessed according to the Glasgow outcome scale (GOS), modified Rankin Scale (mRS) and Barthel Index (BI).

RESULTS

Patients who had DC (21) experienced a statistically significant decrease in short-term mortality compared with those without DC (24, p < 0.05) and showed a decrease in intracranial pressure (ICP) after surgery. However, there was no significant difference in the long-term assessment (GOS/mRS/BI) between the two groups.

CONCLUSIONS

Some critical patients who have refractory ICP after poor-grade aSAH would benefit from DC for prolonging life in the short term if performed early. Nevertheless, the overall outcome for the long term remains disappointing, larger and longer prospective studies are urgently needed to investigate this issue.

Characterization of tissue and functional deficits in a clinically translational pig model of acute ischemic stroke

The acute stroke phase is a critical time frame used to evaluate stroke severity, therapeutic options, and prognosis while also serving as a major tool for the development of diagnostics. To further understand stroke pathophysiology and to enhance the development of treatments, our group developed a translational pig ischemic stroke model. In this study, the evolution of acute ischemic tissue damage, immune responses, and functional deficits were further characterized. Stroke was induced by middle cerebral artery occlusion in Landrace pigs. At 24 h post-stroke, magnetic resonance imaging revealed a decrease in ipsilateral diffusivity, an increase in hemispheric swelling resulting in notable midline shift, and intracerebral hemorrhage. Stroke negatively impacted white matter integrity with decreased fractional anisotropy values in the internal capsule. Like patients, pigs showed a reduction in circulating lymphocytes and a surge in neutrophils and band cells. Functional responses corresponded with structural changes through reductions in open field exploration and impairments in spatiotemporal gait parameters. Characterization of acute ischemic stroke in pigs provided important insights into tissue and functional-level assessments that could be used to identify potential biomarkers and improve preclinical testing of novel therapeutics.

Cerebral edema detection in vivo after middle cerebral artery occlusion using swept-source optical coherence tomography

Cerebral edema is a severe complication of ischemic cerebrovascular disease, which can lead to microcirculation compression resulting in additional ischemic damage. Real-time and continuous in vivo imaging techniques for edema detection are of great significance to basic research on cerebral edema. We attempted to monitor the cerebral edema status in rats with middle cerebral artery occlusion (MCAO) over time, using a wide field-of-view swept-source optical coherence tomography (SS-OCT) system. Optical attenuation coefficients (OACs) were calculated by an optimized depth-resolved estimation method, and en face OAC maps covering the whole cortex were obtained. Then, the tissue affected by edema was segmented from the OAC maps, and the cortical area affected by edema was estimated. Both magnetic resonance image (MRI) and brain water content measurements were used to verify the presence of cerebral edema. The results showed that the average OAC of the ischemic area gradually decreased as cerebral edema progressed, and the edema area detected by SS-OCT had high similarity in position and shape to that obtained by MRI. This work extends the application of OCT and provides an option for detecting cerebral edema in vivo after ischemic stroke.

Decompressive hemicraniectomy for malignant middle cerebral artery infarction. Experience from the Western Province of Saudi Arabia

Objective:

To describe our experience implementing decompressive hemicraniectomy (DH) for eligible patients with malignant middle cerebral artery (MCA) infarcts.

Methods:

We retrospectively collected data of malignant MCA infarction patients requiring DH at King Abdulaziz University Hospital & King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia between October 2010 and July 2015. Clinical outcome was assessed immediately postoperatively using Glasgow Coma Score (GCS), and at 12 months using the modified Rankin scale (mRS) and Barthel index. Survival was evaluated at thirty-days and one year after surgery.

Results:

Six out of 10 patients diagnosed with malignant MCA infarction underwent DH. Among the surgically treated patients (n=6), 4 were males (66%), and the median age was 22.5 years. The median time from admission to surgery was 35.5 hours. The median post-operative GCS was 6.5. Three patients (50%) died within 30 days of DH. In those who survived, the median mRS was 4.5 and BI was 7.5.

Conclusion:

Decompressive hemicraniectomy saves life and has the potential of improving survival functional outcome when done fast and in carefully selected patients. We call for national awareness of the management of such cases and early intervention.

Stereotactic Aspiration of Necrotic Brain Tissue for Treating Malignant Middle Cerebral Artery Infarction: A Report of 13 Consecutive Cases

BACKGROUND

This study aimed to evaluate the efficacy and safety of stereotactic aspiration of necrotic brain tissue for treating malignant middle cerebral artery infarction (MMI) in patients older than 60 years of age.

CASE DESCRIPTION

A total of 13 consecutive patients with MMI (mean age, 67 ± 6.62 years) were enrolled in the study. These patients were treated with stereotactic aspiration of necrotic brain tissue within 72 hours from stroke onset between January 2016 and June 2017. The surgical results and clinical outcomes were evaluated in response to stereotactic aspiration of necrotic brain tissue. The mean preoperative infarction volume in the patients was found to be 153.46 ± 9.39 mL according to the latest computed tomography scan. The 30-day mortality was 2 out of 13 patients (15.4%). Patients were followed-up for 6 months to evaluate the efficacy of stereotactic aspiration of necrotic brain tissue using the modified Rankin Scale (mRS). Among the 11 surviving surgical patients, 6 (54.5%) had an mRS score of 3 (defined as moderate disability), 4 (36.4%) had an mRS score of 4 (defined as moderate to severe disability), and 1 (9.1%) had an mRS score of 5 (defined as severe disability). The probability of 6-month unfavorable outcome, defined as an mRS score of 5 or 6 (death), was 3 out of 13 (23.1%).

CONCLUSIONS

Our results suggest the stereotactic aspiration of necrotic brain tissue is an effective and safe method in patients with MMI who are over 60 years of age.

Timing of Decompressive Hemicraniectomy for Stroke

Background and Purpose—

Previous clinical trials were not designed to discern the optimal timing of decompressive craniectomy for stroke, and the ideal surgical timing in patients with space-occupying infarction who do not exhibit deterioration within 48 hours is debated.

Methods—

Patients undergoing decompressive craniectomy for stroke were extracted from the Nationwide Inpatient Sample (2002–2011). Multivariable logistic regression evaluated the association of surgical timing with mortality, discharge to institutional care, and poor outcome (a composite end point including death, tracheostomy and gastrostomy, or discharge to institutional care). Covariates included patient demographics, comorbidities, year of admission, and hospital characteristics. However, standard stroke severity scales and infarct volume were not available.

Results—

Among 1301 admissions, 55.8% (n=726) underwent surgery within 48 hours. Teaching hospital admission was associated with earlier surgery ( P =0.02). The timing of intervention was not associated with in-hospital mortality. However, when evaluated continuously, later surgery was associated with increased odds of discharge to institutional care (odds ratio, 1.17; 95% confidence interval, 1.05–1.31, P =0.005) and of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.02–1.23; P =0.02). When evaluated dichotomously, the odds of discharge to institutional care and of a poor outcome did not differ at 48 hours after hospital admission, but increased when surgery was pursued after 72 hours. Subgroup analyses found no association of surgical timing with outcomes among patients who had not sustained herniation.

Conclusion

s—In this nationwide analysis, early decompressive craniectomy was associated with superior outcomes. However, performing decompression before herniation may be the most important temporal consideration.

A simple prediction score system for malignant brain edema progression in large hemispheric infarction

Malignant brain edema (MBE) due to hemispheric infarction can result in brain herniation, poor outcomes, and death; outcome may be improved if certain interventions, such as decompressive craniectomy, are performed early. We sought to generate a prediction score to easily identify those patients at high risk for MBE. 121 patients with large hemispheric infarction (LHI) (2011 to 2014) were included. Patients were divided into two groups: those who developed MBE and those who did not. Independent predictors of MBE were identified by logistic regression and a score was developed. Four factors were independently associated with MBE: baseline National Institutes of Health Stroke Scale (NIHSS) score (p = 0.048), Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (p = 0.007), collateral score (CS) (p<0.001) and revascularization failure (p = 0.013). Points were assigned for each factor as follows: NIHSS ≤ 8 (= 0), 9–17 (= 1), ≥ 18 (= 2); ASPECTS≤ 7 (= 1), >8 (= 0); CS<2 (= 1), ≥2 (= 0); revascularization failure (= 1),success (= 0). The MBE Score (MBES) represents the sum of these individual points. Of 26 patients with a MBES of 0 to 1, none developed MBE. All patients with a MBES of 6 developed MBE. Both MBE development and functional outcomes were strongly associated with the MBES (p = 0.007 and 0.002, respectively). The MBE score is a simple reliable tool for the prediction of MBE.

Neurologic Functional Outcomes of Decompressive Hemicraniectomy Versus Conventional Treatment for Malignant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis

OBJECTIVE

The aims of this study were to evaluate decompressive hemicraniectomy (DHC) versus conventional treatment (CT) for patients with malignant middle cerebral artery (MCA) infarction and to investigate the impact of age and surgical timing on neurologic function and mortality.

METHODS

We searched English and Chinese databases for randomized controlled trials or observational studies published before August 2016. Outcomes included good functional outcome (GFO), mortality, and National Institutes of Health Stroke Scale and Barthel index scores.

RESULTS

This meta-analysis included 25 studies (1727 patients). There were statistically significant differences between DHC and CT groups in terms of GFO (P < 0.0001), mortality (P < 0.00001), and National Institutes of Health Stroke Scale and Barthel index scores (P < 0.0001) at different follow-up points. Significant differences were observed between the groups in survival with moderately severe disability (P < 0.00001); no differences were observed in survival with severe disability. In the subgroup analysis, in the DHC group, GFO was less in patients >60 years old (9.65%) versus ≤60 years old (38.94%); more patients >60 years old had moderately severe or severe disability (55.27%) compared with patients ≤60 years old (44.21%).

CONCLUSIONS

DHC could significantly improve GFO and reduces mortality of patients of all ages with malignant MCA infarction compared with CT, without increasing the number of patients surviving with severe disability. However, patients in the DHC group more frequently had moderately severe disability. Patients >60 years old with malignant MCA infarction had a higher risk of surviving with moderately severe or severe disability and less GFO.

Elevated Intracranial Pressure and Cerebral Edema following Permanent MCA Occlusion in an Ovine Model

INTRODUCTION

Malignant middle cerebral artery (MCA) stroke has a disproportionately high mortality due to the rapid development of refractory space-occupying cerebral edema. Animal models are essential in developing successful anti-edema therapies; however to date poor clinical translation has been associated with the predominately used rodent models. As such, large animal gyrencephalic models of stroke are urgently needed. The aim of the study was to characterize the intracranial pressure (ICP) response to MCA occlusion in our recently developed ovine stroke model.

MATERIALS AND METHODS

30 adult female Merino sheep (n = 8-12/gp) were randomized to sham surgery, temporary or permanent proximal MCA occlusion. ICP and brain tissue oxygen were monitored for 24 hours under general anesthesia. MRI, infarct volume with triphenyltetrazolium chloride (TTC) staining and histology were performed.

RESULTS

No increase in ICP, radiological evidence of ischemia within the MCA territory but without space-occupying edema, and TTC infarct volumes of 7.9+/-5.1% were seen with temporary MCAO. Permanent MCAO resulted in significantly elevated ICP, accompanied by 30% mortality, radiological evidence of space-occupying cerebral edema and TTC infarct volumes of 27.4+/-6.4%.

CONCLUSIONS

Permanent proximal MCAO in the sheep results in space-occupying cerebral edema, raised ICP and mortality similar to human malignant MCA stroke. This animal model may prove useful for pre-clinical testing of anti-edema therapies that have shown promise in rodent studies.

Nationwide survey of decompressive hemicraniectomy for malignant middle cerebral artery infarction in Japan

OBJECTIVE

Decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MCA) infarction has been shown to reduce mortality and improve functional outcomes in young adults; however, there is currently debate regarding how routinely such surgery should be performed in the clinical setting, considering the very high rate of disability and functional dependence among survivors. We herein report the current status of the frequency of and indications for DHC for malignant MCA infarction in Japan.

METHODS

We retrospectively studied of cohort cases of DHC for malignant MCA infarction treated at pivotal teaching neurosurgical departments in Japan between January 2011 and December 2011. Information was obtained regarding patient characteristics, radiologic features, and outcomes during follow-up. The end points included 30-day mortality rate and functional outcomes, as measured according to the modified Rankin scale (mRS) score at 3 months.

RESULTS

Three hundred fifty-five patients underwent DHC at 259 neurosurgical departments who replied to the survey, corresponding to a rate of 8.7% of the 4092 candidates with malignant MCA infarction, the latter being equivalent to 8.5% of patients with acute ischemic stroke identified during the same period. Among the patients undergoing DHC, the mean age was 67.0 years, and those ≥60 years of age comprised 80.2% of all DHC patients. The most frequently used modality for vascular imaging was magnetic resonance angiography (77.2%). DHC generally was performed between 24 and 48 hours after onset (38.9%), with 36.9% of patients undergoing surgery at ≥48 hours. At the time of surgery, 26.1% of the patients had a Glasgow Coma Scale score of ≤6. Presurgical midbrain compression was noted in 52.1% of the patients. The 30-day mortality after DHC was 18.6%, and factors affecting death were a Glasgow Coma Scale score of ≤6 (odds ratio [OR] 1.88, 95% confidence interval [95% CI] 1.05-3.32, P = 0.03) and midbrain compression (OR 2.28, 95% CI 1.31-4.09, P = 0.005). According to the multivariate analysis, only midbrain compression was an independent risk factor (OR 2.12, 95% CI 1.16-3.95, P = 0.01) for 30-day mortality. Modified Rankin scale scores at 3 months were available in 175 patients (49.3%), only 5.2% of whom exhibited a favorable functional outcome (mRS score ≤3). Meanwhile, 22.9% of the patients had an mRS score of 4, 26.9% had an mRS score of 5, and 45.1% were found to have died.

CONCLUSIONS

In the present study, less than one-tenth of candidates with malignant MCA infarction in Japan underwent decompressive surgery, and the vast majority of patients were elderly. Age was not found to be an independent factor for immediate mortality in this study, and performing surgery in the elderly may be justified based on additional evidence of functional improvements.

Decompressive hemicraniectomy for spontaneous intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is devastating, with high mortality rates, but its optimum management has not been fully established. Decompressive hemicraniectomy is a surgical procedure used to relieve the malignant elevation of intracranial pressure. The application of decompressive hemicraniectomy in patients with hemispheric ICH has been much less common, although several studies have shown the usefulness of this procedure for large hemispheric ICH. In this review, the present knowledge of the safety and efficacy of this procedure are evaluated. The authors conclude that decompressive hemicraniectomy with hematoma evacuation for large ICH might be a safe and effective procedure in patients with severely disturbed consciousness and large hematoma volume.

Decompressive craniectomy: past, present and future

Decompressive craniectomy (DC)--a surgical procedure that involves removal of part of the skull to accommodate brain swelling--has been used for many years in the management of patients with brain oedema and/or intracranial hypertension, but its place in contemporary practice remains controversial. Results from a recent trial showed that early (neuroprotective) DC was not superior to medical management in patients with diffuse traumatic brain injury. An ongoing trial is investigating the clinical and cost effectiveness of secondary DC as a last-tier therapy for post-traumatic refractory intracranial hypertension. With regard to ischaemic stroke (malignant middle cerebral artery infarction), a recent Cochrane review concluded that DC improves survival compared with medical management, but that a higher proportion of DC survivors experience moderately severe or severe disability. Although many patients have a good outcome, the issue of DC-related disability raises important ethical issues. As DC and subsequent cranioplasty are associated with a number of complications, indiscriminate use of this surgery is not appropriate. Here, we review the evidence and present considerations regarding surgical technique, ethics and cost-effectiveness of DC. Prospective clinical trials and cohort studies are essential to enable optimization of patient care and outcomes.

Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring

Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.