Outcome after decompressive craniectomy in patients with dominant middle cerebral artery infarction: A preliminary report

Efficacy and safety of decompressive craniectomy in acute ischemic stroke patients treated with intravenous thrombolysis

Introduction

The optimal timing for decompressive hemicraniectomy (DHC) after intravenous thrombolysis (IVT) remains unclear. This study in patients with acute ischemic stroke treated with IVT aimed to assess the safety of DHC and patient outcome.

Methods

Data was extracted from the Tabriz stroke registry from June 2011 up to September 2020. In all, 881 patients were treated with IVT. Among these, 23 patients underwent DH. Six patients were excluded due to symptomatic intracranial hemorrhage (parenchymal hematoma type 2 based on SITS-MOST definition) after IVT, but other types of bleeding after venous thrombolysis, including HI1, HI2, and PH1 were not excluded; so the remaining 17 patients were enrolled in the study. Functional Outcome was defined as the proportion of patients who achieved mRS score of 2–3 (moderate disability), 4–5 (severe disability), or 6 (mortality) at 90 days after stroke. mRSwas assess by trained neurologist at the hospital clinic with direct interview Safety outcome was assessed by comparison of two scans just prior to and after craniectomy. Any new hemorrhage or worsening of previous hemorrhage was reported. Parenchymal hematoma type 2, based on ECASS II definition, was considered as major surgical complication. This study was approved by the local ethics committee of the Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1398.420).

Results

At the three-month mRS follow up, six patients (35%) had moderate and five (29%) had severe disability. The outcome of death was observed in six patients (35%).Nine of 15 patients (60%) underwent surgery in the first 48 hours after onset of symptoms. No patient over 60 years of age survived to the three-month follow up; 67% of those who were under60 years and underwent DH in the first 48 hours had favorable outcome. Hemorrhagic complication was seen in 64% of patients but none was major.

Conclusion

Results of this study showed that the rate of major bleeding and outcome of acute ischemic stroke patients who underwent DHC after IVT is comparable with the reported data in the literature and intentionally waiting for the fibrinolytic effects of IVT to disappear may not outweigh the benefits of DHC. Although the findings of the study should be interpreted with caution and larger studies are needed to confirm the results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-03014-4.

Computed tomography perfusion in detecting malignant middle cerebral artery infarct

Background:

Computed tomography perfusion (CTP) is an emerging modality which produces maps of time-to- peak (TTP), cerebral blood flow (CBF), and cerebral blood volume (CBV), with a computerized automated map of the infarct and penumbra. This modality provides a better evaluation of the extent of infarction, making it a potential method for assessing patients suffering from large middle cerebral artery (MCA) infarctions.

Methods:

A prospective cohort study of all patients in Hospital Kuala Lumpur, Malaysia, who presented with the clinical diagnosis of a large MCA infarction within 48 h of onset were subjected to CT brain, and CTP scans on admission and were followed up to determine the development of malignant infarction requiring surgical decompression.

Results:

CTP parameters were generally lower in patients with malignant brain infarct (MBI) group compared to the nonMBI group. The largest mean difference between the group was noted in the TTP values (P = 0.005). CTP parameters had a comparable positive predictive value (83%–90%) and high net present value (88–93). CBF with cutoff value of >32.85 of the hemisphere could accurately predict malignant infarctions in 81.4% of cases. The National Institutes of Health Stroke Scale score of more than 13.5 was also found to be able to accurately determine malignant infarct (97.6%). Functional outcome of patients based on Glasgow outcome scale was similar on discharge, however, showed improvement at 6 months during reviewed base on modified Rankin scale (P < 0.001).

Conclusion:

CTP parameters should be included in the initial evaluation of patients to predict malignant brain infarction and facilitate surgical treatment of large MCA infarctions.

Key messages:

CT perfusion parameters have an important role in predicting malignant brain infarction and should be included in the initial evaluation of patients to facilitate the early identification and surgical treatment of large middle cerebral artery infarctions, to improve patient’s prognosis.