Decompressive craniectomy in childhood posterior circulation stroke: a case series and review of the literature

Few reports address the role of decompressive craniectomy in children with space-occupying cerebral edema attributable to severe ischemic infarction of the posterior cerebral arterial circulation. We describe four children with posterior circulation arterial ischemic stroke who required decompressive craniectomy. These children accounted for 11% of all cases of posterior circulation ischemic stroke at our institution from 2002-2010. Three manifested large, cerebellar hemispheric infarcts, and one manifested a large, temporo-occipital posterior cerebral artery infarct. Deterioration occurred within 72 hours of stroke onset. Two patients demonstrated minimal functional deficits at follow-up, and two demonstrated moderate deficits with functional limitations. Because decompressive craniectomy can be lifesaving in children with severe posterior circulation arterial ischemic stroke, early neurosurgical referral should be considered.     

Decompressive craniectomy: technical note

Quinn TM, Taylor JJ, Magarik JA, Vought E, Kindy MS, Ellegala DB. Decompressive craniectomy: technical note. Acta Neurol Scand: 2011: 123: 239–244.© 2010 John Wiley & Sons A/S. Decompressive craniectomy is a neurosurgical technique in which a portion of the skull is removed to reduce intracranial pressure. The rationale for this procedure is based on the Monro‐Kellie Doctrine; expanding the physical space confining edematous brain tissue after traumatic brain injury will reduce intracranial pressure. There is significant debate over the efficacy of decompressive craniectomy despite its sound rationale and historical significance. Considerable variation in the employment of decompressive craniectomy, particularly for secondary brain injury, explains the inconsistent results and mixed opinions of this potentially valuable technique. One way to address these concerns is to establish a consistent methodology for performing decompressive craniectomies. The purpose of this paper is to begin accomplishing this goal and to emphasize the critical points of the hemicraniectomy and bicoronal (Kjellberg type) craniectomy.     

Decompressive craniectomy for ischemic stroke]

We analysed retrospectively 15 consecutive patients with cerebral infarction undergoing decompressive craniectomy. Ninety-three percent of patients survived, and 53% of them were partially dependent (Barthel Index > 0). We defined the partially dependent patients as good outcome group, and totally dependent as poor outcome group. In good outcome group, compared with poor outcome group, there are more frequent left hemispheric lesion (50%: 0%, p = 0.029), and pre-operative JCS < or = II-30 (62.5%: 14.3%, p = 0.057). Although many patients were severely disabled, 79% of the patients and their family answered that having operation was correct choice. All the patients in good outcome group acquired the ability of oral feeding and communication skill. 87.5% of the patient in good outcome group was satisfied with the outcome. Based on these results, we emphasized that comprehensive evaluations, including satisfaction scale and QOL assessment necessary to decide the indication of decompressive craniectomy for ischemic stroke.     

Decompressive craniectomy: A new complication

There is an increasing amount of published literature supporting the use of decompressive craniectomy in the management of raised intracranial pressure and it appears that this procedure will become established as a method by which intracranial hypertension can be treated. While technically fairly straightforward, a decompressive craniectomy is not without complications. A further complication is presented here, which has not been previously reported. A 56-year-old male fell backwards from a bar stool and struck his occiput. He had a decompressive craniectomy and was making an excellent recovery when he fell and injured the unprotected craniectomy site. He suffered further cerebral injury and subsequently died. Following a detailed review of the case a number of recommendations were made and a specific post-decompressive craniectomy operational policy for the assessment and management of these patients was implemented. While we accept that these particular guidelines are specific to a particular institution, this case highlights the need to view these patients as a particularly high risk and recommend that institutions review or establish a specific policy regarding their management.     

Decompressive hemicraniectomy in severe cerebral venous thrombosis: a prospective case series

Small retrospective case series suggest that decompressive hemicraniectomy can be life saving in patients with cerebral venous thrombosis (CVT) and impending brain herniation. Prospective studies of consecutive cases are lacking. Thus, a single centre, prospective study was performed. In 2006 we adapted our protocol for CVT treatment to perform acute decompressive hemicraniectomy in patients with impending herniation, in whom the prognosis with conservative treatment was considered infaust. We included all consecutive patients with CVT between 2006 and 2010 who underwent hemicraniectomy. Outcome was assessed at 12 months with the modified Rankin Scale (mRS). Ten patients (8 women) with a median age of 41 years (range 26-52 years) were included. Before surgery 5 patients had GCS < 9, 9 patients had normal pupils, 1 patient had a unilaterally fixed and dilated pupil. All patients except one had space-occupying intracranial hemorrhagic infarcts. The median preoperative midline shift was 9 mm (range 3-14 mm). Unilateral hemicraniectomy was performed in 9 patients and bilateral hemicraniectomy in one. Two patients died from progressive cerebral edema and expansion of the hemorrhagic infarcts. Five patients recovered without disability at 12 months (mRS 0-1). Two patients had some residual handicap (one minor, mRS 2; one moderate, mRS 3). One patient was severely handicapped (mRS 5). Our prospective data show that decompressive hemicraniectomy in the most severe cases of cerebral venous thrombosis was probably life saving in 8/10 patients, with a good clinical outcome in six. In 2 patients death was caused by enlarging hemorrhagic infarcts.     

血肿清除加去骨瓣减压术治疗重症高血压基底节脑出血

目的探索血肿清除加去骨瓣减压及硬膜减张缝合在治疗高血压基底节脑出血的患者中的疗效。方法连续收集去骨瓣手术治疗的35例患者,记录的数据包括术前GCS评分,血肿大小,瞳孔反应,ICH评分等。随访指标有30d死亡率以及最近一次的ADL评分。结果 35例患者中27例(77%)30d内存活。27例存活者在平均13个月的随访中16例(62%)神经功能预后良好(ADL评分I-Ⅲ级)。结论高血压基底节脑出血患者施行血肿清除合并去骨瓣减压术有望降低死亡率,改善神经功能预后。     

Decompressive craniectomy for malignant middle cerebral artery infarction: Evidence and controversies

Malignant middle cerebral artery (MCA) infarction (MMI) is associated with a mortality rate of 80%. Decompressive craniectomy is considered a life-saving procedure for patients with this devastating condition. Preclinical and clinical data suggest that this procedure should be undertaken as early as possible, prompting increasing demand for emergency surgery. This article reviews the pathophysiology of MMI, and the experimental and clinical evidence supporting this procedure. We consider some of the controversies surrounding patient selection for this procedure and discuss the role of intracranial pressure monitoring in MMI.     

Decompressive craniectomy is a life-saving procedure in malignant MCA infarction

Objectives:To investigate the indications, timings, and outcomes of decompressive craniectomy (DC) performed for malignant middle cerebral artery (MCA) infarctions at our tertiary care center.Methods:This retrospective case series involved patients who underwent DC for malignant MCA infarction at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, between January 2012 and December 2018. Demographic, clinical, and radiological data were collected, and stroke- and surgery-related complications and discharge outcomes were assessed.Results:Eighteen patients (mean age: 50±10 years), of whom 13 (72%) were men, underwent DC during the study period. Of the patients, 9 (50%) had severe stroke (NIHSS 16–25), 10 (56%) had right MCA infarction, and 11 (61%) received either intravenous thrombolysis or endovascular thrombectomy or their combination. Indications for surgery included clinical deterioration as seen in 16 (89%) patients, ipsilateral pupillary dilatation as seen in 11 (61%) patients, and signs of raised intracranial pressure in 6 (33%) patients. Surgery was performed within 48 h in 14 (78%) patients. The mean Intensive Care Unit stay was 15±7 days. Seven (39%) patients were discharged home and 3 (17%) were transferred to an inpatient rehabilitation unit, and 2 (11%) patients died. All patients had stroke-related complications; one (6%) patient developed cerebrospinal fluid leak, 3 (17%) had sunken skin flap syndrome and wound infection each, and 2 (11%) developed epidural hematoma.Conclusion:The DC was life-saving in the our patients with malignant MCA infarction. Most of the patients had surgery within 48 hours. More than one-third of the patients were discharged home, while mortality occurred in only 2 patients. Moreover, stroke- and surgery-related complications were common in our cohort.

Stroke is one of the leading causes of death and adult disability worldwide.^1,2 The burden of stroke is increasing and is a significant challenge for health care systems across the globe.² Ischemic stroke due to occlusion of proximal middle cerebral artery (MCA), usually involve large portions of a hemisphere and may cause space-occupying cerebral edema, leading to rapid neurological deterioration and cerebral herniation.^2,3 Nearly 35 years ago, Hacke et al⁴ coined the term “malignant” for acute and complete MCA territory infarction involving a space-occupying cerebral edema and subsequently a considerably rapid neurological deterioration and herniation. Malignant MCA infarction involves more than 50% of and often the entire MCA territory.^3-5 In the early phase of malignant MCA infarction, cytotoxic edema develops followed by the development of vasogenic edema.³ Approximately 1-10% of all MCA strokes can turn into malignant MCA infarction with a mortality risk of up to 80% within the first week.^2,3 Acute brain swelling occuring within 48 hours results in elevated intracranial pressure (ICP) or brain herniation, which in turn leads to the deterioration of consciousness or death usually within the first week.^2,3,6 The clinical predictors of malignant transformation include high NIHSS (National Institute of Health Stroke Scale) score, young age, female gender, as well as history of hypertension, ischemic heart disease, and congestive heart failure.^2,6 The radiological predictors of malignant transformation are >66% perfusion deficit, >50% involvement of MCA territory on initial CT scan, and combined involvement of internal carotid artery and MCA, among many others.⁶Control of ICP remains an important challenge in patients with severe post-stroke or post-traumatic brain edema. The medical management for raised ICP include head-of-bed elevation, hyperventilation, osmotic therapy, and sedation.^6,7 Although osmotic therapy has failed to improve treatment outcomes, it can be used to bridge time until definitive surgical treatment can be performed.³ Systemic hypothermia in raised ICP due to malignant MCA infarction has been associated with multiple complications without any clear benefit on outcome.⁶Trephination, an ancient treatment method of brain diseases, may be the earliest form of decompressive craniectomy.⁸ Decompressive craniectomy (DC) was described more than a century ago, but it did not receive acceptance for most of the 20th century.^8,9 One of the earliest reports on DC for malignant MCA infarction was published in 1951.¹⁰ A pooled analysis of three randomized trials conducted in the early part of this century showed for the first time the benefit of early DC in malignant MCA infarction.¹¹ These 3 initial European trials, namely, DECIMAL, DESTINY, and HAMLET, were the first to prove that DC was associated with decreased mortality and with the increased number of patients with favorable outcome.^11-14 The mortality rates decreased from 78% in historical controls to as low as 16% in surgically treated patients, with the number needed to treat (NNT) as low as 2 for survival with mRS (modified Rankin Scale) of ≤4.¹³The DC involves the removal of a part of the skull referred to as bone flap; along with opening of dura to accommodate brain swelling.^8,9 In malignant MCA infarction, only unilateral decompression, also termed as decompressive hemicraniectomy, is performed.⁸ The DC allows an edematous brain tissue to herniate outside, thus preventing neuronal damage in other regions of the brain.^2,8 A meta-analysis of 8 randomized trials and 4 observational studies confirmed the mortality benefit of DC in malignant MCA infarction.⁷ Patients and caregivers were satisfied with their QALY despite the disability of the patients; however, professionals did not consider surgery as favorable treatment due to the high disability rates post-surgery.⁷There is one prior published study about decompressive craniectomy in malignant MCA infarction from Saudi Arabia describing 6 patients undergoing DC.¹⁵ Our study aimed to investigate the indications, timings, and outcomes of DC performed for malignant MCA infarctions at our tertiary care center. We believe that this work will add to the limited literature about this condition from the region.     

去骨瓣减压术治疗大面积脑梗死(附30例报道)

目的 探讨去骨瓣减压治疗大面积脑梗死的意义、手术适应证及手术技巧。方法 回顾分析2010年7月～2015年7月江门市中心医院神经外科收治的30例大面积脑梗死行去骨瓣减压术患者的临床资料,总结分析其手术的意义、手术时机及手术操作的体会。结果 25例患者术后存活,5例死亡。去骨瓣减压术后格拉斯哥昏迷评分(GCS)较术前明显改善(t=-5.08,P<0.05)。术前瞳孔散大24例,术后有16例瞳孔缩小(80%)。术后绝大多数病例CT中线移位较术前回复(28/30)。术后3个月时GOS评分4分7例,3分17例,2分1例,1分5例。结论 去骨瓣减压术是大面积脑梗死的有效治疗手段,早期外科干预、术中充分减压可提高大面积脑梗死患者的生存率。     

Decompressive craniectomy after intravenous tissue plasminogen activator administration for stroke

Objective

Intravenous tissue plasminogen activator (IV tPA) is an approved treatment for acute ischemic stroke. However, the effects of decompressive craniectomy (DC) after IV tPA administration for ischemic stroke are still largely unknown. The aim of this study was to investigate the safety and outcomes of DC after IV tPA administration.

Methods

We retrospectively reviewed patients who underwent DC for malignant hemispheric infarction. We compared 20 patients who underwent DC after IV tPA administration with another 20 patients who underwent DC without prior IV tPA administration.

Results

The patient characteristics did not differ between the DC patients with and without prior IV tPA administration. New intracranial bleeding or worsening of pre-existing ICH occurred in two patients (10%) in each group. Furthermore, the rates of an mRS score of 4–6, 5 or 6, and 6 did not differ significantly between the two groups.

Conclusion

DC may be a safe and useful surgical procedure for space-occupying edema after IV tPA administration for acute stroke.     

翼-颞联合入路去骨瓣减压术治疗大面积脑梗死

目的探讨对符合适应证的大面积脑梗死的患者行“翼-颞联合入路”去骨瓣减压术后的临床效果。方法回顾性分析2006年8月至2008年8月间收治34例大面积脑梗死病例,24例行标准大骨瓣减压术（标准组）,10例行“翼-颞联合入路”去骨瓣减压术（改良组）,以Barthel指数（BAI）和格拉斯哥预后评分（GOS）评定临床效果。结果术后1d,两组脑组织膨出体积比例差异有显著性（t=2．788,P〈0．05）。所有患者均获随访。术后3、6个月,两组病死率比较差异无显著性（P=0．291,0．148,P〉0．05）;而术后3、6个月BAI、GOS评分比较差异都有显著性（t=7．329,4．076,8．734,3．818;P〈0．05）。结论翼-颞联合入路去骨瓣减压术具有操作简便,暴露及减压充分等优点,根据患者的具体情况进行翼-颞联合入路去骨瓣减压术是一种较好的治疗大面积脑梗死的方法。     

Decompressive craniectomy causes a significant strain increase in axonal fiber tracts

Decompressive craniectomy (DC) allows for the expansion of a swollen brain outside the skull and has the potential to reduce intracranial pressure. However, the stretching of axons may contribute to an unfavorable outcome in patients treated with DC. In this study, we present a method for quantifying and visualizing axonal fiber deformation during both the pre-craniectomy and post-craniectomy periods to provide more insight into the mechanical effects of this treatment on axonal fibers. The deformation of the brain tissue in the form of a Lagrangian finite strain tensor for the entire brain was obtained by a non-linear image registration method based on the CT scanning data sets of the patient. Axonal fiber tracts were extracted from diffusion-weighted images. Based on the calculated brain tissue strain tensor and the observed axonal fiber tracts, the deformation of axonal fiber tracts in the form of a first principal strain, axonal strain and axonal shear strain were quantified. The greatest axonal fiber displacement was predominantly located in the treated region of the craniectomy, accompanied by a large axonal deformation close to the skull edge of the craniectomy. The distortion (stretching or shearing) of axonal fibers in the treated area of the craniectomy may influence the axonal fibers in such a way that neurochemical events are disrupted. A quantitative model may clarify some of the potential problems with this treatment.     

Decompressive bifrontal craniectomy for malignant intracranial pressure following anterior communicating artery aneurysm rupture

There are a number of causes of raised intracranial pressure (ICP) following aneurysm rupture. These include primary and diffuse hypoxic brain injury, intracranial hematomas, cerebral ischemia or infarction, and obstructive hydrocephalus. More localized brain swelling can also occur: the result of vasogenic and cytotoxic edema resulting from overlying bleeding in the subar achnoid spaces. In the case of rupture of an anterior communicating artery (ACommA) aneurysm and interhemispheric subarachnoid hemorrhage (SAH), this swelling can occur in both frontal lobes and when extensive, and the resulting intracranial hypertension can be difficult to manage with ventricular drainage and medical treatment. We describe two patients in whom decompressive bifrontal craniectomy was associated with successful ICP management and good clinical outcomes.