Acute Decompressive Hemicraniectomy to Control High Intracranial Pressure in Patients with Malignant MCA Ischemic Strokes

2011 ◽  
Vol 13 (3) ◽  
pp. 225-232 ◽  
Author(s):  
David Z. Wang ◽  
Deepak S. Nair ◽  
Arun V. Talkad
Keyword(s):  
Intracranial Pressure ◽  
Decompressive Hemicraniectomy

scholarly journals Invasive Monitoring of Intracranial Pressure After Decompressive Craniectomy in Malignant Stroke

Stroke ◽  
2020 ◽  
Author(s):  
Silvia Hernández-Durán ◽  
Leonie Meinen ◽  
Veit Rohde ◽  
Christian von der Brelie
Keyword(s):  
Intracranial Pressure ◽  
Mortality Rate ◽  
Operating Characteristic ◽  
Receiver Operating Characteristic Analysis ◽  
High Specificity ◽  
Invasive Monitoring ◽  
Icp Monitoring ◽  
Characteristic Analysis ◽  
Decompressive Hemicraniectomy

Background and Purpose: The role of decompressive hemicraniectomy (DC) in malignant cerebral infarction (MCI) has clearly been established, but little is known about the course of intracranial pressure (ICP) in patients undergoing this surgical measure. In this study, we investigated the role of invasive ICP monitoring in patients after DC for MCI, postulating that postoperative ICP predicts mortality. Methods: In this retrospective observational study of MCI patients undergoing DC, ICP were recorded continuously in hourly intervals for the first 72 hours after DC. For every hour, mean ICP was calculated, pooling ICP of every patient. A receiver operating characteristic analysis was performed for hourly mean ICP. A subgroup analysis by age (≥60 years and <60 years) was also performed. Results: A total of 111 patients were analyzed, with 29% mortality rate in patients <60 years, and 41% in patients ≥60 years. A threshold of 10 mm Hg within the first 72 postoperative hours was a reliable predictor of mortality in MCI, with an acceptable sensitivity of 70% and high specificity of 97%. Established predictors of mortality failed to predict mortality. Conclusions: Our study suggests the need to reevaluate postoperative ICP after DC in MCI and calls for a redefinition of ICP thresholds in these patients to indicate further therapy.

POSTOPERATIVE HYDROCEPHALUS IN PATIENTS UNDERGOING DECOMPRESSIVE HEMICRANIECTOMY FOR ISCHEMIC OR HEMORRHAGIC STROKE

Neurosurgery ◽  
2007 ◽  
Vol 61 (3) ◽  
pp. 489-494 ◽  
Author(s):  
Allen Waziri ◽  
David Fusco ◽  
Stephan A. Mayer ◽  
Guy M. McKhann ◽  
E. Sander Connolly
Keyword(s):  
Intracranial Pressure ◽  
Hemorrhagic Stroke ◽  
Communicating Hydrocephalus ◽  
Imaging Data ◽  
Decompressive Hemicraniectomy ◽  
Pressure Dynamics ◽  
Csf Diversion ◽  
Postoperative Hydrocephalus ◽  
Early Cranioplasty ◽  
Persistent Hydrocephalus

Abstract OBJECTIVE We have frequently observed the development of postoperative communicating hydrocephalus in patients undergoing decompressive hemicraniectomy. This condition may persist in some patients after cranioplasty and require permanent cerebrospinal fluid (CSF) diversion. To confirm an independent correlation between hemicraniectomy and the development of communicating hydrocephalus, and to detail the frequency and potential clinical factors contributing to this complication, we evaluated our series of patients undergoing hemicraniectomy for life-threatening increases in intracranial pressure secondary to ischemic or hemorrhagic stroke. METHODS A retrospective analysis was performed with a cohort of consecutive patients who underwent emergent hemicraniectomy for medically refractory elevations in intracranial pressure. Patients with known independent risk factors for the development of communicating hydrocephalus were excluded. Clinical and imaging data were reviewed to determine the incidence and type of hydrocephalus after hemicraniectomy, the persistence of hydrocephalus after cranioplasty, and the need for permanent CSF diversion. RESULTS Eighty-eight percent of the eligible patients undergoing hemicraniectomy in our cohort developed postoperative communicating hydrocephalus. Half of these patients harbored persistent hydrocephalus after cranioplasty and required placement of a ventriculoperitoneal shunt. We noted a strong correlation between prolonged time to replacement of the bone flap and persistence of hydrocephalus. CONCLUSION Communicating hydrocephalus is an almost universal finding in patients after hemicraniectomy. Delayed time to cranioplasty is linked with the development of persistent hydrocephalus, necessitating permanent CSF diversion in some patients. We propose that early cranioplasty, when possible, may restore normal intracranial pressure dynamics and prevent the need for permanent CSF diversion in patients after hemicraniectomy.

Survival with good outcome after cerebral herniation and Duret hemorrhage caused by traumatic brain injury

2009 ◽  
Vol 110 (6) ◽  
pp. 1242-1246 ◽  
Author(s):  
Shirley I. Stiver ◽  
Alisa D. Gean ◽  
Geoffrey T. Manley
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Scale Score ◽  
Terminal Event ◽  
Raised Intracranial Pressure ◽  
Decompressive Hemicraniectomy ◽  
Young Adult Patient ◽  
Cerebral Herniation ◽  
Acute Epidural Hematoma

Brainstem hemorrhage can occur as a primary or secondary event in traumatic brain injury (TBI). Secondary brainstem hemorrhage that evolves from raised intracranial pressure and transtentorial herniation is referred to as Duret hemorrhage. Duret hemorrhage following TBI has been considered an irreversible and terminal event. The authors report on the case of a young adult patient with TBI who presented with a low Glasgow Coma Scale score and advanced signs of cerebral herniation. She underwent an urgent decompressive hemicraniectomy for evacuation of an acute epidural hematoma and developed a Duret hemorrhage postoperatively. In accordance with the family's wishes, aggressive TBI monitoring and treatment in the intensive care unit was continued even though the anticipated outcome was poor. After a lengthy hospital course, the patient improved dramatically and was discharged ambulatory, with good cognitive functioning and a Glasgow Outcome Scale score of 4. Duret hemorrhage secondary to raised intracranial pressure is not always a terminal event, and by itself should not trigger a decision to withdraw care. Aggressive intracranial monitoring and treatment of a Duret hemorrhage arising secondary to cerebral herniation may enable a good recovery in selected patients after severe TBI.

Treatment of Increased Intracranial Pressure and Vasospasm after Subarachnoid Hemorrhage in a 9-Year-Old Child—A Case Report

2021 ◽  
Author(s):  
Sarah-Hélène Müller ◽  
Christian Taschner ◽  
Stephan Meckel ◽  
Ernst Mayerhofer ◽  
Roland Roelz ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Intracranial Pressure ◽  
Balloon Dilatation ◽  
Rescue Therapy ◽  
Dissecting Aneurysm ◽  
Occipital Artery ◽  
Increased Intracranial Pressure ◽  
Decompressive Hemicraniectomy ◽  
Noninvasive Therapy ◽  
Delayed Neurological Deterioration

AbstractWe report a 9-year-old patient who suffered severe subarachnoid hemorrhage due to ruptured dissecting aneurysm of the left parieto-occipital artery. After endovascular occlusion of the aneurysm, increased intracranial pressure refractory to noninvasive therapy required secondary decompressive hemicraniectomy. Critical vasospasm and delayed neurological deterioration were treated by oral nimodipine and successful endovascular rescue therapy consisting of intra-arterial balloon dilatation.

Fixed, Dilated, and Conversing—Unreactive Pupil With Preserved Consciousness Indicating Acutely Rising Intracranial Pressure due to Traumatic Intraparenchymal Contusions: Case Report and Review of the Literature

2021 ◽  
pp. 194187442110566
Author(s):  
Malia McAvoy ◽  
Gina Lee ◽  
Scott Boop ◽  
Madeline E. Greil ◽  
Kayla A. Durler ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Exceptional Case ◽  
Diabetes Mellitus Type Ii ◽  
Decompressive Hemicraniectomy ◽  
Tactile Stimuli ◽  
History Of ◽  
The Right ◽  
Work Up ◽  
Head Computed Tomography ◽  
Pupillary Change

Patients with fixed and dilated pupils (FDPs) due to rising intracranial pressure (ICP) typically experience a deterioration in consciousness. We describe an exceptional case of a patient with bifrontal contusions who developed worsening edema and a unilaterally FDP while maintaining consciousness and the ability to communicate. A 58-year-old man with history of hypertension and diabetes mellitus type II presented after being assaulted, with bifrontal contusions and right frontal intraparenchymal hemorrhage. On hospital day 8, his right pupil became fixed (NPi 0) and dilated (4.8 mm). The patient was drowsy, arousable to tactile stimuli, answering questions, oriented to place and time, following commands on his right side, maintaining Glasgow Coma Scale of 14 (E4, V5, M6). He described complete loss of vision and could not identify objects or count fingers. His gaze was dysconjugate with impaired vertical excursion and inability to fully abduct to the right side. Corneal reflexes were intact bilaterally. Hypertonic saline and mannitol produced no improvement in his pupillary exam. Head computed tomography showed worsening midline shift and interval increase in subfalcine herniation related to increased peri-hematoma edema. We performed an emergent right-sided decompressive hemicraniectomy with durotomy and duraplasty. His pupil became reactive 5 hours after surgery. While FDP without deterioration of consciousness has been described due to traumatic subdural and epidural hematomas, we report this unusual constellation as a sign of rising ICP and impeding herniation due to intraparenchymal contusions, highlighting that any pupillary change warrants prompt work-up and intervention.

scholarly journals Intracranial pressure following decompressive hemicraniectomy for malignant cerebral infarction: clinical and treatment correlations

2018 ◽  
Vol 76 (12) ◽  
pp. 812-815 ◽  
Author(s):  
Bruno Ferreira Funchal ◽  
Maramélia Miranda Alves ◽  
Ítalo C. Suriano ◽  
Feres Eduardo Chaddad-Neto ◽  
Maria E. M. R. Ferraz ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Cerebral Infarction ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Decompressive Craniectomy ◽  
Tertiary Hospital ◽  
National Institutes Of Health ◽  
Icp Monitoring ◽  
Decompressive Hemicraniectomy

ABSTRACT Decompressive craniectomy (DC) reduces mortality and improves outcome in patients with massive brain infarctions. The role of intracranial pressure (ICP) monitoring following DC for stroke has not been well established. Methods: We evaluated 14 patients admitted to a tertiary hospital with malignant middle cerebral artery infarctions, from October 2010 to February 2015, who underwent DC and had ICP monitoring. Patients with and without episodes of ICP elevation were compared. Results: Fourteen patients were submitted to DC and had ICP monitoring following the procedure during the period. Ten patients (71.4%) had at least one episode of sustained elevated ICP in the first seven days after surgery. Maximal ICP levels had no correlation with age, time to hemicraniectomy or Glasgow Coma Scores at admission, but had a trend toward correlation with the National Institutes of Health Stroke Scale score at admission (p = 0.1). Ventriculitis occurred in 21.4% of the patients. Conclusions: High ICP episodes and ventriculitis were common in patients following hemicraniectomy for malignant middle cerebral artery strokes. Therefore, the implications of ICP and benefits of the procedure should be firmly established.

Intracranial Pressure Soon After Hemicraniectomy in Malignant Middle Cerebral Artery Infarction

2016 ◽  
Vol 33 (5) ◽  
pp. 310-316 ◽  
Author(s):  
Sang-Beom Jeon ◽  
Jung Cheol Park ◽  
Sun U. Kwon ◽  
Yeon-Jung Kim ◽  
Seungjoo Lee ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Glasgow Coma Scale ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Secondary Brain Injury ◽  
Midline Shift ◽  
Middle Cerebral Artery Infarction ◽  
Term Survival ◽  
Coma Scale ◽  
Decompressive Hemicraniectomy

Background: Decompressive hemicraniectomy reduces secondary brain injury related to brain edema and increased intracranial pressure (ICP) in patients with malignant middle cerebral artery infarction (MMI). However, a substantial proportion of patients still die despite hemicraniectomy due to refractory brain swelling. Objective: We aim to investigate whether ICP measured immediately after hemicraniectomy may indicate decompression effects and predict survival in patients with MMI. Methods: We included 25 patients with MMI who underwent ICP monitoring and brain computed tomography within the first hour of hemicraniectomy. Midline shifts were measured as radiological surrogates of decompression. The Glasgow Coma Scale and pupillary enlargements during the first day after hemicraniectomy were assessed as clinical surrogates of decompression. Long-term survival status at 6 months was used as the final outcome. We analyzed the relationships between early ICP and findings of midline shift, Glasgow Coma Scale, pupillary enlargement, and survival. Results: Initial ICP was correlated with mean ICP ( P < .001) and maximal ICP ( P < .001) during the first postoperative day. Intracranial pressure was associated with midline shifts ( P = .009), lower Glasgow Coma Scale scores ( P = .025), and the pupillary enlargement ( P = .015). Sixteen (64.0%) patients survived at 6 months. In a Cox proportional hazard model, elevated ICP was associated with mortality at 6 months (hazard ratio: 1.13; 95% confidence interval: 1.03-1.24; P = .008). Conclusion: Increase in ICP soon after hemicraniectomy was associated with midline shift, poor neurological status, and mortality in patients with MMI. Measurements of ICP soon after hemicraniectomy may permit earlier interventions as well as more refined clinical assessments.

scholarly journals Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and shunt-dependency

2021 ◽  
Author(s):  
Martin Vychopen ◽  
Matthias Schneider ◽  
Valeri Borger ◽  
Patrick Schuss ◽  
Charlotte Behning ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Superior Sagittal Sinus ◽  
Ct Scans ◽  
Raised Intracranial Pressure ◽  
Elevated Intracranial Pressure ◽  
Decompressive Hemicraniectomy ◽  
Sagittal Sinus ◽  
Significant Difference ◽  
Outcome Difference ◽  
Shunt Dependency

Abstract Purpose Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC. Methods Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared. Results Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6–5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9. Conclusions Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.

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