Decompressive Hemicraniectomy for Stroke: An Old Therapy Revisited

Transcranial Doppler (TCD) is a non-invasive method for assessing cerebral hemodynamics in the acute phase of stroke. We report a case of a 33-year-old man who presented with a massive left hemispheric infarct developing into “malignant” MCA infarction. TCD was utilized to monitor intracranial hemodynamics while the clinical and neuroimaging findings were used to help us in the decision to proceed with decompressive craniectomy (DC). Pre-operatively, there was reduced mean flow velocities (MFV) of the middle cerebral artery (MCA) with increasing pulsatility index (PI) ipsilateral to the infarct. The subsequent but smaller rise in the PI in the contralateral MCA was suggestive of very high intracranial pressure (ICP) from massive brain swelling. Serial TCD examinations post-operatively showed normalization of the PI, and subsequent rise in the left MCA MFV. Clinical improvement was also noted as the TCD findings improved. The asymmetry in TCD findings can be attributed to occlusion of the MCA with subsequent spontaneous recanalisation, occlusion of the MCA with subsequent recanalisation due to the DC, or initial occlusion and subsequent pressure effects on the arterioles of the MCA due to the “malignant” edema of that hemisphere that was relieved by DC. This case illustrates the value of TCD as a useful modality in monitoring intracranial hemodynamics in acute stroke.

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Anesthetic Management of a Child with β-Thalassemia Major and Cortical Venous Thrombosis

Journal of Neuroanaesthesiology and Critical Care ◽

10.1055/s-0040-1715357 ◽

2020 ◽

Author(s):

Mayank Tyagi ◽

Surya K. Dube ◽

Vanitha Rajagopalan ◽

Gyaninder P. Singh

Keyword(s):

Venous Thrombosis ◽

Sinus Thrombosis ◽

Anesthetic Management ◽

Thalassemia Major ◽

Severe Form ◽

Thromboembolic Events ◽

Blood Disorders ◽

Decompressive Hemicraniectomy ◽

Cerebral Sinus ◽

Cortical Venous Thrombosis

Abstractβ-thalassemia are a group of inherited blood disorders with reduced hemoglobin levels. β-thalassemia major is the severe form of disease, and the patients often display an array of associated organ dysfunction which thus increase the risk associated with surgery and anesthesia. Patients with β-thalassemia major can have multiple pathological defects that may lead to thromboembolic events. Here, we report such a case who was complicated by occurrence of cerebral sinus thrombosis and presented for decompressive hemicraniectomy under general anesthesia. The anesthetic challenges during in such scenario have been discussed.

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Simultaneous Cranioplasty and External Ventricular Drain Implantation in Patients with Hydrocephalus: Case Series and Literature Review

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0041-1730332 ◽

2021 ◽

Author(s):

Lívio Pereira de Macêdo ◽

Arlindo Ugulino Netto ◽

Kauê Franke ◽

Pierre Vansant Oliveira Eugenio ◽

John Anderson da Silva Rocha ◽

...

Keyword(s):

External Ventricular Drain ◽

Neurological Complication ◽

Case Series ◽

Neurological Deficits ◽

Time Interval ◽

Automobile Accidents ◽

Decompressive Hemicraniectomy ◽

Cerebral Herniation ◽

Intraoperative Period ◽

The Brain

Abstract Introduction The increase in intracranial pressure (ICP) is a neurological complication resulting from numerous pathologies that affect the brain and its compartments. Therefore, decompressive craniectomy (DC) is an alternative adopted to reduce ICP in emergencies, especially in cases refractory to clinical therapies, in favor of patient survival. However, DC is associated with several complications, including hydrocephalus (HC). The present study presents the results of an unusual intervention to this complication: the implantation of an external ventricular drain (EVD) in the intraoperative period of cranioplasty (CP). Methods Patients of both genders who presented with HC and externalization of the brain through the cranial vault after decompressive hemicraniectomy and underwent EVD implantation, to allow the CP procedure, in the same surgical procedure, were included. Results Five patients underwent DC due to a refractory increase in ICP, due to automobile accidents, firearm projectiles, falls from stairs, and ischemic strokes. All evolved with HC. There was no uniform time interval between DC and CP. The cerebrospinal fluid (CSF) was drained according to the need for correction of cerebral herniation in each patient, before undergoing cranioplasty. All patients progressed well, without neurological deficits in the immediate postoperative period. Conclusion There are still several uncertainties about the management of HC resulting from DC. In this context, other CP strategies simultaneous to the drainage of CSF, not necessarily related to ventriculoperitoneal shunt (VPS), should be considered and evaluated more deeply, in view of the verification of efficacy in procedures of this scope, such as the EVD addressed in this study.

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Bone Flap Necrosis After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction

Neurocritical Care ◽

10.1007/s12028-013-9892-4 ◽

2013 ◽

Vol 20 (1) ◽

pp. 91-97 ◽

Cited By ~ 13

Author(s):

Christian Ewald ◽

Pedro Duenisch ◽

Jan Walter ◽

Theresa Götz ◽

Otto W. Witte ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Bone Flap ◽

Flap Necrosis ◽

Middle Cerebral Artery Infarction ◽

Decompressive Hemicraniectomy

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Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp.2008.155630 ◽

2009 ◽

Vol 80 (7) ◽

pp. 799-801 ◽

Cited By ~ 42

Author(s):

E Guresir ◽

A Raabe ◽

M Setzer ◽

H Vatter ◽

R Gerlach ◽

...

Keyword(s):

Subarachnoid Haemorrhage ◽

Brain Swelling ◽

Decompressive Hemicraniectomy

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Abstract T P405: Improvement in Midline Shift is Associated with Survival After Decompressive HemiCraniectomy in Large Hemispheric Infarctions

Stroke ◽

10.1161/str.46.suppl_1.tp405 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Joanna I Ramiro ◽

Rajat Dhar ◽

Eli Feen ◽

Abhay Kumar

Keyword(s):

Hospital Mortality ◽

Care Facility ◽

Imaging Data ◽

Midline Shift ◽

Term Care ◽

Nihss Score ◽

Decompressive Hemicraniectomy ◽

Long Term Care Facility ◽

Risk Of Death ◽

Neuro Imaging

Background and Purpose: It remains uncertain which patients with malignant edema after large hemispheric infarction (LHI) remain at risk of death despite decompressive hemicraniectomy (DHC). We investigated factors associated with in-hospital mortality in a cohort of patients with LHI who underwent DHC. Methodology: This retrospective cohort study conducted over a five-year period identified 24 LHI patients who underwent DHC. Patient demographics, pre- and post-DHC clinical and neuro-imaging data were recorded (including midline shift [MLS] at the level of lateral ventricles). These variables were then analyzed in relation to in-hospital mortality. Results: Patients were predominantly male (17/24), with mean age of 55±15 years and baseline NIHSS score of 18.5± 4. Despite DHC, performed at a median of 52 hours, mortality still occurred in 9 patients (38%), with 11 (46%) going to acute rehabilitation and remainder to long-term care facility (LTC). Patients had a mean pre-operative MLS of 11 ± 3 mm. When compared with a head CT obtained 48 hours after DHC, MLS improved the most in patients going to rehabilitation (by 6 ± 4.2 mm), compared to those going to LTC (3.2 ± 5 mm), while the least improvement was seen in those who died (1 ± 5 mm). Survivors had significant improvement in MLS (5.3 ± 4.4 mm) compared to the non-survivors (1 ± 5 mm), p = 0.04. The survivors were also significantly younger (50 ± 17 years) compared to those who died (62 ± 7 years). Thirteen patients (54% of the cohort) received intracranial pressure (ICP) monitors ipsilateral to the infarct during DHC but measured ICPs were statistically similar in survivors vs non-survivors. Other variables (baseline NIHSS score, MLS and time to surgery) did not predict death in the cohort. Conclusion: Mortality remains high in LHI patients even after DHC. Improvement in MLS after DHC appears to separate survivors from non-survivors while post-DHC ICPs do not. However, our sample size is small and additional studies with larger population sizes are required for validation of our findings.

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