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

2011 ◽  
Vol 30 (6) ◽  
pp. E18 ◽  
Author(s):  
Omar M. Arnaout ◽  
Salah G. Aoun ◽  
H. Hunt Batjer ◽  
Bernard R. Bendok
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Randomized Trials ◽  
Middle Cerebral Artery Infarction ◽  
Decompressive Hemicraniectomy ◽  
Randomized Controlled ◽  
Randomized Controlled Studies ◽  
Life Saving ◽  
Shed Light

Malignant middle cerebral artery stroke carries a very poor prognosis. Significant retrospective data support the hypothesis that decompressive hemicraniectomy decreases mortality rates due to this disease entity. Recently, 3 randomized controlled studies have been published and shed light on these issues and enhance the quality of evidence revolving around this procedure. In this review, the rationale, risks, benefits, and unanswered questions related to hemicraniectomy for acute ischemic stroke are reviewed with an emphasis on how 3 randomized trials have influenced knowledge on this life-saving yet controversial procedure. Further randomized studies are needed to clarify lingering questions regarding age indications and impact on quality of life.

scholarly journals Hemicraniectomy for Massive Middle Cerebral Artery Infarction: A Review

2008 ◽  
Vol 35 (5) ◽  
pp. 544-550 ◽  
Author(s):  
Dulka Manawadu ◽  
Ahmed Quateen ◽  
J. Max Findlay
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Surgical Intervention ◽  
Middle Cranial Fossa ◽  
Midline Shift ◽  
Middle Cerebral Artery Infarction ◽  
Randomized Controlled ◽  
Life Saving ◽  
Cranial Fossa ◽  
Saving Measure

Hemicraniectomy and opening underlying dura mater permits the expansion of infarcted, swollen brain outwards, reversing dangerous intracranial pressure elevations and the risk of fatal transtentorial temporal lobe or diencephalic herniation. Recently published randomized controlled trials have proven this procedure a powerful life-saving measure in the setting of malignant middle cerebral artery infarction and allayed concerns that a reduction in mortality is accompanied by an unacceptable increase in patients suffering severe neurological impairments. Appropriate patients are relatively young, in the first five decades of life, suffering infarction of a majority of the middle cerebral artery (MCA) territory in either hemisphere, and decompression should be performed prior to progression to coma or two dilated, fixed pupils. Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider and discuss surgical intervention. Families and, when possible, patients themselves, should be informed of the certainty of at least moderate to mild permanent deficits, and the possibility of worse. To be successful decompression must be extensive, targeting a bone flap measuring 14 cm from front to back, and extending 1 to 2 cms lateral to the midline sagittal suture to the floor of the middle cranial fossa at the level of the coronal suture. An augmentation duraplasty is mandatory.

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

2013 ◽  
Vol 20 (1) ◽  
pp. 91-97 ◽  
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

scholarly journals Outcome After Decompressive Craniectomy for Middle Cerebral Artery Infarction: Timing of the Intervention

Neurosurgery ◽  
2020 ◽  
Vol 86 (3) ◽  
pp. E318-E325 ◽  
Author(s):  
Taco Goedemans ◽  
Dagmar Verbaan ◽  
Bert A Coert ◽  
Bertjan Kerklaan ◽  
René van den Berg ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Decompressive Craniectomy ◽  
Meta Analysis ◽  
Unfavorable Outcome ◽  
Stroke Onset ◽  
Middle Cerebral Artery Infarction ◽  
Randomized Controlled ◽  
Current Guidelines ◽  
Hemispheric Infarct

Abstract BACKGROUND Based on randomized controlled trials (RCTs), clinical guidelines for the treatment of space-occupying hemispheric infarct employ age (≤60 yr) and time elapsed since stroke onset (≤48 h) as decisive criteria whether to perform decompressive craniectomy (DC). However, only few patients in these RCTs underwent DC after 48 h. OBJECTIVE To study the association between the timing of DC and (un)favorable outcome in patients with space-occupying middle cerebral artery (MCA) infarct undergoing DC. METHODS We performed a single-center cohort study from 2007 to 2017. Unfavorable outcome at 1 yr was defined as a Glasgow outcome scale 1 to 3. Additionally, we systematically reviewed the literature up to November 2018, including studies reporting on the timing of DC and other predictors of outcome. We performed Firth penalized likelihood and random-effects meta-analysis with odds ratio (OR) on unfavorable outcome. RESULTS A total of 66 patients were enrolled. A total of 26 (39%) patients achieved favorable and 40 (61%) unfavorable outcomes (13 [20%] died). DC after 48 h since stroke diagnosis did not significantly increase the risk of unfavorable outcome (OR 0.8, 95% CI 0.3-2.3). Also, in the meta-analysis, DC after 48 h of stroke onset was not associated with a higher risk of unfavorable outcome (OR 1.11; 95% CI 0.89-1.38). CONCLUSION The outcome of DC performed after 48 h in patients with malignant MCA infarct was not worse than the outcome of DC performed within 48 h. Contrary to current guidelines, we, therefore, advocate not to set a restriction of ≤48 h on the time elapsed since stroke onset in the decision whether to perform DC.

Novel Hemicraniectomy Technique for Malignant Middle Cerebral Artery Infarction: Technical Note

2019 ◽  
Vol 17 (3) ◽  
pp. 273-276 ◽  
Author(s):  
Kristopher A Lyon ◽  
Nitesh P Patel ◽  
Yilu Zhang ◽  
Jason H Huang ◽  
Dongxia Feng
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Technical Note ◽  
Surgical Morbidity ◽  
Middle Cerebral Artery Infarction ◽  
Decompressive Hemicraniectomy ◽  
Bone Window ◽  
Large Bone

Abstract BACKGROUND AND IMPORTANCE Decompressive hemicraniectomy (DH) is the mainstay of treatment for malignant middle cerebral artery infarction (MMI). Although this operation significantly reduces mortality and improves functional outcomes, the conventional technique involves a reverse question mark incision starting anterior to the tragus that can injure the scalp's major blood supply, the superficial temporal artery (STA), which increases the risk of postoperative complications. CLINICAL PRESENTATION We developed a modified DH technique to reduce surgical morbidity associated with injury to the STA, accommodate a large bone window for effective decompression, and improve operative speed. After performing hospital chart review, a total of 34 patients were found who underwent this DH technique for MMI. Of these, 22 patients had this performed for right-sided MMI and 12 patients had this performed for left-sided MMI. CONCLUSION In each case, our approach preserved the STA and thereby minimized the risk for ischemic necrosis of the scalp flap. Since our technique avoids dissection of the preauricular temporalis muscle, we believe operative times can be decreased while still accommodating a large bone window to allow for effective decompression of the infarcted brain parenchyma.

Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A systematic review and meta-analysis

The Surgeon ◽  
2015 ◽  
Vol 13 (4) ◽  
pp. 230-240 ◽  
Author(s):  
Ming-Hao Yang ◽  
Hong-Yu Lin ◽  
Jun Fu ◽  
Gopaul Roodrajeetsing ◽  
Sheng-Liang Shi ◽  
...  
Keyword(s):  
Systematic Review ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Meta Analysis ◽  
Middle Cerebral Artery Infarction ◽  
Decompressive Hemicraniectomy

Quality of life and neurobehavioral changes in survivors of malignant middle cerebral artery infarction

2009 ◽  
Vol 256 (7) ◽  
pp. 1126-1133 ◽  
Author(s):  
Bessy Benejam ◽  
Juan Sahuquillo ◽  
Maria Antonia Poca ◽  
Laura Frascheri ◽  
Elisabeth Solana ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Middle Cerebral Artery Infarction
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