scholarly journals Timing of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Single-Center Analysis

Medicina ◽  
2019 ◽  
Vol 55 (2) ◽  
pp. 31
Author(s):  
Mustafa Kilic ◽  
Devrimsel Harika Ertem ◽  
Burak Ozdemir
Keyword(s):  
Glasgow Coma Scale ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Decompressive Craniectomy ◽  
Demographic Data ◽  
High Morbidity ◽  
Middle Cerebral Artery Infarction ◽  
Coma Scale ◽  
Scale Scores ◽  
Gcs Score

Background and aim: Malignant middle cerebral artery infarction (MMCAI) usually leads to brain edema that may result in transtentorial herniation and brainstem compression. The prognosis of MMCAI is generally poor. The aim of this study was to discuss our experience with surgical decompression for MMCAI, and determine the association between timing of craniectomy and neurological outcomes. Methods: We identified consecutive patients diagnosed with MMCAI who underwent decompressive craniectomy (DC). Clinical and demographic data were obtained from electronic medical records, including: age, sex, preoperative Glasgow Coma Scale (GCS) score, surgery timing, postoperative GCS scores, and modified Rankin Scale (mRS) scores. Results: This study included 27 stroke patients (aged 38–80 years) operated within 72 h of the onset of neurological symptoms. Sixteen, five, and six patients underwent DC within 24 h, between 24 and 48 h, and after 48 h after onset of symptoms, respectively. Five patients died after the surgery. Patients who underwent DC within 24 h and 24–48 h had better mean GCS scores than those who underwent DC after 48 h (p = 0.000, p = 0.015). In addition, patients who underwent DC within 24 h had better mean postoperative mRS scores (p = 0.000) than other patients. Patients older than 60 years had significantly lower GCS scores (p = 0.027) and higher mRS scores (p = 0.033) than younger patients. Conclusion: Our findings support that DC had satisfying outcomes in patients who underwent DC within 24 h. Older age and lower Glasgow Coma Scale scores among DC patients with MMCAI are associated with high morbidity and mortality.

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 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.

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