Decompressive Craniectomy in Pregnant Women

Malignant middle cerebral artery (MCA) infarction warranting decompressive craniectomy (DC) is unusual in the population younger than 40 years. Specifically, only a few cases affecting pregnant women have been described in the literature. We present the case of a 39-year-old woman in the 24th week of pregnancy who suffered a right malignant MCA infarction that eventually required DC. The patient delivered a healthy baby and underwent a second surgery for cranioplasty 7 months later. We present both this case and a review of the literature, including all cases of DC in pregnant women published to date.

Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review

Background: Subacute subdural hematomas (ASDH) are only treated surgically when they cause mass effect significant enough to give symptoms. Rarely, sub-ASDH may cause enough pressure to result in a malignant middle cerebral artery (MCA) territory infarction. Decompressive craniectomy (DC) is the last resort to reduce intracranial pressure following malignant MCA infarction. Herein, we review the literature and describe a case of MCA/posterior cerebral artery (PCA) territories infarction following drainage of a sub-ASDH that was treated with DC with good outcome. Case Description: We report a case of malignant right-sided MCA/PCA infarction in a 62-year-old man who presented with progressive headache following a cycling incident leading to a head injury. Initial CT head demonstrated a small right ASDH. He had no neurological deficit, headache settled on analgesia, and there was no expansion of the SDH on the repeat CT; therefore, he was managed conservatively. He was admitted 6-days later with worsening headaches and hyponatremia. Repeat CT revealed an increase in size of the hematoma and mass effect leading to a mini-craniotomy and evacuation of hematoma. He developed left-sided hemiplegia, slurred speech and hyponatremia, and CT head demonstrated a right-sided MCA/PCA infarction with significant mass effect. He underwent emergent DC and subsequent cranioplasty and ultimately recovered to mRS of 2. Conclusion: SDH are frequent neurosurgical entities. Malignant MCA/PCA strokes following mini-craniotomies are rare but need to be considered especially during the consent process.

Abstract P687: Acute Kidney Failure in Patients With Malignant Middle Cerebral Artery Infarction Undergoing Osmotherapy With Mannitol

Introduction: To explore kidney safety profile of osmotic diuretic mannitol in patients with malignant middle cerebral artery (MCA) infarction. Methods: We analyzed data from consecutive patients with malignant MCA infarction (01/2008-12/2017). Malignant MCA infarction was defined according to clinical and radiographic DESTINY criteria. Clinical and laboratory variables were collected for all patients. We compared clinical endpoints including acute kidney failure (AKF; according to Kidney Disease: Improving Global Outcomes [KDIGO] definition) and hemodialysis between patients who received mannitol and those who did not. Multivariable model was built to explore predictor variables of AKF, in-hospital death and functional outcome at discharge. Results: Overall, 228 patients with malignant MCA infarction were analyzed: median age 67 years (IQR, 56-76), 58% men, median NIHSS 23 (17-32) points. Decompressive craniectomy was performed in 103/228 (45.2%) patients. Mannitol was administered in 100/228 (43.9%) patients over an average of 85 (30.3-139.3) hours. Average dosage was 700 (250-1050) g. Patients treated with mannitol more frequently suffered from AKF (40% vs. 7.9%; p<0.0001) and needed hemodialysis (7.4% vs. 0.9%; p=0.024) than patients without mannitol. At discharge, kidney function completely recovered in 38.5% and 20%, respectively (p=0.459). In multivariable model adjusted for age, history of chronic kidney disease, nephrotoxic premedication, admission systolic blood pressure, concurrent urinary tract infection, contrast agent exposure and peak osmolality, mannitol therapy emerged as single predictor of AKF (OR 4.14, 95%CI 1.2-14.2; p=0.024). Neither AKF nor mannitol therapy was associated with in-hospital death or short-term functional outcome (p>0.05). Conclusions: Acute kidney failure appears to be a frequent complication of osmotic diuretic mannitol in patients with malignant MCA infarction. Given the lack of evidence supporting effectiveness of mannitol in these patients, its use should be carefully considered.

Effects of early decompressive craniectomy on functional outcome of patients with malignant middle cerebral artery infarctions

Background: This study aimed to compare the functional outcome of patients with malignant middle cerebral artery (MCA) infarction who had undergone either early decompressive craniectomy (DC) or optimal medical therapy (OMT). Methods: This study was conducted during a 2- year period in Golestan Hospital of Ahvaz, Iran. The selected patients with malignant MCA infarction who were admitted within 48 hours of presenting signs were included. The patients were randomly assigned to undergo either early DC (n = 12) or OMT (n = 12) in the neurosurgical intensive care unit (ICU). The functional outcomes in the subjects were evaluated with the Glasgow Outcome Scale (GOS) and the National Institutes of Health Stroke Scale (NIHSS) at discharge, 6, and 12-month intervals. Results: The patients who underwent DC had significantly higher GOS at discharge (P = 0.013), 6 (P = 0.022), and 12 (P = 0.042) months as compared to the medical therapy group. However, the NIHSS score did not show any significant difference between the two groups during the study. Likewise, DC was associated with lower mortality at 6 (P = 0.027) and 12 (P = 0.014) months; moreover, the lower mortality rate (P = 0.014), severe disability (P = 0.040), higher good recovery (P < 0.001), and moderate disability (P < 0.001) were observed after 12 months of follow-up. Conclusion: These findings suggest that early DC in patients with malignant MCA can decrease mortality and improve the functional outcome according to GOS criteria compared to medical therapy.

Asymmetric TCD Findings in Malignant MCA Infarction, Resolution after Decompressive Hemicraniectomy: A Case Report

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.

Abstract WP202: Decompressive Hemicraniectomy After Malignant Middle Cerebral Artery Ischemic Stroke in a Developing Country is Associated With Poor Long Term Functional Outcome and High Mortality

Background: Decompressive hemicraniectomy (DH) is a level IA therapy for malignant middle cerebral artery (MCA) infarction. However, randomized trials were performed in high income countries with better access to post-stroke care and rehabilitation services. We aimed to assess long term functional outcome and the associated prognostic factors of patients undergoing DH in Brazil. Methods: From January 2013 and July 2018, all patients undergoing DH for malignant MCA infarction in a single comprehensive stroke center were retrospectively identified. Outcomes were the modified Rankin Scale (mRS) (dichotomized as ≤ 4 vs. > 4) and mortality at follow-up. The mRS at follow-up was collected prospectively by telephone using a validated structured interview. Logistic regression analysis was performed to assess independent predictors of outcome. Results: Eighty patients who underwent DH for malignant MCA infarction were identified. Age ranged from 16 to 78 years (median 48 years, IQR 42 - 54,7 years), 46 (57.6%) were males and median time from stroke onset to hemicraniectomy was 30.75 hours (IQR 17.8-46.0). Hospital discharge mRS ≤ 3 and ≤ 4 was observed in 5 (6.2%) and 74 (92,5%) patients respectively. Follow-up information was available for 65 (81.2%) patients. At follow-up (raging from 1.1 to 5.6 years), mRS ≤ 4 was observed in 23 (35.3%) patients. In binary logistic regression analysis, age (OR 1.09, 95% CI 1.02 - 1.17, p=0.01), and right MCA infarction (OR 16.70, 95% CI 1.8-152.30, p=0.01) were independently associated with a worse functional outcome at follow-up. Admission NIHSS (OR 1.0 ,95% CI 0.8-1.3, p=0.45), IV rt-PA (OR 0.5, 95% CI 0.08-3.00, p=0.46) or time of hemicraniectomy (OR 1.00, 95% CI 1.00 - 1.00, p=0.94) were not associated with functional outcome at follow-up. Mortality was 26% (N=21) at hospital discharge and 46% (N=30) at follow-up. Conclusion: The large effect size of DH for malignant MCA infarction is significantly diminished in the population of patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country. Poor access to post-stroke care and rehabilitation services might be possible reasons for the results observed.