Introduction: Stroke is a worldwide leading cause of mortality and disability, and there are substantial economic costs for post-stroke. A large hemispheric ischemic stroke is a severe form of stroke that may occur in up to 10% of stroke cases. In these cases, decompressive craniectomy (DC) is an effective strategy to reduce early case fatality. In this study, the authors present their experience in the management of large hemispheric stroke in patients who underwent decompressive craniectomy. Patients and Methods: This study is a retrospective analysis of 9 patients who underwent decompressive craniotomy for large hemispheric stroke from February 2021 to January 2024. Demographic, clinical, and radiologic variables were collected from the hospital archives. All patients underwent head CT scan or MRI showing the involvement of the majority or complete middle cerebral artery distribution area. Hemicraniectomy with duraplasty was the main surgical procedure. The mortality and the outcome using Modified Rankin Scale (mRS) were reported. Results: A total of 9 patients with large hemispheric stroke who underwent DC were reviewed retrospectively. The mean age was 53 years with extremes of 39- and 67-year-old. There were 6 males and 3 females. The main risk factors of stroke were hypertension and diabetes in 5 and 3 cases, respectively. The large craniectomy was made and the dura was opened in the stellate fashion. Duraplasty was performed using epicrane in 7 patients and fascia lata aponeurosis in 2 patients. In the postoperative course, 4 (44%) patients died in 1 month and the mortality rate was 66.6% in 6 months. Conclusion: Decompressive craniectomy is a life-saving procedure used to manage cerebral edema after stroke onset. In our study, the high mortality rate could be explained by many factors, such as patient selection criteria and timing of surgery. Early surgery within the first 48 hours in patients less than 60 years old with large hemispheric stroke is recommended.
References
[1]
Rajsic, S., Gothe, H., Borba, H.H., Sroczynski, G., Vujicic, J., Toell, T., et al. (2018) Economic Burden of Stroke: A Systematic Review on Post-Stroke Care. The European Journal of Health Economics, 20, 107-134. https://doi.org/10.1007/s10198-018-0984-0
[2]
Heinsius, T., Bogousslavsky, J. and Van Melle, G. (1998) Large Infarcts in the Middle Cerebral Artery Territory Etiology and Outcome Patterns. Neurology, 50, 341-350. https://doi.org/10.1212/wnl.50.2.341
[3]
Hao, Z., Chang, X., Zhou, H., Lin, S. and Liu, M. (2015) A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice. Medicine, 94, e1039. https://doi.org/10.1097/md.0000000000001039
[4]
Hacke, W. (1996) ‘Malignant’ Middle Cerebral Artery Territory Infarction: Clinical Course and Prognostic Signs. Archives of Neurology, 53, 309-315. https://doi.org/10.1001/archneur.1996.00550040037012
[5]
Ropper, A.H. (1984) Brain Edema After Stroke: Clinical Syndrome and Intracranial Pressure. Archives of Neurology, 41, 26-29. https://doi.org/10.1001/archneur.1984.04050130032017
[6]
Wu, S., Yuan, R., Wang, Y., Wei, C., Zhang, S., Yang, X., et al. (2018) Early Prediction of Malignant Brain Edema after Ischemic Stroke: A Systemic Review and Meta-Analysis. Stroke, 49, 2918-2927. https://doi.org/10.1161/strokeaha.118.022001
[7]
Hatashita, S. and Hoff, J.T. (1987) The Effect of Craniectomy on the Biomechanics of Normal Brain. Journal of Neurosurgery, 67, 573-578. https://doi.org/10.3171/jns.1987.67.4.0573
[8]
Forsting, M., Reith, W., Schabitz, W., Heiland, S., von Kummer, R., Hacke, W., et al. (1995) Decompressive Craniectomy for Cerebral Infarction: An Experimental Study in Rats. Stroke, 26, 259-264. https://doi.org/10.1161/01.str.26.2.259
[9]
Doerfler, A., Forsting, M., Reith, W., Staff, C., Heiland, S., Schäbitz, W., et al. (1996) Decompressive Craniectomy in a Rat Model of “Malignant” Cerebral Hemispheric Stroke: Experimental Support for an Aggressive Therapeutic Approach. Journal of Neurosurgery, 85, 853-859. https://doi.org/10.3171/jns.1996.85.5.0853
[10]
Kocher, T. (1901) Treatment of Intracranial Pressure. In: Hoelder, A., ED., Concussions, Intracranial Pressure and Surgical Interventions for Brain Diseases, Hoelder, 262-266.
[11]
Schwab, S., Steiner, T., Aschoff, A., Schwarz, S., Steiner, H.H., Jansen, O., et al. (1998) Early Hemicraniectomy in Patients with Complete Middle Cerebral Artery Infarction. Stroke, 29, 1888-1893. https://doi.org/10.1161/01.str.29.9.1888
[12]
Rieke, K., Schwab, S., Krieger, D., von Kummer, R., Aschoff, A., Schuchardt, V., et al. (1995) Decompressive Surgery in Space-Occupying Hemispheric Infarction: Results of an Open, Prospective Trial. Critical Care Medicine, 23, 1576-1587. https://doi.org/10.1097/00003246-199509000-00019
[13]
Delashaw, J.B., Broaddus, W.C., Kassell, N.F., Haley, E.C., Pendleton, G.A., Vollmer, D.G., et al. (1990) Treatment of Right Hemispheric Cerebral Infarction by Hemicraniectomy. Stroke, 21, 874-881. https://doi.org/10.1161/01.str.21.6.874
[14]
Uhl, E., Kreth, F.W., Elias, B., et al. (2004) Outcome and Prognostic Factors of Hemicraniectomy for Space Occupying Cerebral Infarction. Journal of Neurology, Neurosurgery and Psychiatry, 75, 270-274.
[15]
Wirtz, C.R., Steiner, T., Aschoff, A., Schwab, S., Schnippering, H., Steiner, H.H., et al. (1997) Hemicraniectomy with Dural Augmentation in Medically Uncontrollable Hemispheric Infarction. Neurosurgical Focus, 2, E7. https://doi.org/10.3171/foc.1997.2.5.7
[16]
Gupta, R., Connolly, E.S., Mayer, S. and Elkind, M.S.V. (2004) Hemicraniectomy for Massive Middle Cerebral Artery Territory Infarction: A Systematic Review. Stroke, 35, 539-543. https://doi.org/10.1161/01.str.0000109772.64650.18
[17]
Vahedi, K., Hofmeijer, J., Juettler, E., Vicaut, E., George, B., Algra, A., et al. (2007) Early Decompressive Surgery in Malignant Infarction of the Middle Cerebral Artery: A Pooled Analysis of Three Randomised Controlled Trials. The Lancet Neurology, 6, 215-222. https://doi.org/10.1016/s1474-4422(07)70036-4
[18]
Cruz-Flores, S., Berge, E. and Whittle, I.R. (2012) Surgical Decompression for Cerebral Oedema in Acute Ischaemic Stroke. Cochrane Database of Systematic Reviews, No. 1, Article ID: CD003435. https://doi.org/10.1002/14651858.cd003435.pub2
[19]
Jüttler, E., Schwab, S., Schmiedek, P., Unterberg, A., Hennerici, M., Woitzik, J., et al. (2007) Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (Destiny): A Randomized Controlled Trial. Stroke, 38, 2518-2525. https://doi.org/10.1161/strokeaha.107.485649
[20]
Vahedi, K., Vicaut, E., Mateo, J., Kurtz, A., Orabi, M., Guichard, J., et al. (2007) Sequential-Design, Multicenter, Randomized, Controlled Trial of Early Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction (DECIMAL Trial). Stroke, 38, 2506-2517. https://doi.org/10.1161/strokeaha.107.485235
[21]
Hofmeijer, J., Kappelle, L.J., Algra, A., Amelink, G.J., van Gijn, J. and van der Worp, H.B. (2009) Surgical Decompression for Space-Occupying Cerebral Infarction (the Hemicraniectomy after Middle Cerebral Artery Infarction with Life-Threatening Edema Trial [HAMLET]): A Multicentre, Open, Randomised Trial. The Lancet Neurology, 8, 326-333. https://doi.org/10.1016/s1474-4422(09)70047-x
[22]
Walz, B., Zimmermann, C., Böttger, S. and Haberl, R.L. (2002) Prognosis of Patients after Hemicraniectomy in Malignant Middle Cerebral Artery Infarction. Journal of Neurology, 249, 1183-1190. https://doi.org/10.1007/s00415-002-0798-x
[23]
Powers, W.J., Rabinstein, A.A., Ackerson, T., Adeoye, O.M., Bambakidis, N.C., Becker, K., et al. (2019) Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke, 50, e344-e418. https://doi.org/10.1161/str.0000000000000211
[24]
Harscher, S., Reichart, R., Terborg, C., Hagemann, G., Kalff, R. and Witte, O.W. (2005) Outcome after Decompressive Craniectomy in Patients with Severe Ischemic Stroke. Acta Neurochirurgica, 148, 31-37. https://doi.org/10.1007/s00701-005-0617-0
