FIGURE 8.1 CT scan (A, B) showing extensive decompressive craniectomy (with duraplasty using bovine pericardial graft) for swollen hemispheric infarct. Replacement of bone flap seen on repeat CT scan 6 months later (C).
Doing nothing knowing the patient will lapse into coma is not an option in a relatively young person. Further swelling of a major territorial infarct can be anticipated in acute carotid artery occlusion, and often these are patients who deteriorate beyond drowsiness. Medical management with osmotic diuretics is often ineffective, and patients may worsen rather quickly. Decompressive hemicraniectomy may result in a recovery that could potentially be meaningful for the patient. Yet, when it comes to the question of creating space to swell, preemptive removal of half the skull at the site of a newly developing hemispheric infarct may be perceived as overly aggressive. Responsible physicians will have to weigh in expected quality of life, social factors such as support from family members, age, and comorbidity.
What do we know from clinical trials? In a recent pooled analysis of (incompleted) randomized trials the natural history of a large hemispheric infarct (i.e., occlusion of the middle cerebral artery or carotid artery occlusion) was death in 60% and severe disability in nearly 30%. Comparison of the “natural history” with the outcome of patients undergoing decompressive hemicraniectomy remains seriously flawed due to unavoidable less aggressive care in non-surgically treated patients.
There is however good data showing that decompressive hemicraniectomy may be a life-saving procedure. There are also good physiologic arguments for decompressive surgery when performed early in the process. Apart from preventing permanent brainstem injury from direct compression, a reduction of intracranial pressure—even if marginally elevated—may improve cerebral blood flow and brain tissue oxygenation. These effects could allow an improved functional recovery in a proportion of survivors, as observed in recent trials.
The questions are: can we identify the best candidates for decompressive craniectomy, and what should trigger surgery in patients with hemispheric infarcts? Should this large hemicraniectomy be offered to all patients regardless of age, level of consciousness, involvement of vascular territories, or hemispheric dominance? Could early MRI predict clinical deterioration or does it only predict radiologic worsening? We have no satisfactory answers to most of these questions. Some criteria to help in a decision are shown in Table 8.1.
Timing of surgery remains undefined, but clinical deterioration is needed for most neurosurgeons to act. More than a few neurosurgeons confronted with a patient with a massive swollen infarct will still have to be convinced there is benefit to be gained from surgery. Other uncertainties are the technique of decompression—size of craniectomy, removal of additional bone from the squamous part of the temporal bone, extent of the durotomy, removal of the temporalis muscle, among other options.
TABLE 8.1 Criteria for Decompressive Craniectomy in Large Hemispheric Stroke
| Age less than 60 years |
| Rehabilitation opportunities |
| Patient able to cope with severe handicap |
| No major comorbidity |
| Any clinical deterioration in consciousness and need for intubation |
| Anticipated or documented multiple territorial involvement |
| Early (< 24 h) evidence of mass effect on CT scan |
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
