I.

Evidence-based Nursing Present Practice Evidenced-Based Nursing

Recommendations to Present Practice The endovascular treatment of Removal of skull sections has Decompressive acute ischemic stroke has been been suggested as a drastic Craniotomy is a procedure revolutionized in the past years by measure for the management performed to relieve the introduction of new devices for of elevated ICP unresponsive pressure inside the skull. It mechanical thrombectomy. to other therapies. It is is commonly done to Several tools were already thought that surgical relieve the pressure caused available in 2008. The majority decompression could improve by mass effect, which can allowed the recanalization of the damage caused by occur after strokes, bleeds acutely occluded intracranial secondary injury (delayed and/or trauma. In order to arteries with acceptable levels of brain damage) such as high prevent damage to the safety and efficacy, and with ICP and reduced oxygenation delicate tissues of the occasional failures. of the brain. In a recent metabrain, during this analysis by Sahuquillo and procedure, a section of the In 2003, completely independent Arikan (2006), the authors skull is removed to allow a of the efforts on engineering stroke identified two types of relief of the intracranial devices, a new stent for the surgical decompression: pressure, which gives the endovascular treatment of prophylactic or primary brain space to swell intracranial aneurysms was decompression and without causing further developed by Dendron (Bochum, therapeutic or secondary damage. Germany).This stent received the decompressive craniectomy. CE mark in 2004. Dendron was The former involves The concept of acquired by MTI (Irvine, performing the surgical decompressive California, USA) in 2002. The procedure as a preventive craniectomy is by no Solitaire stent now manufactured measure against expected means novel; it can be and distributed by ev3 (Irvine, increases in ICP while the defined as the removal of a California, USA), became latter is performed to control large area of skull to available for the treatment of wide high ICP refractory to increase the potential necked aneurysms in Europe in maximal medical therapy volume of the cranial December 2007. (Sahuquillo & Arikan, 2006). cavity (Fig. 1). At the However, debate regarding if beginning of the last Solitaire(tm) FR Revascularization and when to perform these century, Kocher, asserted Device is a mechanical surgeries continues. Factors that "if there is no CSF thrombectomy device combining such as age and initial GCS pressure, but brain pressure the ability to restore blood flow, score have been proposed as exists, then pressure relief administer medical therapy, and potential prognostic factors must be achieved by retrieve clot in patients (Guerraet al., 1999; Munchet opening the skull." Since experiencing acute ischemic al., 2000). Of course, any then, decompressive stroke. It mechanically breaks up surgical procedure is craniectomy has been in and removes the blood clot. It has associated with inherent risks. and out of vogue with the optimal radial force for flowing The majority of recognition that, although through all clot types, stable decompressive techniques are the procedure is recanalization for the adjunctive therefore precipitated by

theoretically attractive, a number of fundamental questions remain as to whether or not it should be performed. Across a spectrum of pathological entities, there is concern that the operation is performed unnecessarily in patients who have a good prognosis with medical treatment alone and that decompressive craniectomy can save lives by controlling brain edema but could shift outcome to vegetative state and severe disability. What is different about this procedure now, compared with several years ago, however, is that it is being performed in the context of modern intensive care as part of protocol-driven therapy and is being evaluated in randomized controlled trials.

use of medical therapy, and optimal metal to tissue ratio for reliable clot retrieval. It has demonstrated effective clot removal in vessels sized 2 to 5.5 mm. The primary goal of the ideal endovascular treatment of acute ischemic stroke is the fast and technically simple recanalization of the occluded vessel(s) with the least possible vessel wall injury, without displacement of thrombotic material either distally or proximally from the primary site of occlusion, and without any impact on the coagulation system. Because of the different pathophysiology, lessons learned from coronary interventions for myocardial ischemia can only partly be used for the treatment of cerebral ischemia. The different underlying causes of cerebral artery occlusion (eg, cardioembolic, arterio-arterial and veno-arterial emboli; cerebral artery stenosis, plaque or dissection) require different methods and tools for revascularization. Thrombectomy with the Solitaire stent was an incidental success, neither planned nor anticipated during the development of the device. The essential constructive features of the device (eg, the eccentric fixation to the insertion wire, a longitudinal slit, the mesh size and the radial force) were found to be adequate for the retrieval of thrombus and coils.
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evacuation of a mass lesion (Compagnoneet al., 2005). Once decompression is decided upon, resection of a larger bone fragment is generally recommended to allow for greater dural expansion with less risk of herniation (Compagnone et al., 2005; Skoglundet al.,2006; Csokay et al., 2001) Therapeutic decompressive craniectomy is only performed after other therapeutic measures (CSF drainage, moderate hypocapnia, mannitol, barbiturates, hyperventilation, hypothermia etc.) have failed to control ICP (Morgallaet al., 2008). A 2006 Cochrane review found no evidence to recommend routine use of decompressive craniectomy to reduce unfavorable outcomes in adults with uncontrolled ICP (Sahuquillo & Arikan, 2006). However, they do recommend that decompressive craniectomy may be a useful option in the pediatric population when maximal medical treatment has failed to control ICP.

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