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4 - 01-03-07 - J Neurosurg 2007 - Decompressive Hemicraniectomy in Malignant MCA Infarction
4 - 01-03-07 - J Neurosurg 2007 - Decompressive Hemicraniectomy in Malignant MCA Infarction
Object. Middle cerebral artery infarction often occurs at a younger age than other strokes and is associated with sig-
nificant rates of mortality and morbidity. After a period of pessimism regarding decompressive hemicraniectomy in the
management of acute stroke, the method has reemerged in the past decade. The present study was undertaken to assess
the immediate and long-term outcome of this intervention and to help better define the selection criteria for surgery.
Methods. The authors conducted a nonrandomized prospective study using decompressive hemicraniectomy with
duraplasty in patients at various stages of clinical deterioration due to a space-occupying middle cerebral artery infarct.
Patients were assessed at 6 and 12 months postinfarction by using functional scales. Subjective reconsideration was as-
sessed using a questionnaire.
Twenty-six patients were included in the study. The mean age was 48.4 6 11.2 years, and the mean preoperative
Glasgow Coma Scale score was 9.9 6 3.2. The median time from ictus to surgery was 54 hours (range 13–288 hours).
The rate of survival at 1 year postsurgery was 73%. Among survivors, 33.3% were independent (Barthel Index [BI] .
95) and 55.6% were partially dependent (BI 60–95) at 1 year postsurgery, with 72% attaining the ability to walk inde-
pendently by 1 year postsurgery. No patient remained in a vegetative state. The 1-year BI score was inversely related
to patient age (r = 20.47, p = 0.048).
Conclusions. Survival after decompressive hemicraniectomy was better than previously reported using medical man-
agement alone. A vegetative state was avoided and functional independence was possible, especially in younger pa-
tients. Increasing age was a statistically significant predictor of disability and long-term functional dependence.
IDDLE cerebral artery infarction often results in sig- ICP. The outcome in such cases with the best medical man-
Data from several previous studies have already demon- Surgical Procedure
strated improved outcomes in surgically treated patients Decompressive hemicraniectomy was performed using
compared with medically treated controls.2,12,16,18 The objec- a large frontoparietotemporal curvilinear incision. A large
tives of the present prospective nonrandomized study were hemicraniectomy bone flap, including the frontal, parietal,
as follows: 1) to help better define the selection criteria for and temporal squamous bone, was removed. The temporal
performing decompressive hemicraniectomy in cases of squama was removed to the middle cranial fossa floor to re-
malignant MCA infarcts; 2) to assess the immediate out- duce the chance of subsequent uncal herniation. A curvilin-
come in terms of time to conscious recovery and survival; ear dural incision was used with radial cuts following major
and 3) to assess long-term outcome using standard QOL sulcal vessels to prevent kinking at the dural margin by ede-
and functional assessment scales. matous brain. No brain parenchyma was resected. A lax du-
raplasty was performed using pericranium and temporalis
Clinical Material and Methods fascia.
Postoperative Management
Selection Process and Inclusion Criteria
Postoperatively, all patients were sedated and paralyzed
Patients presenting with acute MCA infarction to the and received ventilation for a minimum of 48 hours. After
Amrita Institute of Medical Science, a tertiary care univer- obtaining a CT scan at 48 hours postsurgery, sedation and
sity teaching hospital, during the period between August paralysis were withdrawn and ventilation was stopped as
2001 and September 2004 were considered for enrollment soon as patients were conscious with spontaneous eye open-
in this study. An institutional protocol was formed with ing and a localizing motor score. Tracheostomy was per-
inclusion criteria (Table 1). Informed consent was obtained formed to facilitate ventilator weaning if the endotracheal
after detailed discussion with the relatives regarding the tube had not been removed by the 7th postoperative day.
option of surgical decompression to improve the chance of Barbiturates were not administered.
survival given the expected long-term neurological seque-
lae. Patients with both dominant- and nondominant-hemi- Bone Flap Storage and Reimplantation
sphere infarcts satisfying the CT criteria (Table 1) but not
yet showing clinical signs of deterioration were admitted to Bone flaps were stored at –70˚C until reimplantation. At
the stroke unit and underwent surgery only if the clinical 12 to 20 weeks postsurgery, the bone flap was reimplant-
criteria were met. If the initial CT scan failed to meet the se- ed after having been disinfected by boiling in sterile saline
lection criteria, the scan was repeated within 12 to 24 hours (first six patients) or autoclaving (last 20 patients).17
or as soon as significant neurological worsening occurred Outcome Analyses and Long-Term Follow Up
whenever there was clinical suspicion of a large cortical
infarct. All patients were assessed just before surgery using the
GCS, NIHSS, and standard neurological examination. The
Medical Management immediate outcome measures included the number of days
to conscious recovery (assessed by spontaneous eye-open-
All patients were admitted to the acute stroke unit and ing and localizing motor score), the number of days of ven-
treated with osmotic therapy (20% mannitol 0.5-g/kg bolus tilation, and the duration of the ICU stay. In all except two
followed by 0.25–0.5 g/kg every 4–6 hrs, furosemide 10–20 of the surviving patients (one lost to follow up and one fol-
mg every 4–6 hrs). Patients meeting the inclusion criteria lowed up telephonically), long-term follow up was main-
despite maximum medical therapy underwent surgery with- tained through regular outpatient clinic visits. At each visit
in 4 to 6 hours. Patients presenting with a poor GCS score the patients were assessed using the NIHSS, BI, GOS, and
(, 9) or pupil asymmetry immediately underwent intuba- the FIM walking score. With regard to assessment with the
tion and received ventilation; all other patients received GOS scale, a score of 4 (moderate disability) meant that the
ventilation just prior to surgery. patient was independently mobile at home and performing
activities beyond the activities of daily living but had mod-
erate motor aphasia precluding involvement in all previous
activities and/or severe hemiparesis preventing functional
use of the paretic arm. To further assess the QOL, a subjec-
TABLE 1 tive retrospective reconsideration questionnaire was sent to
Selection criteria for study inclusion all survivors. On this questionnaire, the patient (if possible)
Variable Description
and the relative involved in the most caregiving (general-
ly a spouse, parent, or child of the patient) were asked the
age #65 yrs question, “If you were faced with a similar situation in the
CT findings large hypodensity in .50% of the MCA territory future for yourself or someone close to you, would you
w/ significant effacement of sulci & ventricles again make the same decision?” The answer was recorded
midline shift using a five-point scale (1 = definitely no, 5 = definitely
GCS score #14 (nondominant hemisphere) or #9 (domi-
nant hemisphere) yes).
herniation/brainstem no signs
reflexes
Statistical Analysis
operative risk acceptable regarding other major comorbidities Statistical analyses were performed using SPSS software
(for example, coronary artery disease, renal (standard version 11.01; SPSS, Inc.). Continuous variables
failure, and so forth)
were reported as the means 6 SD. Categorical variables
TABLE 3
Summary of long-term outcome characteristics
No. (%)
Variable 6 Mos 1 Yr
(4 = probably yes, 5 = definitely yes). When an outlying our data and that from the available literature, we propose
point (that from a 65-year-old patient who died after 21 that younger patients with infarcts in the nondominant
months) was removed, we observed a significant downward hemisphere are likely to benefit significantly and thus
trend (r = 20.61, p = 0.028, Spearman correlation) in the re- should undergo surgery. Although patients with dominant-
consideration score over time (Fig. 1B). hemisphere infarcts are likely to survive with more dis-
abling deficits, surgery can be undertaken with the hope of
Surgical Complications and Other Long-Term Sequelae reducing the hospital stay and rates of morbidity and mor-
Two patients suffered postoperative extradural hemato- tality. We are reluctant to operate on elderly patients (. 65
mas requiring reexploration and evacuation. Three patients years age) given that they tend to recover poorly (Table 4).
(one receiving anticoagulation therapy for atrial fibrillation) Data from animal studies certainly support the proposal
had hematomas after reimplantation of the bone flap—one for earlier surgery. A reversal of the diffusion/perfusion
thin chronic subdural hematoma and two extradural hema- mismatch on magnetic resonance imaging studies was dem-
tomas, both of which resolved with conservative manage- onstrated in rats undergoing experimental MCA occlusion
ment. There were three cases of delayed osteomyelitis of followed by early decompressive hemicraniectomy, thus in-
the reimplanted bone flap. One of these cases subsided with dicating salvage of ischemic penumbra.5,6 A statistically sig-
antibiotic treatment and two involved extradural abscesses nificant, time-to-surgery–dependent improved functional
requiring drainage and delayed acrylic cranioplasty. There outcome and a decrease in the infarct volume of killed ani-
were no cases of meningitis. The incidence of delayed mals were also demonstrated. It was proposed that decom-
(poststroke) generalized seizures by the 6th to 12th month pressive hemicraniectomy helps in the reestablishment of
postsurgery (seven [37%] of 19 patients) was significantly leptomeningeal collateral vessels, which are lost when com-
greater than the reported incidence for poststroke epilepsy pressed by edematous brain, ultimately leading to a reduced
(4.1–13%).19 The control of seizures often required anticon- infarct volume. Severe brain edema causes a regional in-
vulsion polytherapy. Two patients (8%) suffered major os- crease in ICP, further reducing the regional cerebral perfu-
teoporotic fractures of the paretic lower limb requiring sur- sion pressure and cerebral blood flow, which may potenti-
gical internal fixation at 2 to 2.5 years postinfarction. ate further infarction and thus create a vicious cycle (Fig. 2).
Decompressive hemicraniectomy probably helps to break
this cycle.
Discussion
Radiological Selection Criteria
Selection Criteria
Computed tomography inclusion criteria described to
As decompressive hemicraniectomy emerges as a viable date have generally involved MCA infarction greater than
treatment option for a select group of patients with space- 50% of the MCA territory together with findings of mass
occupying MCA infarction, an institutional protocol involv- effect. Specifically, we used midline shift in this study.
ing the stroke neurologist, intensivist, and neurosurgeon is Several authors have included hemorrhagic transformation
required for timely identification of patients who will bene- among the exclusion criteria. In the present study, we did
fit from this intervention. Several other investigators report- not observe any difference in outcome in this subgroup of
ing poor results seemed either to utilize decompressive sur- patients. Authors of one large-scale retrospective study de-
gery as a salvage therapy in patients at various stages of scribed volumetric analysis to predict malignant behavior,
herniation or operate on an older population. A comparison that is, an infarct volume of 200 cm3 having a 91% accura-
of initial study data published by Rieke et al.16 with that by cy for predicting malignant behavior.12 As there is a trend
Schwab et al.18 supports the notion that outcome is worse toward earlier surgery, there may be a more important role
when surgery is performed during the stages of herniation. for diffusion-weighted magnetic resonance imaging as de-
Authors of several previously reported studies have shown scribed in several recent reports.2
an improved outcome when surgery is undertaken earlier
in the course of neurological deterioration.2,15,18 A higher
Technical Considerations in Decompressive
chance of a vegetative outcome when surgery is performed
Hemicraniectomy
in the late stages of herniation has been reported.15 Our
study data failed to demonstrate a direct correlation between Authors of other case series have reported on the removal
clinical outcome and timing of surgery from the acute onset of edematous temporal lobe to achieve further reduction in
of symptoms due to ischemia. We believe that the stage of ICP and prevent herniation.2 With the possible exception of
clinical deterioration rather than the time since infarction is hemispheric infarcts involving all three arterial territories,
probably more important in determining outcome. Based on we found that this step was generally not necessary. A gen-
TABLE 4
Proposed selection of patients for decompressive hemicraniectomy
Candidacy Age (yrs) Infarct Location
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1988 Address reprint requests to: Dilip Panikar, M.Ch., Department of
12. Mori K, Nakao Y, Yamamoto T, Maeda M: Early external decom- Neurosurgery, Amrita Institute of Medical Sciences, Amrita Vishwa
pressive craniectomy with duroplasty improves functional recov- Vidyapeetham University, Amrita Lane, Elamakkara P.O., Kochi,
ery in patients with massive hemispheric embolic infarction: tim- Kerala, India 682026. email: panikar@aims.amrita.edu.