Predictors of clinical failure of decompressive hemicraniectomy for malignant hemispheric infarction

Highlights

• Retrospective study of patients with decompressive craniectomy for malignant MCA infarct.

• Treatment failure defined based on imaging and clinical criteria.

• Preoperative anisocoria was the only variable predicting treatment failure.

• Patients with preoperative anisocoria might be candidates for strokectomy.

Abstract

Object

The aim of this study is to identify pre-operative clinical and/or radiological predictors of clinical failure of decompressive hemicraniectomy (DH) in the setting of malignant hemispheric infarction. These predictors could guide the decision for adjunctive internal brain decompression (e.g. strokectomy) at the time of the initial DH.

Methods

Retrospective chart review of all patients with malignant hemispheric infarction who underwent DH at our institution, from November 2008 to January 2013. Demographics, pre- and post-operative clinical characteristics and neuroimaging data were reviewed. The surgical outcome after DH was evaluated and clinical failure was defined as follows: lack of post-operative resolution of basal cistern effacement, and/or failure to achieve a post-operative decrease in midline shift by at least 50%, and/or post-operative neurological deterioration felt to be due to persistent mass effect, with or without a second, salvage operation (strokectomy).

Results

Out of 26 patients included in the study, 7 were considered to have clinical failure of their DH. Preoperative clinical and imaging variables were similar in the two groups, except that the presence of a nonreactive pupil immediately before surgery was associated clinical failure of the DH (p = 0.0015). Patients in the clinical failure group had a lower postoperative GCS motor score and a strong but not statistically significant trend towards less favorable functional outcome (GOS 1–3).

Conclusions

The presence of a nonreactive pupil before surgery is associated with clinical failure of DH, and should be taken into account when deciding whether to perform strokectomy at the time of DH.

Introduction

Decompressive hemicraniectomy (DH) is an established procedure for the management of malignant brain edema complicating the course of massive hemispheric infarctions. Class I evidence from three randomized, controlled clinical trials support the concept that, when performed within 48 h of stroke onset, DH reduces mortality and increases the incidence of favorable functional outcomes (modified Rankin Scale score ≤ 4) in patients < 60 years of age [2], [5], [18]. Unfortunately, some patients develop severe edema in the affected hemisphere that is not effectively relieved by simple expansion of the cranial vault and dura, which may result in poor outcomes after conventional DH. Resection of infarcted frontal and/or temporal lobe (“strokectomy”) has been proposed in order to optimize surgical decompression after ischemic hemispheric stroke [9]. However, strokectomy involves removal of what might include viable brain tissue, and many patients with ischemic stroke receive preoperative antiplatelet agents, making hemostasis difficult after resection of even infarcted brain tissue. For these reasons, our surgeons do not routinely perform strokectomy at the time of DH. We have encountered several patients who had persistent and dramatic midline shift after DH, with or without neurologic deterioration, who then underwent strokectomy. The need for two consecutive surgeries introduced additional surgical risks, and delays in achieving adequate decompression of the non-infarcted brain. We decided to retrospectively study our experience with DH for ischemic hemispheric stroke in order to identify variables which might identify patients for whom strokectomy should be considered at the time of DH.