Predictors of clinical failure of decompressive hemicraniectomy for malignant hemispheric infarction
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.
Section snippets
Study design
Approval was obtained from the University of Miami Institutional Review Board prior to commencing this retrospective chart review study. Departmental billing records were used to identify patients undergoing DH for supratentorial ischemic stroke between November 2008 and January 2013 at our institution, a time period for which comprehensive electronic medical records and archived imaging studies were available for review. Patients with ischemic stroke in the setting of severe head trauma,
Results
We identified 32 patients who underwent a DH for cerebral edema. Six were excluded for the following reasons: 2 subarachnoid patients, 2 patients were admitted for a cardiac arrest and then developed the ischemic stroke, 1 patient developed a hemorrhagic conversion of a previous ischemic stroke and 1 patient was an oncology patient with pancytopenia.
Twenty six patients met our inclusion criteria and were analyzed. Of these, 7 patients (clinical failure group) had at least one adverse outcome
Strokectomy for treatment of malignant hemispheric infarction
There is a robust and growing body of literature supporting DH in the setting of supratentorial ischemic MCA stroke with significant edema and mass effect. The DH procedure is relatively straightforward, rapid, and associated with acceptably low risk of hemorrhage and damage to viable brain tissue in the affected hemisphere; our experience suggests that this is true even in the setting of patients receiving antiplatelet agents such as aspirin. While strokectomy is often performed for treatment
Conclusions
The presence of a nonreactive pupil preoperatively is associated with a greater likelihood of clinical failure of DH in the setting of hemispheric ischemic stroke, and should be considered as one of many clinical considerations when deciding whether strokectomy should be performed concurrently with DH. Further larger studies are needed to validate our finding, identify additional predictors of malignant edema refractory to simple DH, and ultimately answer the question of whether strokectomy
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Herniation despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Strokes
2018, Journal of Stroke and Cerebrovascular DiseasesCitation Excerpt :Timely decompressive surgery for malignant MCA stroke has demonstrated a marked reduction in mortality to approximately 30%.3-5 Despite DHC, lack of clinical improvement secondary to progressive herniation necessitating a second decompressive procedure and mortality has been reported.6-11 Common causes of mortality in patients that underwent DHC include various neurological factors (e.g., herniation, new infarctions, and hemorrhagic complications), non-neurological factors (e.g., pulmonary embolism, pneumonia, sepsis, and myocardial infarction), and withdrawal of care.3,9,12,13
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2021, AORN JournalCitation Excerpt :The nurse should monitor patients for signs of increased ICP, such as pupillary changes and Cushing’s triad, which are indications of a poor outcome trajectory.12 Patients with worsening herniation status after DHC often will have a nonreactive pupil before decompression.19 Additional complications after DHC may include bleeding, infections, seizures, hydrocephalus, contralateral subdural effusions, external brain tamponade, and delayed paradoxical herniation.20
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2021, Journal of Neurosurgical Sciences