Decompressive craniectomy for acute ischemic stroke

Abstract

Malignant stroke occurs in a subgroup of patients suffering from ischemic cerebral infarction and is characterized by neurological deterioration due to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique aiming to open the “closed box” represented by the non-expandable skull in cases of refractory intracranial hypertension. It is a valuable modality in the armamentarium to treat patients with malignant stroke: the life-saving effect has been proven for both supratentorial and infratentorial DC in virtually all age groups. This leaves physicians with the difficult task to decide who will require early or preemptive surgery and who might benefit from postponing surgery until clear evidence of deterioration evolves. Together with the patient’s relatives, physicians also have to ascertain whether the patient will have acceptable disability and quality of life in his or her presumed perception, based on preoperative predictions. This complex decision-making process can only be managed with interdisciplinary efforts and should be supported by continued research in the age of personalized medicine.

Statistical Cerebrovascular Reactivity Signal Properties after Secondary Decompressive Craniectomy in Traumatic Brain Injury: A CENTER-TBI Pilot Analysis

“…Various studies have evaluated the utility of DC in malignant stroke, in relation to global patient outcome. 27 To date, there have not been studies evaluating continuously measured cerebrovascular reactivity pre-and post-DC. It is quite possible that different statistical time-series relationships may be seen in this pathology.…”

First-In-Human Experience With Integration of Wireless Intracranial Pressure Monitoring Device Within a Customized Cranial Implant

“… 21 , 22 Indeed, pooled subgroup analysis from multiple randomized control trialss have demonstrated consistent and significant mortality benefit of DC for malignant middle cerebral artery stroke, with a risk reduction of almost 50%. 23 Given the renewed support and research aimed at optimizing DC, parallel efforts need to be undertaken to optimize cranial reconstruction and to develop “smart” implants capable of neuromonitoring, especially for TBI and ischemic stroke patients at risk for secondary sequelae such as intracranial hypertension, hydrocephalus, and epilepsy.…”

Predictors of outcome in 1-month survivors of large middle cerebral artery infarcts treated by decompressive hemicraniectomy

“…Short delays from symptom onset to surgery independently predicted early mortality but not long-term outcome. To date, the impact of timing is still uncertain, especially when surgery is performed within the first 48 hours from stroke onset 32–34. Shorter delays predicted early mortality probably because, in clinical practice, neurologically severe patients are referred to the hospital with shorter delays and, once arrived, they are rapidly operated.…”