Decompressive craniectomy in a rat model of “malignant” cerebral hemispheric stroke: experimental support for an aggressive therapeutic approach

Abstract

Acute ischemia in the complete territory of the carotid artery may lead to massive cerebral edema with raised intracranial pressure and progression to coma and death due to uncal, cingulate, or tonsillar herniation. Although clinical data suggest that patients benefit from undergoing decompressive surgery for acute ischemia, little data about the effect of this procedure on experimental ischemia are available. In this article the authors present results of an experimental study on the effects of decompressive craniectomy performed at various time points after endovascular middle cerebral artery (MCA) occlusion in rats. Focal cerebral ischemia was induced in 68 rats using an endovascular occlusion technique focused on the MCA. Decompressive craniectomy was performed in 48 animals (in groups of 12 rats each) 4, 12, 24, or 36 hours after vessel occlusion. Twenty animals (control group) were not treated by decompressive craniectomy. The authors used the infarct volume and neurological performance at Day 7 as study endpoints. Although the mortality rate in the untreated group was 35%, none of the animals treated by decompressive craniectomy died (mortality 0%). Neurological behavior was significantly better in all animals treated by decompressive craniectomy, regardless of whether they were treated early or late. Neurological behavior and infarction size were significantly better in animals treated very early by decompressive craniectomy (4 hours) after endovascular MCA occlusion (p < 0.01); surgery performed at later time points did not significantly reduce infarction size. The results suggest that use of decompressive craniectomy in treating cerebral ischemia reduces mortality and significantly improves outcome. If performed early after vessel occlusion, it also significantly reduces infarction size. By performing decompressive craniectomy neurosurgeons will play a major role in the management of stroke patients.

Effect of early bilateral decompressive craniectomy on outcome for severe traumatic brain injury

“…Following DC and dura opening, the edematous brain may herniate through the craniectomy opening rather than through the tentorial incisura, which prevents brainstem compression (7,8). More sufficient decompression and suitable ICP decreases may be achieved if this extracalvarial movement is bilateral.…”

Effects of decompressive surgery in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils

“…[6,26] It is widely accepted that DS should not be postponed so long that irreversible brainstem changes, such as Duret hemorrhages, occur. [17] However, the optimal time at which DS should be performed remains debatable.…”

“…According to the EBIC and the American Brain Injury Consortium (ABIC) guidelines for SHI, [12,15] DS is one therapeutic option for brain edema that does not respond to conventional therapeutic measures such as hyperventilation, osmotherapy with mannitol, ventricular drainage of CSF, and metabolic suppression therapy. [12,[16][17][18][19][20] However, specific indications and timing for this intervention have not been standardized as yet. It has been reported that the indications for DS in patients with SHI are the appearance of diffuse unilateral or bilateral brain swelling with correlating clinical deterioration; worsening of GCS score and/or dilation of pupils unresponsive to light; therapy-resistant increase in ICP to >30 mmHg and/or a reduction in CPP to <45 mmHg; and initial GCS score of ≥4 and a GCS score of at least 4 on the 1st posttraumatic day.…”

Effect of Decompressive Craniectomy on Outcome Following Subarachnoid Hemorrhage in Mice

“…9 In recent years, both animal and clinical studies reported beneficial effects of DC for treating conditions, such as traumatic brain injury 10,11 and malignant middle cerebral artery (MCA) infarction. 12,13 With respect to SAH, however, relatively few studies have been published regarding the application of DC and its effect on outcome; moreover, the results published to date are contradictory and controversial. [14][15][16][17][18] To address these questions, we performed DC to evaluate the role of SAH-induced elevated ICP and subsequent global ischemia and to investigate whether DC may serve as a therapeutic option for SAH using a standardized animal model.…”