Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome

Bongiorni, Gianise Toboliski; Hockmuller, Marjeane Cristina Jaques; Klein, Cristini; Antunes, Ápio Cláudio Martins

doi:10.1590/0004-282x20170053

Cited by 14 publications

(13 citation statements)

References 19 publications

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“…Although decompressive craniectomy has been shown to effectively reduce ICP (4), there remains much controversy regarding its effect on overall clinical outcome, especially following TBI (5). Additionally, it is becoming clear that factors such as timing of decompressive craniectomy may play a significant role in determining the therapeutic benefit of this procedure.…”

Section: Introductionmentioning

confidence: 99%

Timing of Decompressive Craniectomy for Ischemic Stroke and Traumatic Brain Injury: A Review

2019

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While studies have demonstrated that decompressive craniectomy after stroke or TBI improves mortality, there is much controversy regarding when decompressive craniectomy is optimally performed. The goal of this paper is to synthesize the data regarding timing of craniectomy for malignant stroke and traumatic brain injury (TBI) based on studied time windows and clinical correlates of herniation. In stroke patients, evidence supports that early decompression performed within 24 h or before clinical signs of herniation may improve overall mortality and functional outcomes. In adult TBI patients, published results demonstrate that early decompressive craniectomy within 24 h of injury may reduce mortality and improve functional outcomes when compared to late decompressive craniectomy. In contrast to the stroke data, preliminary TBI data have demonstrated that decompressive craniectomy after radiographic signs of herniation may still lead to improved functional outcomes compared to medical management. In pediatric TBI patients, there is also evidence for better functional outcomes when treated with decompressive craniectomy, regardless of timing. More high quality data are needed, particularly that which incorporates a broader set of metrics into decision-making surrounding cranial decompression. In particular, advanced neuromonitoring and imaging technologies may be useful adjuncts in determining the optimal time for decompression in appropriate patients.

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Section: Introductionmentioning

confidence: 99%

Timing of Decompressive Craniectomy for Ischemic Stroke and Traumatic Brain Injury: A Review

2019

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“…Beyond conventional treatment, decompressive craniectomy (DC), defined as removal of cranium and subsequent durotomy/duroplasty, has become one of the treatment strategies in these patients, especially aiming at reducing the intracranial pressure (7)(8)(9)(10). Besides, both medical and decompression treatment aims to restore regional perfusion, correct midline shift, and reduce brainstem pressure (2).…”

Section: Introductionmentioning

confidence: 99%

What is the optimum time to decompressive surgery in the patients with malignant middle cerebral artery infarction?

Yücetaş¹,

Üçler²,

Kafadar³

et al. 2019

Ann Med Res

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In the patients with malignant middle cerebral artery (MCA) infarctions, the mortality was as high as 70% with conservative treatment. Decompressive craniectomy (DC) was shown to decrease mortality especially in 48 hours. We aimed to investigate both the effect of decompression time and the size of craniectomy on the mortality in this patient group. Material and Methods: 45 adult patients underwent to DC due to malignant MCA infarction were evaluated in this study. The demographic and clinical features were recorded retrospectively. The patients were splitted into three groups: Group 1, DC in the first 24 hours; group 2, in 24-48th hours; group3, in 48-96th hours of the admission. The size of craniectomy was the same as the infarct (standard), or it was two centimeters larger than the size of infarct (larger). Results: Of all patients, 53.3% (n=24) was female; and mean age of the sample was 67.38±4.76. 66.7% (n=30) of the patients died due to malign MCA infarction. The size of craniectomy was larger in 26.7% (n=12), and was standard in the others. Mean time to surgery was 43.07±29.87 hours. Mortality rate was minimum in group 2 (p=0.01). The patients undergoing to larger craniectomy survived longer than the others, but the difference was non-significant (p=0.06). Conclusion: We suggested that not the approach of "surgery as soon as possible" but the surgery between 24-48th hours of the admission would be the optimal approach. This issue is especially important, because earlier or later interventions not only have a less benefit on the outcome but also may lead several unnecessary complications.

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“…Dear Editor, We read with interest the recent article "Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcomes" 1 . Decompressive craniectomy (DC) for stroke is a well-established procedure for saving lives, despite the potential risk of it leading to severe disability in some patients.…”

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confidence: 99%

Decompressive craniectomy for stroke in Brazil

Filho

Joaquim

Bazan

et al. 2017

Arq. Neuro-Psiquiatr.

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Craniectomia descompressiva para acidente vascular cerebral no BrasilDear Editor, We read with interest the recent article "Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcomes" 1 . Decompressive craniectomy (DC) for stroke is a well-established procedure for saving lives, despite the potential risk of it leading to severe disability in some patients. Because most of the published data comes from developed countries, with different socio-cultural characteristics, the article by Bongiorni et al. is very welcome, adding new and useful information about the reality of the Brazilian health care system. The authors reported, in the 20 patients enrolled in their study, a mortality rate of 30% after a 30-day follow-up.However, we disagree with the authors when they state that theirs was "the first study that assessed the role of DC outcome in malignant MCA infarction in an academic hospital in Brazil". Actually, in 2008, Fiorot Jr et al. analyzed 18 patients, obtaining a mortality rate of 55% in 90 days. They attributed this high mortality rate to a late decision for surgery 4 presented the greater Brazilian case series, with 60 patients, showing significant differences in mortality rates in patients under, or above, 60 years of age (41% vs 67%, p = 0.039).These conflicting differences in mortality rates (as well as in functional outcomes) in the different teaching hospitals reflect the heterogeneity of analysis, indications, protocols and study designs. However, they provide useful and important information for Brazilian doctors who manage strokes. Multicenter studies, with standardized protocols, may provide more consistent information regarding the benefits of DC in our country, as well as helping with the selection of patients who may have greater benefits from this life-saving procedure considering, not only mortality, but also quality of life of the survivors.

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Decompressive craniotomy for the treatment of malignant infarction of the middle cerebral artery: mortality and outcome

Cited by 14 publications

References 19 publications

Timing of Decompressive Craniectomy for Ischemic Stroke and Traumatic Brain Injury: A Review

Timing of Decompressive Craniectomy for Ischemic Stroke and Traumatic Brain Injury: A Review

What is the optimum time to decompressive surgery in the patients with malignant middle cerebral artery infarction?

Decompressive craniectomy for stroke in Brazil

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