Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review

Abstract

Purpose Malignant stroke is a life-threatening emergency, with a high mortality rate (1–3). Despite strong evidence showing decreased morbidity and mortality in the adult population, decompressive hemicraniectomy (DCH) has been scarcely reported in the pediatric stroke population, and its indication remains controversial, while it could be a potential lifesaving option. Methods and results We performed an extensive literature review on pediatric malignant arterial ischemic stroke (pmAIS) and selected 26 articles reporting 97 cases. Gathering the data together, a 67% mortality rate is observed without decompressive therapy, contrasting with a 95.4% survival rate with it. The median modified Rankin score (mRS) is 2.1 after surgery with a mean follow-up of 31.8 months. For the 33% of children who survived without surgery, the mRS is 3 at a mean follow-up of 19 months. As an illustrative case, we report on a 2-year-old girl who presented a cardioembolic right middle cerebral artery stroke with subsequent malignant edema and ongoing cerebral transtentorial herniation in the course of a severe myocarditis requiring ECMO support. A DCH was done 32 h after symptom onset. At the age of 5 years, she exhibits an mRS of 3. Conclusion Pediatric stroke with malignant edema is a severe condition with high mortality rate if left untreated and often long-lasting consequences. DCH might minimize the vicious circle of cerebral swelling, increasing intracranial pressure and brain ischemia. Our literature review underscores DCH as an efficient therapeutic measure management of pmAIS even when performed after a significant delay; however, long-lasting morbidities remain high.

Severe Pediatric Open Skull Fracture With Exposed Brain Matter: A Case Report

“…For instance, the RESCUEicp trial assessed 408 patients aged 10-65 years with TBI and increased ICP and found that usage of decompressive craniectomy would increase the number of survivors and percentage of individuals being independent at home after the procedure [ 10 ]. Signs of brain herniation and anisocoria are clear indications for the usage of decompressive craniectomy, and the procedure has shown promise as a treatment option for increased ICP after a pediatric TBI [ 10 , 11 ]. Temporal lobectomy may serve as an additional surgical intervention to help combat progressively increasing ICP after a severe TBI [ 12 ].…”