Hemicraniectomy with dural augmentation in medically uncontrollable hemispheric infarction

Abstract

<jats:p>Surgical decompression to alleviate raised intracranial pressure has been reported repeatedly in the past decades in small series of patients. Only recently have there been indications from larger trials that surgical decompression may be beneficial in treating space-occupying hemispheric infarction. However, surgical requirements for the procedure to be effective have not yet been defined.</jats:p> <jats:p>Based on theoretical criteria, the authors operated on 43 patients with medically uncontrollable hemispheric infarctions. The craniectomies were planned to be as large as possible and performed in combination with a subtemporal decompression. Postoperative computerized tomography scans were evaluated for these criteria.</jats:p> <jats:p>The mean survival rate for the group of 43 patients was 72.1% and no surviving patient ended up in a vegetative state. The mean area of craniectomy was found to be 84.3 ± 16.5 cm<jats:sup>2</jats:sup> and the mean distance of the inferior craniectomy margin to the middle fossa was 1.8 ± 1.3 cm. Comparison of survivors and nonsurvivors failed to show a significant difference in the size of craniectomy or the distance to the floor of the middle fossa.</jats:p> <jats:p>Compared with the reported 80% fatality rate for medically treated stroke patients, in this subgroup the outcome (72.1% survival rate) is remarkably good. The authors conclude that decompressive craniectomy is an effective treatment, able to reduce mortality, and to improve neurological outcome in patients with space-occupying cerebral infarction if the size of craniectomy is large enough. Nevertheless, there is a need for further investigation to identify patients who will benefit from surgery and predictors to optimize the timing of surgical intervention.</jats:p>

Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction

“…Recent studies have shown that early decompressive hemicraniectomy decreases mortality to 16-42 % [4, 6, 15, 16, 17, 26, 27, 31, 32, 33, 34, 38]. The aim of decompressive surgery is to give room for expansion of the swelling, restore cerebral perfusion and optimize retrograde perfusion through leptomeningeal collateral vessels [7,40]. Since young patients are especially affected by malignant middle cerebral infarctions, in addition to reducing the death rate, lowering morbidity and improving quality of life are essential goals of decompressive hemicraniectomy.…”

Decompressive Hemicraniectomy in Patients With Supratentorial Intracerebral Hemorrhage

“…The opening of the dura was performed in a stellate fashion, and the exposed brain was covered by the loosely replaced dura, then covered with Surgicel (Ethicon, Inc., NJ) in accordance with the rapid closure technique. [14][15][16] …”

Decompressive hemicraniectomy after malignant middle cerebral artery infarction: rationale and controversies

“…This conclusion is validated by the fact that some studies suggest that doubling the diameter from 6 cm to 12 cm potentially increases the decompressive volume from 9 to 86 ml. 26,29 Ideally, hemicraniectomy should be performed in the frontotemporoparietal region and reach the floor of the middle cranial fossa. The midline should be spared to avoid injury to the superior sagittal sinus.…”