Hemicraniectomy with dural augmentation in medically uncontrollable hemispheric infarction.

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. 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. 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 cm2 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. 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.

[1]  R. Kjellberg,et al.  Bifrontal decompressive craniotomy for massive cerebral edema. , 1971, Journal of neurosurgery.

[2]  M. Numoto,et al.  Surgical Decompression for Cerebral and Cerebellar Infarcts , 1974, Stroke.

[3]  J. Ausman,et al.  Decompressive craniectomy for the encephalopathy of Reye's syndrome. , 1976, Surgical neurology.

[4]  P. Cooper,et al.  Enhancement of experimental cerebral edema after decompressive craniectomy: implications for the management of severe head injuries. , 1979, Neurosurgery.

[5]  R. Spetzler,et al.  Therapeutics for focal cerebral ischemia. , 1980, Neurosurgery.

[6]  G. Tomei,et al.  Traumatic brain lacerations in children: surgical results and follow-up. , 1981, Child's brain.

[7]  D. Lewis,et al.  Massive cerebral edema associated with fulminant hepatic failure in acetaminophen overdose: possible role of cranial decompression. , 1981, The American journal of gastroenterology.

[8]  S. Batnitzky,et al.  Hemicraniectomy for acute massive cerebral infarction. , 1981, Neurosurgery.

[9]  K. Smith,et al.  Surgical decompression after cerebral hemispheric stroke: indications and patient selection. , 1982, Southern medical journal.

[10]  T. Yoshimoto,et al.  Clinical course of acute middle cerebral artery occlusion. , 1986, Journal of neurosurgery.

[11]  A. Ropper,et al.  Lateral displacement of the brain and level of consciousness in patients with an acute hemispheral mass. , 1986, The New England journal of medicine.

[12]  D. Kondziolka,et al.  Functional recovery after decompressive craniectomy for cerebral infarction. , 1988, Neurosurgery.

[13]  W C Broaddus,et al.  Treatment of right hemispheric cerebral infarction by hemicraniectomy. , 1990, Stroke.

[14]  E. Nussbaum,et al.  Complete temporal lobectomy for surgical resuscitation of patients with transtentorial herniation secondary to unilateral hemispheric swelling. , 1991, Neurosurgery.

[15]  H. Klugkist,et al.  Surgical treatment of space-occupying cerebellar infarctions--4 1/2 years post-operative follow-up. , 1991, Neurosurgical review.

[16]  D. Krieger,et al.  General Principles in the Treatment of Acute Ischemic Stroke , 1991 .

[17]  R. Heros.  Surgical treatment of cerebellar infarction. , 1992, Stroke.

[18]  T. Lee,et al.  Treatment of Cerebellar Infarction by Decompressive Suboccipital Craniectomy , 1992, Stroke.

[19]  H. Yonas,et al.  An aggressive approach to massive middle cerebral artery infarction. , 1993, Archives of neurology.

[20]  D. Krieger,et al.  Monitoring therapeutic efficacy of decompressive craniotomy in space occupying cerebellar infarcts using brain-stem auditory evoked potentials. , 1993, Electroencephalography and clinical neurophysiology.

[21]  W Hacke,et al.  Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. , 1994, AJNR. American journal of neuroradiology.

[22]  W. Hacke,et al.  Intensive Care of Acute Ischemic Stroke , 1994 .

[23]  W. Hacke,et al.  Decompressive craniectomy for cerebral infarction. An experimental study in rats , 1995 .

[24]  D. Krieger,et al.  Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial. , 1995, Critical care medicine.

[25]  W. Hacke,et al.  Decompressive craniectomy for cerebral infarction. An experimental study in rats. , 1995, Stroke.

[26]  D. Krieger,et al.  [Craniectomy in space-occupying middle cerebral artery infarcts]. , 1995, Der Nervenarzt.

[27]  W. Hacke,et al.  The value of intracranial pressure monitoring in acute hemispheric stroke , 1996, Neurology.

[28]  W. Hacke,et al.  'Malignant' middle cerebral artery territory infarction : Clinical course and prognostic signs , 1996 .

[29]  W. Hacke,et al.  Decompressive craniectomy in a rat model of "malignant" cerebral hemispheric stroke: experimental support for an aggressive therapeutic approach. , 1996, Journal of neurosurgery.