J Cerebrovasc Endovasc Neurosurg.  2019 Sep;21(3):138-143. 10.7461/jcen.2019.21.3.138.

Maximum Decompressive Hemicraniectomy for Patients with Malignant Hemispheric Infarction

• Kwak Y
• Kim BJ
• Park J

• KMID: 2465243
• DOI: http://doi.org/10.7461/jcen.2019.21.3.138

Abstract

OBJECTIVE
The authors applied maximum external decompression for malignant hemispheric infarction and investigated the functional outcome according to the patient age.
METHODS
Twenty-five patients with malignant hemispheric infarction were treated using a hemicraniectomy with maximum external decompression, comprising a larger (>14cm) hemicraniectomy, resection of the temporalis muscle and its fascia, spaciously expansive duraplasty, and approximation of the skin flap. The medical and diagnostic imaging records for the patients were reviewed, and 1-year functional outcome data obtained for the younger group (aged ≤ 60 years) and elderly group (aged > 60 years).
RESULTS
The patients (n=25) who underwent maximum surgical decompression revealed a minimal mortality rate (n=2, 8.0%). The patients (n=14) in the younger group all survived with mRS scores of 2 (n=1, 7.1%), 3 (n=7, 50.0%), 4 (n=3, 21.4%), or 5 (n=3, 21.4%). A majority of the younger patients (57.1% with mRS ≤3) lived with functional independence. When the 1-year mRS scores were dichotomized between favorable (mRS ≤3) and unfavorable (mRS ≥4) outcomes, the younger group had significantly more patients with a favorable outcome than the elderly group (57.1% versus 9.1%, p=0.033). In contrast, in the elderly group, most patients showed unfavorable outcomes with the mRS scores of 4 (n=5, 45.5%), 5 (n=3, 27.3%), or 6 (n=2, 18.2%), whereas only one patient showed favorable outcome (mRS 3). A majority of the elderly patients (45.5% with mRS 4) survived with moderately severe disability.
CONCLUSION
For malignant hemispheric infarction, a hemicraniectomy with maximum external decompression was found to considerably increase survival with a favorable outcome in functional independence (mRS ≤3) for younger patients aged ≤60 years. It can be optimal surgical treatment for younger patients.

Keyword

Cerebral infarction; Decompressive hemicraniectomy; Surgical decompression; Temporalis muscle; Treatment outcome

MeSH Terms

Aged
Cerebral Infarction
Decompression
Decompression, Surgical
Diagnostic Imaging
Fascia
Humans
Infarction*
Mortality
Skin
Treatment Outcome

Figure

• 

  Fig. 1 Intraoperative photograph showing hemicraniectomy with maximum external decompression. The temporalis muscle (arrows) and its fascia are cut at the level of the zygomatic arch.

Reference

1. Bruno A, Akinwuntan AE, Lin C, Close B, Davis K, Baute V, et al. Simplified modified rankin scale questionnaire: reproducibility over the telephone and validation with quality of life. Stroke. 2011; 8. 42(8):2276–2279. PMID: 21680905.

2. Daou B, Kent AP, Montano M, Chalouhi N, Starke RM, Tjoumakaris S, et al. Decompressive hemicraniectomy: predictors of functional outcome in patients with ischemic stroke. Journal of neurosurgery. 2016; 6. 124(6):1773–1779. PMID: 26613165.

3. Geurts M, van der Worp HB, Kappelle LJ, Amelink GJ, Algra A, Hofmeijer J. Surgical decompression for space-occupying cerebral infarction: outcomes at 3 years in the randomized HAMLET trial. Stroke. 2013; 9. 44(9):2506–2508. PMID: 23868265.

4. Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004; 2. 35(2):539–543. PMID: 14707232.

5. Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. The Lancet Neurology. 2009; 4. 8(4):326–333. PMID: 19269254.

6. Huh JS, Shin HS, Shin JJ, Kim TH, Hwang YS, Park SK. Surgical management of massive cerebral infarction. Journal of Korean Neurosurgical Society. 2007; 10. 42(4):331–336. PMID: 19096565.

7. Juttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007; 9. 38(9):2518–2525. PMID: 17690310.

8. Juttler E, Unterberg A, Woitzik J, Bosel J, Amiri H, Sakowitz OW, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. The New England journal of medicine. 2014; 3. 370(12):1091–1100. PMID: 24645942.

9. Park J, Goh DH, Sung JK, Hwang YH, Kang DH, Kim Y. Timely assessment of infarct volume and brain atrophy in acute hemispheric infarction for early surgical decompression: strict cutoff criteria with high specificity. Acta neurochirurgica. 2012; 1. 154(1):79–85. PMID: 21979162.

10. Park J, Kim E, Kim GJ, Hur YK, Guthikonda M. External decompressive craniectomy including resection of temporal muscle and fascia in malignant hemispheric infarction. Journal of neurosurgery. 2009; 1. 110(1):101–105. PMID: 18834267.

11. Qureshi AI, Suarez JI, Yahia AM, Mohammad Y, Uzun G, Suri MF, et al. Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review. Critical care medicine. 2003; 1. 31(1):272–277. PMID: 12545028.

12. Robertson SC, Lennarson P, Hasan DM, Traynelis VC. Clinical course and surgical management of massive cerebral infarction. Neurosurgery. 2004; 7. 55(1):55–61. discussion 61–2. PMID: 15214973.

13. Ropper AH, Shafran B. Brain edema after stroke. Clinical syndrome and intracranial pressure. Archives of neurology. 1984; 1. 41(1):26–29. PMID: 6606414.

14. Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. The Lancet Neurology. 2007; 3. 6(3):215–222. PMID: 17303527.

15. Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007; 9. 38(9):2506–2517. PMID: 17690311.