J Korean Neurosurg Soc.  2024 Mar;67(2):227-236. 10.3340/jkns.2023.0130.

Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy

• Im SH
• Yoo DS
• Park HK

• KMID: 2553129
• DOI: http://doi.org/10.3340/jkns.2023.0130

Abstract

Objective
: Numerous studies have indicated that early decompressive craniectomy (DC) for patients with major infarction can be life-saving and enhance neurological outcomes. However, most of these studies were conducted by neurologists before the advent of intra-arterial thrombectomy (IA-Tx). This study aims to determine whether neurological status significantly impacts the final clinical outcome of patients who underwent DC following IA-Tx in major infarction.
Methods
: This analysis included 67 patients with major anterior circulation major infarction who underwent DC after IA-Tx, with or without intravenous tissue plasminogen activator. We retrospectively reviewed the medical records, radiological findings, and compared the neurological outcomes based on the “surgical time window” and neurological status at the time of surgery.
Results
: For patients treated with DC following IA-Tx, a Glasgow coma scale (GCS) score of 7 was the lowest score correlated with a favorable outcome (p=0.013). Favorable outcomes were significantly associated with successful recanalization after IA-Tx (p=0.001) and perfusion/diffusion (P/D)-mismatch evident on magnetic resonance imaging performed immediately prior to IA-Tx (p=0.007). However, the surgical time window (within 36 hours, p=0.389; within 48 hours, p=0.283) did not correlate with neurological outcomes.
Conclusion
: To date, early DC surgery after major infarction is crucial for patient outcomes. However, this study suggests that the indication for DC following IA-Tx should include neurological status (GCS ≤7), as some patients treated with early DC without considering the neurological status may undergo unnecessary surgery. Recanalization of the occluded vessel and P/D-mismatch are important for long-term neurological outcomes.

Keyword

Decompressive craniectomy; Mechanical thrombolysis; Intracranial pressure; Ischemic stroke; Cerebral infarction

Figure

• 

  Fig. 1. Flow diagram of the treatment protocol. CT : computed tomography, IV-tPA : intravenous tissue plasminogen activator, MRI : magnetic resonance imaging.

• 

  Fig. 2. A : A preoperative brain computed tomography (CT) image reveals massive brain edema, midline shift, and reperfusion injury of the right cerebral hemisphere after intraarterial thrombectomy. B : Brain CT images taken after right side decompressive hemicraniectomy and insertion of extraventricular drainage catheter. C : A three dimensional-reconstructed CT image after decompressive craniectomy. The image shows a large skull bone defect on the right side, and the burr hole at the left Kocher's point for extra-ventricular drainage.

• 

  Fig. 3. Patient who doesn’t need not decompressive craniectomy (DC) after major infarction. brain computed tomography (CT) image (upper row) initial brain CT at ictus (29/March), six follow-up brain CT without DC (9/April) (lower row).

Reference

References

1. Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 34:1056–1083. 2003.

2. Adams HP Jr, Brott TG, Crowell RM, Furlan AJ, Gomez CR, Grotta J, et al. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 25:1901–1914. 1994.

3. Akins PT, Axelrod YV, Arshad ST, Guppy KH. Initial conservative management of severe hemispheric stroke reduces decompressive craniectomy rates. Neurocrit Care. 25:3–9. 2016.

4. Astrup J, Siesjö BK, Symon L. Thresholds in cerebral ischemia - the ischemic penumbra. Stroke. 12:723–725. 1981.

5. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 372:11–20. 2015.

6. Berrouschot J, Sterker M, Bettin S, Köster J, Schneider D. Mortality of space-occupying (‘malignant’) middle cerebral artery infarction under conservative intensive care. Intensive Care Med. 24:620–623. 1998.

7. Bounds JV, Wiebers DO, Whisnant JP, Okazaki H. Mechanisms and timing of deaths from cerebral infarction. Stroke. 12:474–477. 1981.

8. 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. J Neurosurg. 124:1773–1779. 2016.

9. Davis S, Donnan GA. Time is penumbra: imaging, selection and outcome. The Johann jacob wepfer award 2014. Cerebrovasc Dis. 38:59–72. 2014.

10. Delashaw JB, Broaddus WC, Kassell NF, Haley EC, Pendleton GA, Vollmer DG, et al. Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke. 21:874–881. 1990.

11. Eun J, Huh J, Yang SY, Huh HY, Ahn JK, Cho KW, et al. Determining the lower limit of cerebral perfusion pressure in patients undergoing decompressive craniectomy following traumatic brain injury. World Neurosurg. 111:e32–e39. 2018.

12. Frank JI, Schumm LP, Wroblewski K, Chyatte D, Rosengart AJ, Kordeck C, et al. Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial. Stroke. 45:781–787. 2014.

13. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA. 282:2003–2011. 1999.

14. Gorelick PB, Wong KS, Bae HJ, Pandey DK. Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke. 39:2396–2399. 2008.

15. Göttsche J, Flottmann F, Jank L, Thomalla G, Rimmele DL, Czorlich P, et al. Decompressive craniectomy in malignant MCA infarction in times of mechanical thrombectomy. Acta Neurochir (Wien). 162:3147–3152. 2020.

16. Hacke W, Kaste M, Skyhoj Olsen T, Orgogozo JM, Bogousslavsky J. European Stroke Initiative (EUSI) recommendations for stroke management. The European Stroke Initiative Writing Committee. Eur J Neurol. 7:607–623. 2000.

17. Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 53:309–315. 1996.

18. Hofmeijer J, Amelink GJ, Algra A, van Gijn J, Macleod MR, Kappelle LJ, et al. Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema trial (HAMLET). Protocol for a randomised controlled trial of decompressive surgery in space-occupying hemispheric infarction. Trials. 7:29. 2006.

19. Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, et al. 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. Lancet Neurol. 8:326–333. 2009.

20. Hofmeijer J, van der Worp HB, Kappelle LJ. Treatment of space-occupying cerebral infarction. Crit Care Med. 31:617–625. 2003.

21. Holtkamp M, Buchheim K, Unterberg A, Hoffmann O, Schielke E, Weber JR, et al. Hemicraniectomy in elderly patients with space occupying media infarction: improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry. 70:226–228. 2001.

22. Hong KS, Ko SB, Yu KH, Jung C, Park SQ, Kim BM, et al. Update of the Korean clinical practice guidelines for endovascular recanalization therapy in patients with acute ischemic stroke. J Stroke. 18:102–113. 2016.

23. Hossmann KA. Ischemia-mediated neuronal injury. Resuscitation. 26:225–235. 1993.

24. Hussein HM, Georgiadis AL, Vazquez G, Miley JT, Memon MZ, Mohammad YM, et al. Occurrence and predictors of futile recanalization following endovascular treatment among patients with acute ischemic stroke: a multicenter study. AJNR Am J Neuroradiol. 31:454–458. 2010.

25. Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med. 375:1119–1130. 2016.

26. Jüttler 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. 38:2518–2525. 2007.

27. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 370:1091–1100. 2014.

28. Larrue V, von Kummer R, Müller A, Bluhmki E. Risk factors for severe hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen activator: a secondary analysis of the European-Australasian Acute Stroke Study (ECASS II). Stroke. 32:438–441. 2001.

29. Lewandowski CA, Frankel M, Tomsick TA, Broderick J, Frey J, Clark W, et al. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: emergency management of stroke (EMS) bridging trial. Stroke. 30:2598–2605. 1999.

30. Lin J, Frontera JA. Decompressive hemicraniectomy for large hemispheric strokes. Stroke. 52:1500–1510. 2021.

31. Mazighi M, Serfaty JM, Labreuche J, Laissy JP, Meseguer E, Lavallée PC, et al. Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study. Lancet Neurol. 8:802–809. 2009.

32. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 333:1581–1587. 1995.

33. Pan J, Konstas AA, Bateman B, Ortolano GA, Pile-Spellman J. Reperfusion injury following cerebral ischemia: pathophysiology, MR imaging, and potential therapies. Neuroradiology. 49:93–102. 2007.

34. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 46:3020–3035. 2015.

35. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 49:e46–e110. 2018.

36. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 38:967–973. 2007.

37. Ropper AH, Shafran B. Brain edema after stroke. Clinical syndrome and intracranial pressure. Arch Neurol. 41:26–29. 1984.

38. Rumalla K, Ottenhausen M, Kan P, Burkhardt JK. Recent nationwide impact of mechanical thrombectomy on decompressive hemicraniectomy for acute ischemic stroke. Stroke. 50:2133–2139. 2019.

39. Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 29:1888–1893. 1998.

40. Slezins J, Keris V, Bricis R, Millers A, Valeinis E, Stukens J, et al. Preliminary results of randomized controlled study on decompressive craniectomy in treatment of malignant middle cerebral artery stroke. Medicina (Kaunas). 48:521–524. 2012.

41. Tracol C, Vannier S, Hurel C, Tuffier S, Eugene F, Le Reste PJ. Predictors of malignant middle cerebral artery infarction after mechanical thrombectomy. Rev Neurol (Paris). 176:619–625. 2020.

42. 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. Lancet Neurol. 6:215–222. 2007.

43. 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. 38:2506–2517. 2007.

44. Walz B, Zimmermann C, Böttger S, Haberl RL. Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction. J Neurol. 249:1183–1190. 2002.

45. Wardlaw JM, Murray V, Berge E, del Zoppo G, Sandercock P, Lindley RL, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet. 379:2364–2372. 2012.

46. Wu S, Yuan R, Wang Y, Wei C, Zhang S, Yang X, et al. Early prediction of malignant brain edema after ischemic stroke. Stroke. 49:2918–2927. 2018.

47. Yoo DS, Kim DS, Cho KS, Huh PW, Park CK, Kang JK. Ventricular pressure monitoring during bilateral decompression with dural expansion. J Neurosurg. 91:953–959. 1999.

48. Yoo DS, Won YD, Huh PW, Shin HE, Kim KT, Kang SG, et al. Therapeutic results of intra-arterial thrombolysis after full-dose intravenous tissue plasminogen activator administration. AJNR Am J Neuroradiol. 31:1536–1540. 2010.

49. Yuan R, Wu S, Cheng Y, Ye K, Hao Z, Zhang S, et al. Association between preoperative midline shift growing rate and outcomes of decompressive craniectomy in patients with malignant middle cerebral artery infarction. Curr Neurovasc Res. 17:131–139. 2020.

50. Zhao J, Su YY, Zhang Y, Zhang YZ, Zhao R, Wang L, et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care. 17:161–171. 2012.