Benzion Blech | Neurosurgery Presentation

Decompressive Craniectomy in Malignant MCA Ischemic Stokes

Epidemiology, etiology, SS of malignant MCA ischemic strokes
Composes of 10% of all supratentorial ischemic strokes
Occurs due to thrombosis of ICA or proximal MCA
Within 24-48 hours progressive deterioration due to edema ICP increase destroys healthy brain
(malignant MCA infarction) uncal or transtentorial herniation
Mortality up to 80%
Symptoms: contralateral hemiplegia, hemiparesis, aphasia (if dominant lobe), eye deviation, coma, death
Imaging:
Initial workup CT scan
May need repeat 3 days later for extent of injuries/infarct
Definition of malignant MCA stroke with imaging requires at least 2/3 of MCA territory to be infarcted
Treatment:
Sedation, intubation, mechanical ventilation
Mannitol, glycerol, hypertonic saline reduces ICP
o Efficacy not proven yet in malignant MCA strokes
Head elevation, barbiturates, hyperventilation, steroids, mannitol
Case studies have shown that even with maximum conservative treatment, there seems to be little to no
clinical effect on malignant MCA strokes with pharmacology (Huttner et al, 2009)
Hypothermia treatment
o Patient is cooled to 33-35 Celsius reduces free radicals, attenuates post-ischemic inflammatory
response and apoptosis less edema
o Results are promising, still preliminary
Decompressive Craniectomy (DC):
Hemicraniectomy + duraplasty, ? shape incision, 12 cm bone removed (frontal, parietal, temporal, occipital)
Dural patch inserted
Ischemic brain not resected
ICP probe insertion
6 weeks 6 months later: cranioplasty stored bone flap, artificial replacement
Efficacy of DC
Meta analysis (Lu X et al, 2014)
14 studies, 747 pts, 8 RCTs
Early DC within 48 hours of stroke onset decreased mortality (OR=0.14, 95%CI=0.08- 0.25, p<0.0001),
and decrease poor functional outcome (mRS <3) at 12 months f/u (OR=0.38, 95%CI=0.20, 0.73, p=0.004)
After 48 hrs not effective
Improved outcomes in both younger and older pts
Early DC saved lives and improved neuropsycological outcomes in patients >60 years of age
Seizure risk of DC:
Creutzfeldt et al, 2013
o Patients from 2002-2011 who had malignant MCA stroke
o 55 pts (7 died, 28 declined, 20 interviewed), followed 311 days, chart review to get pts.
o Asked 7 questions over phone
o 49% - seizures (all at least one generalized), 45% developed epilepsy, 38% had mRS <3 (moderate
disability)
o 40% of pts w/ seizures felt was major drawback
o All 20 would want DC again
Psychosocial aspects of DC:
McKenna et al, 2012
o 5 pts, retrospective review of surgery
o Premorbid and current IQ, attention, visual/auditory memory, executive functioning, visual-spatial
acuity, depression, anxiety, QOL.
o All showed neuropsychosocial impairments in some way
o Depression in 2, QOL within average limits in , 4 stated they were happy with surgery
o Preserved abilities + social support = protective against depression and unacceptable QOL
Sundseth et al, 2014
o Hypothesis: Speech-dominant infarct less favorable outcome than non-speech dominant
o Functional outcome, QOL, mental health comparison
o 1998-2010, retrospective analysis of patient info by interviewing the patients and family. 45 pts, 48.1
yrs (19-74)

Determined aphasia, l/r dominance, marital/working status, comorbidities, depression, DM,

previous stroke, func level prior (mRS) score
o Primary outcome mRS <= 3 = good
o 46.7 hrs to DC, L hemisphere affected in 17 pts (38%)
o Results: no difference between dom/non-dom pts.

2/13 pts w/ aphasia regained almost normal speech function, additional 2 pts able to speak
understandable sentences
Knowing outcome most pts retrospectively consented to treatment

Huttner H, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and
future perspectives. Lancet Neurol 2009; 8: 949-58
McKenna A, Wilson F, Caldwell S, et al. Long-term neuropsychological and psychosocial outcomes of decompressive
hemicraniectomy following malignant middle cerebral artery infarctions. Disability and Rehabilitation 2012; 34(17):
1444-1455
Sundseth J, Sundseth A, Thommessen B. Long-Term Outcome and Quality of Life After Craniectomy in SpeechDominant Swollen Middle Cerebral Artery Infarction. Neurocrit Care 2014. DOI 10.1007/s12028-014-0056-y
Lu X, Huang B, Zheng J, et al. Decompressive craniectomy for the treatment of malignant infarction of the middle
cerebral artery. Scientific Reports 2014; 4: 7070. DOI: 10.1038/srep07070