Decompressive hemicraniectomy

Leonhardt G, Wilhelm H, Doerfler A, Ehrenfeld CE, Schoch B, Rauhut F, Hufnagel A, Diener HC. Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in mca infarction. J Neurol 2002 249 1433-1440. 

Rabinstein AA, Mueller-Kronast N, Maramattom BV, Zazulia AR, Bamlet WR, Diringer MN, Wijdicks EF. Factors predicting prognosis after decompressive hemicraniectomy for hemispheric infarction. Neurology 2006 67 891-893. 

Decompressive hemicraniectomy was indirectly compared with moderate hypothermia (33°C) in a series of 36 patients from Georgiadis et al. They found a lower mortality rate for the patients who underwent hemicraniectomy (47% vs. 12%), as well as a lower complication rate. However, this was not a randomized study, and there was no comparison arm of patients who did not undergo either experimental therapy. 

Foerch C, Lang JM, Krause J, Raabe A, Sitzer M, Seifert V, Steinmetz H, Kessler KR. Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Neurosurg 2004 101(2) 248-254. 

The thrombolysis algorithm is based on the assumption that the hypotheses discussed above are proven to be correct. That is, primarily (1) the presence of significant perfusion-diffusion mismatch (qualitatively +/- quantitatively assessed) predicts treatment response, and (2) a large DWI lesion (qualitatively > V2 MCA territory, and/or quantitatively > 100 cm3) predicts haemorrhagic transformation. Patients excluded from thrombolysis because of extensive DWI lesions with or without perfusion-diffusion mismatch maybe considered for more aggressive measures such as hypothermia or decompressive hemicraniectomy (Schwab et al. 1998,2001). 

Kastrau et al. Stroke 2005 36(4) 825-829 Retrospective evaluation of aphasia in patients with hemicraniectomy for dominant sphere infarcts 14 patients with surgery evaluated with psychometric quantification twice over 470 days Evolution of aphasic symptoms 13/14 patients with improved scores and increased ability to communicate from baseline in 13 patients. Young age and early decompressive surgery were main... 

Peri-infarct edema reduces local cerebral blood flow and causes brain shift and herniation, the last being the most common neurological cause of death. This complication is a common explanation for worsening over the first few days and can often be detected by CT scan. Intravenous mannitol may reduce the deficit for a while but is unlikely to have a major impact on outcome. Recently, surgical decompression using hemicraniectomy has been shown to improve survival, with satisfactory functional outcome in many patients (Ch. 21). 

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