Decompressive Hemicraniectomy and Durotomy for Malignant Middle Cerebral Artery Infarction
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Decompressive Hemicraniectomy and Durotomy for Malignant Middle Cerebral Artery Infarction Raphael A. Carandang Æ Derk W. Krieger
Published online: 29 November 2007 Ó Humana Press Inc. 2007
Abstract The high early case fatality among patients with massive hemispheric strokes calls for effective treatments. Release of the restriction created by the dura mater and bony skull to allow the infarcted brain tissue to swell has been successfully adopted by some while considered controversial by others. A recent pooled analysis provides estimates for the efficacy of decompressive surgery. Further analyses of current trial data suggest that in particular patient age and timing of surgery determine outcome. Nonetheless, in order to guide the management of individual patients, carefully adjusted medical care, ongoing futility analysis, and simultaneous caregiver meetings should be conducted to reach a joint decision addressing any ethical concerns. In conclusion, decompressive surgery increases the probability of survival but produces patients with moderate or moderately severe disability (albeit not severe disability). Currently, the decision to perform decompressive surgery should remain an individual one in each and every patient. Keywords Malignant MCA infarction Decompressive hemicraniectomy A Clinical Vignette A 59-year-old healthy Caucasian female with medically treated hypertension, coronary artery disease, and
congestive heart failure presents with acute onset of leftsided hemiplegia and altered level of consciousness. She arrives at the ER brought in by EMS after being found by a relative in her home reportedly last seen normal approximately 2 h prior by a neighbor. Her examination is significant for drowsiness, although she is arousable with moderate stimulation and follows simple commands. She appears disoriented. Her eyes are in forced deviation to the right and she has a complete left lower face droop. She is hemiplegic with no strength or movement of her left arm and her left leg is able to move but cannot be lifted off the stretcher. She also has left-sided sensory loss and slurred speech. Her initial stroke severity is 15 on the NIH stroke scale. Although she presented within the therapeutic window, CT-imaging revealed a large wedge-shaped area of hypodensity encompassing more than a third of the right MCA territory with a well matched perfusion deficit as well as a right proximal middle cerebral artery/M1 cut-off on CT Angiogram. Given the large area of irreparable brain ischemia on her non-contrast CT scan, she was deemed a high hemorrhage risk for iv-thrombolysis and not salvageable by intra-arterial intervention. She was subsequently admitted to the intensive care unit for close observation and noted to worsen on the evening of her second hospital day, approximately 36 h after the initial ictus, becoming less arousable and not following any commands. Repeat imaging shows further evolution of the hypodense area with increasing mass effect and some midline shift.
R. A. Ca
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