What is the optimum time to decompressive surgery in the patients with malignant middle cerebral artery infarction?
What is the optimum time to decompressive surgery in the patients with malignant middle cerebral artery infarction?
Aim: In the patients with malignant middle cerebral artery (MCA) infarctions, the mortality was as high as 70% with conservativetreatment. Decompressive craniectomy (DC) was shown to decrease mortality especially in 48 hours. We aimed to investigate boththe effect of decompression time and the size of craniectomy on the mortality in this patient group.Material and Methods: 45 adult patients underwent to DC due to malignant MCA infarction were evaluated in this study. Thedemographic and clinical features were recorded retrospectively. The patients were splitted into three groups: Group 1, DC in the first24 hours; group 2, in 24-48th hours; group3, in 48-96th hours of the admission. The size of craniectomy was the same as the infarct(standard), or it was two centimeters larger than the size of infarct (larger).Results: Of all patients, 53.3% (n=24) was female; and mean age of the sample was 67.38±4.76. 66.7% (n=30) of the patients died dueto malign MCA infarction. The size of craniectomy was larger in 26.7% (n=12), and was standard in the others. Mean time to surgerywas 43.07±29.87 hours. Mortality rate was minimum in group 2 (p=0.01). The patients undergoing to larger craniectomy survivedlonger than the others, but the difference was non-significant (p=0.06).Conclusion: We suggested that not the approach of “surgery as soon as possible” but the surgery between 24-48th hours of theadmission would be the optimal approach. This issue is especially important, because earlier or later interventions not only have aless benefit on the outcome but also may lead several unnecessary complications.
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- 1. Hacke W, Schwab S, Horn M, et al. Malignant middle cerebral
artery territory infarction: clinical course and prognostic
signs. Arch Neurol 1996;53:309-15.
- 2. Landreneau MM, Sheth KN.Decompressive craniectomy for
malignant middle cerebral artery stroke. Semin Respir Crit
Care Med 2017;38:737-44.
- 3. Brondani R, Garcia de Almeida A, Abrahim Cherubini P, et
al. High risk of seizures and epilepsy after decompressive
hemicraniectomy for malignantmiddle cerebral artery
stroke. Cerebrovasc Dis Extra 2017;7:51-61.
- 4. Heiss WD. Malignant MCA Infarction: Pathophysiology and
Imaging for Early Diagnosis and Management Decisions.
Cerebrovasc Dis 2016;41:1-7.
- 5. Berrouschot J, Sterker M, Bettin S, et al. Mortality of spaceoccupying
(‘malignant’) middle cerebral artery infarction
under conservative intensive care. Intensive Care Med
1998;24:620-3.
- 6. Marmarou A, Anderson R, Ward J, et al. Impact of ICP
instability and hypotension on outcome in patients with
severe head injury. J Neurosurg 1991;75:59-66.
- 7. Bongiorni GT, Hockmuller MCJ, Klein C, et al. Decompressive
craniotomy for the treatment of malignantinfarction of
the middlecerebralartery: mortality and outcome. Arq
Neuropsiquiatr 2017;75:424-8.
- 8. Lu X, Huang B, Zheng J, et al. Decompressive craniectomy
for the treatment of malignant infarction of the middle
cerebral artery. Sci Rep 2014;4:7070.
- 9. Neugebauer H, Juttler E. Hemicraniectomy for malignant
middle cerebral artery infarction: current status and future
directions. Int J Stroke 2014;9:460-7.
- 10. Kurland D, Khaladj-Ghom A, Stokum J, et al. Complications
Associated with decompressive craniectomy: a systematic
review. Neurocrit Care 2015;23:292-304.
- 11. Huh J, Yang SY, Huh HY, et al. compare the intracranial
pressure trend after the decompressive craniectomy
between massive intracerebral hemorrhagic and major
ischemic stroke patients. J Korean Neurosurg Soc
2018;61:42-50.
- 12. Taylor B, Lopresti M, Appelboom G, et al. Hemicraniectomy
for malignant middle cerebral artery territory infarction: an
updated review.J Neurosurg Sci 2015;59:73-8.
- 13. Kamran S, Akhtar N, Salam A, et al. Decompressive
hemicraniectomy for malignant middle cerebral artery
stroke: south asian experience. J Stroke Cerebrovasc Dis
2017;26:2306-12.
- 14. Elsawaf A, Galhom A. decompressive craniotomy for
malignant middle cerebral artery infarction: optimal timing
and literature review. World Neurosurg 2018;116:71-8.
- 15. Paliwal P, Kazmi F, Teoh HL, et al. early decompressive
hemicraniectomy for malignant middle cerebral artery
infarction in asian patients: a single-center study. World
Neurosurg 2018;111:722-8.
- 16. Cabral LS, Passos PE Filho. Prospective studies on
decompressive craniotomy for malignant MCA infarctions in Brazil: ready for prime time. Arq Neuropsiquiatr 2017;75:839.
- 17. Cruz-Flores S, Berge E, Whittle I. Surgical decompression
for cerebral oedema in acute ischaemic stroke (Review).
Cochrane Database of Syst Rev 2012; 1:CD003435.
- 18. Gul W, Fuller HR, Wright H, Sen J. A Systematic review
and meta-analysis of the effectiveness of surgical
decompression in treating patients with malignant
middle cerebral artery infarction, World Neurosurgery
2018;120:902-20.
- 19. Miller K, Eljamel S. Does size and site matter in therapeutic
decompressive craniectomy? A Laboratory-Based
Experimental Study World Neurosurg 2016; 95:441-6.
- 20. Sundseth J, Sundseth A, Jacobsen EA, et al. Predictors of
early in-hospital death after decompressive craniectomy
in swollen middle cerebral artery infarction. Acta Neurochir
2017;159: 301–6.
- 21. Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive
surgery in malignant infarction of the middle cerebral artery:
a pooled analysis of three randomised controlled trials.
Lancet Neurol 2007;6:215–22.
- 22. Hofmeijer J, Kapelle LJ, Algra A, 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 2009;8:326–33.
- 23. Zhao J, Su YY, Zhang Y, et al. Decompressive
hemicraniectomy in malignant middle cerebral artery
infarct: a randomized controlled trial enrolling patients up to
80 years old. Neurocrit Care 2012;17:161-71.
- 24. Yang MH, Lin HY, Fu J, et al. Decompressive hemicraniectomy
in patients with malignant middle cerebral artery infarction:
A systematic review and meta-analysis. Surgeon
2015;13:230-40.
- 25. Rajwani KM, Crocker M, Moynihan B. Decompressive
craniectomy for the treatment of malignant middle cerebral
artery infarction. Br J Neurosurg 2017:31:4: 401-9.
- 26. Slezins J, Keris V, Bricis R, et al. Preliminary results of
randomized controlled study on decompressive craniectomy
in treatment of malignant middle cerebral artery stroke.
Medicina (Kaunas) 2012;48:521–4.
- 27. Back L, Nagaraja V, Kapur A, et al. Role of decompressive
hemicraniectomy in extensive middle cerebral artery
strokes: a meta-analysis of randomised trials. Intern Med J
2015;45:711–17.
- 28. Frank JI, Schumm LP, Wroblewski K, et al. Hemicraniectomy
and durotomy upon deterioration from infarction-related
swelling trial: randomized pilot clinical trial. Stroke
2014;45:781-7.
- 29. Gupta R, Elkind MSV, Decompressive hemicraniectomy for
malignant middle cerebral artery territory infarction [Online].
Up-To-Date 2015. Available from: http://www.uptodate.
com/contents/decompressive-hemicraniectomy- formalignant-
middle-cerebral-artery-territory-infarction.
- 30. Torbey MT, Bosel J, Rhoney DH, et al. Evidence-based
guidelines for the management of large hemispheric
infarction: a statement for health care professionals from
the. Neurocrit Care 2015;22:146–64.
- 31. Lammy S, Al-Romhain B, Osborne L, et al. 10-Year
institutional retrospective case series of decompressive
craniectomy for malignant middle cerebral artery infarction
(mMCAI). World Neurosurgery 2016;96:383-9.
- 32. Albert AF, Kirkman MA. Clinical and radiological predictors
of malignant middle cerebral artery infarction development
and outcomes. J Stroke Cerebrovasc Dis 2017:26:2671-
2679.
- 33. Raffiq MM, Haspani MM, Kandasamy R, et al. Decompressive
craniectomy for malignant middle cerebral artery infarction:
Impact on mortality and functional outcome. Surg Neurol Int
2014;5:102.
- 34. Vahedi K, Vicaut E, Mateo J, et al. Sequential-design,
multicenter, randomized, controlled trial of early
decompressive craniectomy in malignant middle cerebral
artery infarction (DECIMAL Trial). Stroke 2007;38:2506-17.
- 35. Juttler E, Schwab S, Schmiedek P, et al. Decompressive
Surgery for the Treatment of Malignant Infarction of the
Middle Cerebral Artery (DESTINY): a randomized, controlled
trial. Stroke 2007;38:2518-25.
- 36. Rai VK, Bhatia R, Prasad K, et al. Long-term outcome of
decompressive hemicraniectomy in patients with malignant
middle cerebral artery infarction: a prospective observational
study. Neurol India 2014;62:26-31.
- 37. Dasenbrock HH, Robertson FC, Aziz-Sultan MA, et al.
patient age and the outcomes after decompressive
hemicraniectomy for stroke: a nationwide inpatient sample
analysis. Neurocrit Care 2016;25:371-83.
- 38. Juttler E, Unterberg A, Woitzik J, et al. Hemicraniectomy in
older patients with extensive middle-cerebral-artery stroke.
N Engl J Med 2014;370:1091-100.