Background: Decompressive hemicraniectomy (DHC) reduces mortality and improves outcome after malignant middle cerebral artery infarction (MMI) but early in-hospital mortality remains high between 22 and 33%. Possibly, this circumstance is driven by cerebral herniation due to space-occupying brain swelling despite decompressive surgery. As the size of the removed bone flap may vary considerably between surgeons, a size too small could foster herniation. Here, we investigated the effect of the additional volume created by an extended DHC (eDHC) on early in-hospital mortality in patients suffering from MMI. Methods: We performed a retrospective single-center cohort study of 97 patients with MMI that were treated either with eDHC (n = 40) or standard DHC (sDHC; n = 57) between January 2006 and June 2012. The primary study end point was defined as in-hospital mortality due to transtentorial herniation. Results: In-hospital mortality due to transtentorial herniation was significantly lower after eDHC (0 vs. 11%; p = 0.04), which was paralleled by a significantly larger volume of the craniectomy (p < 0.001) and less cerebral swelling (eDHC 21% vs. sDHC 25%; p = 0.03). No statistically significant differences were found in surgical or non-surgical complications and postoperative intensive care treatment. Conclusion: Despite a more aggressive surgical approach, eDHC may reduce early in-hospital mortality and limit transtentorial herniation. Prospective studies are warranted to confirm our results and assess general safety of eDHC.

Keywords:
Malignant middle cerebral artery infarction, Space-occupying edema, Hemicraniectomy, Decompressive surgery
1.
Unterberg A, Juettler E: The role of surgery in ischemic stroke: decompressive surgery. Curr Opin Crit Care 2007;13:175-179.
2.
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 1996;53:309-315.
3.
Bardutzky J, Schwab S: Antiedema therapy in ischemic stroke. Stroke 2007;38:3084-3094.
4.
Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, Hacke W: Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998;29:1888-1893.
5.
Mori K, Aoki A, Yamamoto T, Horinaka N, Maeda M: Aggressive decompressive surgery in patients with massive hemispheric embolic cerebral infarction associated with severe brain swelling. Acta Neurochir (Wien) 2001;143:483-491; discussion 491-492.
6.
Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, Amelink GJ, Schmiedeck P, Schwab S, Rothwell PM, Bousser MG, van der Worp HB, Hacke W; DECIMAL, DESTINY, and HAMLET Investigators: Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007;6:215-222.
7.
Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W; DESTINY II Investigators: Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014;370:1091-1100.
8.
Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetzky E, Hacke W; DESTINY Study Group: Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke 2007;38:2518-2525.
9.
Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, Boutron C, Couvreur G, Rouanet F, Touzé E, Guillon B, Carpentier A, Yelnik A, George B, Payen D, Bousser MG; DECIMAL Investigators: Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007;38:2506-2517.
10.
Chung J, Bang OY, Lim YC, Park SK, Shin YS: Newly suggested surgical method of decompressive craniectomy for patients with middle cerebral artery infarction. Neurologist 2011;17:11-15.
11.
Kenning TJ, Gooch MR, Gandhi RH, Shaikh MP, Boulos AS, German JW: Cranial decompression for the treatment of malignant intracranial hypertension after ischemic cerebral infarction: decompressive craniectomy and hinge craniotomy. J Neurosurg 2012;116:1289-1298.
12.
Wagner S, Schnippering H, Aschoff A, Koziol JA, Schwab S, Steiner T: Suboptimum hemicraniectomy as a cause of additional cerebral lesions in patients with malignant infarction of the middle cerebral artery. J Neurosurg 2001;94:693-696.
13.
Kilincer C, Asil T, Utku U, Hamamcioglu MK, Turgut N, Hicdonmez T, Simsek O, Ekuklu G, Cobanoglu S: Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study. Acta Neurochir (Wien) 2005;147:587-594; discussion 594.
14.
Jiang JY, Xu W, Li WP, Xu WH, Zhang J, Bao YH, Ying YH, Luo QZ: Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: a multicenter, prospective, randomized controlled study. J Neurotrauma 2005;22:623-628.
15.
Bor-Seng-Shu E, Figueiredo EG, Fonoff ET, Fujimoto Y, Panerai RB, Teixeira MJ: Decompressive craniectomy and head injury: brain morphometry, ICP, cerebral hemodynamics, cerebral microvascular reactivity, and neurochemistry. Neurosurg Rev 2013;36:361-370.
16.
Jüttler E, Köhrmann M, Aschoff A, Huttner HB, Hacke W, Schwab S: Hemicraniectomy for space-occupying supratentorial ischemic stroke. Future Neurol 2008;3:251-264.
17.
MacCallum C, Churilov L, Mitchell P, Dowling R, Yan B: Low alberta stroke program early CT score (ASPECTS) associated with malignant middle cerebral artery infarction. Cerebrovasc Dis 2014;38:39-45.
18.
Delashaw JB, Broaddus WC, Kassell NF, Haley EC, Pendleton GA, Vollmer DG, Maggio WW, Grady MS: Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke 1990;21:874-881.
19.
Zweckberger K, Juettler E, Bösel J, Unterberg WA: Surgical aspects of decompression craniectomy in malignant stroke: review. Cerebrovasc Dis 2014;38:313-323.
20.
Güresir E, Vatter H, Schuss P, Oszvald A, Raabe A, Seifert V, Beck J: Rapid closure technique in decompressive craniectomy. J Neurosurg 2011;114:954-960.
21.
Holland M, Nakaji P: Craniectomy: surgical indications and technique. Oper Tech Neurosurg 2004;7:10-15.
22.
Cooper PR, Hagler H, Clark WK, Barnett P: Enhancement of experimental cerebral edema after decompressive craniectomy: implications for the management of severe head injuries. Neurosurgery 1979;4:296-300.
23.
Engelhorn T, Doerfler A, de Crespigny A, Beaulieu C, Forsting M, Moseley ME: Multilocal magnetic resonance perfusion mapping comparing the cerebral hemodynamic effects of decompressive craniectomy versus reperfusion in experimental acute hemispheric stroke in rats. Neurosci Lett 2003;344:127-131.
24.
Hatashita S, Koike J, Sonokawa T, Ishii S: Cerebral edema associated with craniectomy and arterial hypertension. Stroke 1985;16:661-668.
25.
Poca MA, Benejam B, Sahuquillo J, Riveiro M, Frascheri L, Merino MA, Delgado P, Alvarez-Sabin J: Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg 2010;112:648-657.
26.
Forsting M, Reith W, Schäbitz WR, Heiland S, von Kummer R, Hacke W, Sartor K: Decompressive craniectomy for cerebral infarction. An experimental study in rats. Stroke 1995;26:259-264.
27.
Lazaridis C, Czosnyka M: Cerebral blood flow, brain tissue oxygen, and metabolic effects of decompressive craniectomy. Neurocrit Care 2012;16:478-484.
28.
Chung J, Bang OY, Lim YC, Park SK, Shin YS: Newly suggested surgical method of decompressive craniectomy for patients with middle cerebral artery infarction. Neurologist 2011;17:11-15.
© 2016 S. Karger AG, Basel
2016
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.