Makindo Medical Notes

Decompressive hemicraniectomy with durotomy, a procedure pioneered by Harvey Cushing in 1905, became widely considered for stroke treatment in 1956.

About

• Decompressive hemicraniectomy may benefit certain patients with malignant middle cerebral artery (MCA) infarction, especially when performed within 24 to 48 hours of symptom onset.
• This operation is potentially lifesaving, though it often leads to moderate to severe disability in survivors.
• The surgery involves removing a section of the skull and incising the dura mater to allow the swollen brain tissue to herniate upwards through the surgical defect, avoiding downward herniation and brainstem compression.
• Primarily used for malignant MCA syndrome, it is also applicable in cases of severe encephalitis and large parenchymal intracerebral hemorrhage.

Current Selection Criteria for Hemicraniectomy

• Patients aged 60 years or younger (criteria may vary by center).
• Clinical deficits indicative of MCA territory infarction.
• NIH Stroke Scale (NIHSS) score > 15.
• Reduced level of consciousness (NIHSS item 1a score ≥ 1).
• CT evidence of infarct covering ≥ 50% of MCA territory or infarct volume > 145 cm³ on diffusion-weighted MRI, with or without infarction in adjacent territories.

2018 AHA Guidelines (USA)

• A decline in consciousness due to brain swelling is a reasonable criterion for decompressive craniectomy.
• For patients ≤ 60 years with unilateral MCA infarctions and neurological deterioration within 48 hours despite medical therapy:
  • Decompressive craniectomy with dural expansion reduces mortality by nearly 50%.
  • Approximately 55% of surgical survivors achieve moderate disability (able to walk) or better, with 18% achieving independence (mRS score 2) at 12 months.
• For patients > 60 years with unilateral MCA infarctions and deterioration within 48 hours despite medical therapy:
  • Decompressive craniectomy reduces mortality by approximately 50%.
  • About 11% of surgical survivors reach moderate disability (mRS score 3, able to walk), though none achieve full independence (mRS score 2) at 12 months.
• Osmotic therapy is recommended for patients with cerebral swelling and neurological decline.
• Brief moderate hyperventilation (target Pco₂: 30-34 mm Hg) is advisable as a bridge to more definitive therapies in cases of severe neurological decline from brain swelling.
• Corticosteroids should not be administered for cerebral edema and increased intracranial pressure in ischemic stroke, due to lack of efficacy and risk of infections.