Critical Care Medicine-Neurologic Disorders>>>>>Increased Intracranial Pressure
Question 7#

A 53-year-old, right-handed, previously independent male with no past medical history was found down at home. He was brought to the emergency department where he was found to have a large, wellestablished L MCA ischemic stroke on CT with a proximal L M1 thrombus on CT angiogram. He was not a candidate for IV tPA or intra-arterial therapy given the well established infarction and his last known well-being over 12 hours prior to presentation. He was admitted to the intensive care unit for ongoing management. Over the course of the next 24 hours he has progressive decline in his mental status and required intubation. A repeat head CT shows evolution of the ischemic stroke with left-to-right midline shift.

What is the best description of the anticipated outcome following a hemicraniectomy for malignant ischemic stroke?

A. A hemicraniectomy can potentially be a life-saving intervention and will improve neurologic recovery
B. A hemicraniectomy can potentially be a life-saving intervention but will not improve neurologic recovery
C. Because the ischemic stroke is on the dominate hemisphere, hemicraniectomy should be completed as there is a higher chance of recovery
D. Hemicraniectomy without durotomy is preferred as there is a lower risk of infection as compared to hemicraniectomy with durotomy

Correct Answer is B

Comment:

Correct Answer: B

There have been a number of trials that have evaluated hemicraniectomy with durotomy for malignant MCA ischemic strokes: DESTINY, DECIMAL, DECIMAL 2, and HAMLET. The trials involved a total of 314 patients and demonstrated a decrease in mortality from 71% to 30% (odds ratio 0.19) with number needed to treat 2.4. With the pooled data there was increase in patients with slight disability and increase in moderate to severe disability which outweighed the slight disability improvement. 

Treatment choice should not depend on hemispheric involvement. Mortality, functional outcome, and quality of life do not seem to depend on the dominate hemisphere involved. Rather, neuropsycholoigcal defects seen in patients with infarcts in the nondominant hemisphere may be as disabling as language deficits. The surgical procedure involves removal of a generous bone flap and durotomy which has been demonstrated to provide further decrease in intracerebral pressure and is not associated with increased complications. 

References:

  1. Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniotomy in malignant middle cerebral artery infarction (DECIMAL trial). Stroke. 2007;38:2506-2517.
  2. Frank JL, Schumm LP, Wroblewski K, et al. Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial. Stroke. 2014;45:781-787.
  3. 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;38:2518-2525.
  4. Hofmeijer J, Kappelle 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 multicenter, open, randomized trial. Lancet Neurol. 2009;8:326-333.
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  8. Schneck MJ, Origitano TC. Hemicraniectomy and durotomy for malignant middle cerebral artery infarction. Neurol Clinics. 2007;24:715-727.