Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in children
Sabrina E Smith1, Fenella J Kirkham, Gabrielle Deveber
1Department of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. smithsa@email.chop.edu
Aim:
Mortality from malignant middle cerebral artery infarction (MMCAI) approaches 80% in adult series. Although decompressive craniectomy decreases mortality and leads to an acceptable outcome in selected adult patients, there are few data on MMCAI in children with stroke. This study evaluated the frequency of MMCAI and the use of decompressive craniectomy in children.
Method:
We retrospectively reviewed cases of MMCAI from five pediatric tertiary care centers.
Results:
Ten children (two females, eight males; median age 9y 10mo, range 22mo-14y) had MMCAI, with a median Glasgow Coma Scale score of 6 (range 3-9). MMCAI represented fewer than 2% of cases of pediatric arterial ischemic stroke. Three patients who did not undergo decompression, all of whom had monitoring of intracranial pressure, developed intractable intracranial hypertension, and fulfilled criteria for brain death. In contrast, seven patients underwent decompressive craniectomy and survived, with rapid improvement in their level of consciousness postoperatively. All seven survivors now walk independently with mild to moderate residual hemiparesis and speak fluently, even though four had left-sided infarcts.
Interpretation:
Decompressive craniectomy can lead to a moderately good outcome for children with MMCAI and should be considered, even with symptomatic stroke and deep coma. Monitoring of intracranial pressure may delay life-saving treatment.
Insights
Decompressive craniectomy improves outcomes for children with malignant middle cerebral artery infarction (MMCAI). This procedure offers a chance for survival and functional recovery in pediatric stroke patients.
Area of Science:
- Pediatric Neurology
- Cerebrovascular Diseases
- Neurosurgery
Background:
- Malignant middle cerebral artery infarction (MMCAI) has high mortality in adults.
- Limited data exist on MMCAI and decompressive craniectomy in pediatric stroke patients.
Purpose of the Study:
- To evaluate the frequency of MMCAI in children.
- To assess the efficacy of decompressive craniectomy in pediatric MMCAI cases.
Main Methods:
- Retrospective review of MMCAI cases across five pediatric tertiary care centers.
- Analysis of patient demographics, clinical presentation, and treatment outcomes.
Main Results:
- MMCAI occurred in 10 children, representing <2% of pediatric arterial ischemic strokes.
- Three non-decompressed patients died from intracranial hypertension.
- Seven patients undergoing decompressive craniectomy survived with independent ambulation and fluent speech, despite residual hemiparesis.
Conclusions:
- Decompressive craniectomy is a viable treatment for pediatric MMCAI, improving survival and functional outcomes.
- The procedure should be considered even in severe cases with deep coma.
- Intracranial pressure monitoring may delay critical, life-saving interventions.
