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Herniation despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Strokes.

Archana Hinduja1, Rohan Samant2, Dongxia Feng3

  • 1Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio.

Journal of Stroke and Cerebrovascular Diseases : the Official Journal of National Stroke Association
|November 7, 2017
PubMed
Summary

In large middle cerebral artery (MCA) strokes, a significant volume of brain tissue outside the craniectomy bed after surgery is linked to progressive herniation. This finding highlights the importance of precise surgical placement during decompressive hemicraniectomy (DHC).

Keywords:
Middle cerebral arterycraniectomydecompressive hemicraniectomyherniationischemic stroke

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Area of Science:

  • Neurosurgery
  • Neurology
  • Radiology

Background:

  • Decompressive hemicraniectomy (DHC) is used for large middle cerebral artery (MCA) strokes to manage cerebral edema.
  • Despite DHC, progressive herniation and death can still occur in some patients.
  • Identifying predictive surgical parameters for outcomes after DHC is crucial.

Purpose of the Study:

  • To identify surgical parameters on brain computed tomography (CT) scans associated with progressive herniation after DHC in large MCA strokes.
  • To evaluate the relationship between specific radiological measurements and patient outcomes.

Main Methods:

  • Retrospective review of 41 patients with malignant hemispheric infarction who underwent DHC.
  • Calculation of infarct volume on CT scans within 24 hours of ictus.
  • Measurement of craniectomy bone flap size, brain herniation volume, craniectomy centering over the stroke bed, and infarct volume outside the craniectomy bed (VNC) on postoperative CT scans.

Main Results:

  • Seven out of 41 patients experienced progressive herniation leading to death.
  • Insufficient centering of the craniectomy, larger VNC, anterior cerebral artery infarction, and smaller craniectomy length were associated with progressive herniation.
  • Multivariate analysis showed a higher VNC was significantly linked to progressive herniation (P=.029).

Conclusions:

  • Large infarct volume outside the craniectomy bed (VNC) is a significant predictor of progressive herniation after DHC in large MCA strokes.
  • Precise surgical technique, particularly centering the craniectomy over the stroke bed, is vital.
  • Further prospective studies are needed to validate these findings.