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Published on: July 21, 2013
Cisternostomy for malignant middle cerebral artery infarction: proposed pathophysiological mechanisms and preliminary
Salvatore Massimiliano Cardali1, Maria Caffo1, Gerardo Caruso2
1Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy.
Insights
Cisternostomy, a novel surgical approach for malignant middle cerebral artery ischemia, offers favorable outcomes. This treatment avoids cranioplasty, reducing potential complications and improving patient recovery.
Area of Science:
- Neurosurgery
- Neurology
- Vascular Surgery
Background:
- Middle cerebral artery (MCA) ischemic stroke presents high mortality and morbidity.
- Current treatments for MCA stroke are not always effective.
- Decompressive craniectomy can mitigate secondary brain damage from increased intracranial pressure.
Purpose of the Study:
- To evaluate the efficacy of a novel surgical treatment for malignant MCA ischemia.
- To assess the outcomes of cisternostomy in patients with MCA stroke.
Main Methods:
- 16 patients with malignant MCA ischemia underwent cisternostomy between August 2018 and December 2019.
- Diagnosis was confirmed via clinical history, neurological examination, and neuroimaging (CT, CT angiography, MRI).
- Patient outcomes were assessed using the Glasgow Coma Scale and National Institutes of Health Stroke Scale.
Main Results:
- The study included 16 patients (10 males, 6 females; mean age 60.1 years).
- Two deaths (12.5%) were recorded.
- A favorable functional outcome (mRS 0-3) was observed in 9 patients (64.2%) at 9 months post-discharge; 5 patients (35.7%) had a poor outcome (mRS 4-6).
Conclusions:
- Cisternostomy demonstrated functional outcomes comparable to decompressive craniectomy.
- This technique potentially eliminates the need for cranioplasty, avoiding associated complications.
- Further studies with larger cohorts are required to confirm these findings.
Background:
The ischaemic stroke of the territory of the middle cerebral artery represents an event burdened by high mortality and severe morbidity. The proposed medical treatments do not always prove effective. Decompressive craniectomy allows the ischaemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. In this study, we propose a novel treatment for these patients characterised by surgical fenestration of the cisterns of the skull base.
Methods:
We have treated 16 patients affected by malignant middle cerebral artery ischaemia and treated with cisternostomy between August 2018 and December 2019. The clinical history, neurological examination findings and neuroradiological studies (brain CT, CT angiography, MRI) were performed to diagnose stroke. Clinical examination was recorded on admission and preoperatively using the Glasgow Coma Scale and the National Institutes of Health Stroke Scale.
Results:
The study included 16 patients, 10 males and 6 females. The mean age at surgery was 60.1 years (range 19-73). Surgical procedure was performed in all patients. The patients underwent immediate postoperative CT scan and were in the early hours evaluated in sedation window. In total, we recorded two deaths (12.5%). A functional outcome between mRS 0-3, defined as favourable, was observed in 9 (64.2%) patients 9 months after discharge. A functional outcome between mRS 4-6, defined as poor, was observed in 5 (35.7%) patients 9 months after discharge.
Conclusions:
The obtained clinical results appear, however, substantially overlapping to decompressive craniectomy. Cisternostomy results in a favourable functional outcome after 9 months. This proposed technique permits that the patient no longer should be undergone cranioplasty thus avoiding the possible complications related to this procedure. The results are certainly interesting but higher case numbers are needed to reach definitive conclusions.
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