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How much space is needed for decompressive surgery in malignant middle cerebral artery infarction: Enabling
Matteo Montalbetti1, Sylvia Lörcher1, Andreas Nowacki1
1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
Insights
The bone removed during decompressive hemicraniectomy (DCE) often provides enough space for brain swelling after malignant middle cerebral artery (MCA) infarction. This finding supports single-stage surgical strategies for improved patient outcomes.
Area of Science:
- Neurosurgery
- Radiology
- Neurology
Background:
- Decompressive hemicraniectomy (DCE) is a critical procedure for managing intracranial pressure following malignant middle cerebral artery (MCA) infarction.
- Patients undergoing DCE face risks like traumatic brain injury and the syndrome of the trephined until cranioplasty.
- Current cranioplasty procedures after DCE have high complication rates, highlighting the need for improved surgical strategies.
Purpose of the Study:
- To assess the necessary volume for safe brain expansion, aiming to facilitate single-stage surgical interventions.
- To determine if the bone removed during DCE is sufficient for accommodating brain swelling.
Main Methods:
- Retrospective radiological and volumetric analysis of patients who underwent DCE between January 2009 and December 2018.
- Investigation of prognostic parameters in perioperative imaging.
- Assessment of clinical outcomes in relation to surgical interventions.
Main Results:
- Out of 86 patients, 44 met inclusion criteria. Median brain swelling was 75.35 mL.
- Median bone flap volume was 113.3 mL, with removed bone volume exceeding the required intracranial volume for swelling in 79.6% of cases.
- The space created by bone removal was generally sufficient for brain expansion.
Conclusions:
- The volume of bone removed during DCE is typically adequate for accommodating brain swelling post-malignant MCA infarction.
- Single-stage surgical approaches, potentially utilizing a subgaleal space-expanding flap, can offer protection without hindering brain expansion.
Introduction:
Decompressive hemicraniectomy (DCE) is routinely performed for intracranial pressure control after malignant middle cerebral artery (MCA) infarction. Decompressed patients are at risk of traumatic brain injury and the syndrome of the trephined until cranioplasty. Cranioplasty after DCE is itself associated with high complication rates. Single-stage surgical strategies may eliminate the need for follow-up surgery while allowing for safe brain expansion and protection from environmental factors.
Research Question:
Assess the volume needed for safe expansion of the brain to enable single-stage surgery.
Materials And Methods:
We performed a retrospective radiological and volumetric analysis of all patients that had DCE in our clinic between January 2009 and December 2018 and met inclusion criteria. We investigated prognostic parameters in perioperative imaging and assessed clinical outcome.
Results:
Of 86 patients with DCE, 44 fulfilled the inclusion criteria. Median brain swelling was 75.35 mL (8.7-151.2 mL). Median bone flap volume was 113.3 mL (73.34-146.1 mL). Median brain swelling was 1.62 mm below the previous outer rim of the skull (5.3 mm to -2.19 mm). In 79.6% of the patients, the volume of removed bone alone was equivalent to or larger than the additional intracranial volume needed for brain swelling.
Discussion And Conclusion:
The space provided by removal of the bone alone was sufficient to match the expansion of the injured brain after malignant MCA infarction in the vast majority of our patientsA subgaleal space-expanding flap with a minimal offset can provide protection from trauma and atmospheric pressure without compromising brain expansion.
