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Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke.

Jüttler E, Schellinger PD, Aschoff A, Zweckberger K, Unterberg A, Hacke W - Crit Care (2007)

Bottom Line: Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%.The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%.However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany. eric.juettler@med.uni-heidelberg.de

ABSTRACT
The treatment of patients with large hemispheric ischaemic stroke accompanied by massive space-occupying oedema represents one of the major unsolved problems in neurocritical care medicine. Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%. Therefore, the term 'malignant brain infarction' was coined. Because conservative treatment strategies to limit brain tissue shift almost consistently fail, these massive infarctions often are regarded as an untreatable disease. The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%. However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability. Due to the lack of conclusive evidence of efficacy from randomised trials, controversy over the benefit of these treatment strategies remained, leading to large regional differences in the application of this procedure. Meanwhile, data from randomised trials confirm the results of former observational studies, demonstrating that hemicraniectomy not only significantly reduces mortality but also significantly improves clinical outcome without increasing the number of completely dependent patients. Hypothermia is another promising treatment option but still needs evidence of efficacy from randomised controlled trials before it may be recommended for clinical routine use. This review gives the reader an integrated view of the current status of treatment options in massive hemispheric brain infarction, based on the available data of clinical trials, including the most recent data from randomised trials published in 2007.

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Left hemispheric malignant middle cerebral artery infarction after hemicraniectomy (magnetic resonance imaging). The swollen brain is allowed to expand outside.
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Figure 2: Left hemispheric malignant middle cerebral artery infarction after hemicraniectomy (magnetic resonance imaging). The swollen brain is allowed to expand outside.

Mentions: Two different techniques are used: external decompression (removal of the cranial vault and duraplasty) or internal decompression (removal of nonviable, infarcted tissue [that is, in the case of malignant MCA infarction, temporal lobectomy]). The two can be combined [109,110]. In theory, resection of the temporal lobe may reduce the risk of uncal herniation. However, this has never been proven consistently by clinical studies, which show similar results as series using external decompression [111,112]. Resection of infarcted tissue is more complicated, and it is difficult to distinguish between already infarcted and potentially salvageable tissue. Therefore, in most institutions, external decompressive surgery (consisting of a large hemicraniectomy and dura-plasty) is performed: In short, a large (reversed) question mark-shaped skin incision based at the ear is made. A bone flap with a diameter of at least 12 cm (including the frontal, parietal, temporal, and parts of the occipital squama) is removed. Additional temporal bone is removed so that the floor of the middle cerebral fossa can be explored. Then the dura is opened and an augmented dural patch, consisting of homologous periost and/or temporal fascia, is inserted (usually, a patch of 15 to 20 cm in length and 2.5 to 3.5 cm in width is used). The dura is fixed at the margin of the craniotomy to prevent epidural bleeding. The temporal muscle and the skin flap are then reapproximated and secured. In surviving patients, cranioplasty usually is performed after 6 to 12 weeks, using the stored bone flap or an artificial bone flap (Figures 1 and 2). Complications occur rarely and include postoperative epidural and subdural haemorrhage and hygromas or wound and bone flap infections [77,109]. These can be recognized easily and usually do not contribute to perioperative mortality. A more common and far more serious problem is a hemicraniectomy that is too small. Because the proportion of brain tissue to be allowed to shift outside the skull is closely related to the diameter of the bone flap (which is removed), small hemicraniectomies not only are insufficient but may lead to herniation through the craniectomy defect [113]. Ventriculostomy is not recommended; although it may help to decrease ICP by allowing drainage of cerebrospinal fluid, it promotes brain tissue shifts at the same time and therefore may be detrimental.


Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke.

Jüttler E, Schellinger PD, Aschoff A, Zweckberger K, Unterberg A, Hacke W - Crit Care (2007)

Left hemispheric malignant middle cerebral artery infarction after hemicraniectomy (magnetic resonance imaging). The swollen brain is allowed to expand outside.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2556730&req=5

Figure 2: Left hemispheric malignant middle cerebral artery infarction after hemicraniectomy (magnetic resonance imaging). The swollen brain is allowed to expand outside.
Mentions: Two different techniques are used: external decompression (removal of the cranial vault and duraplasty) or internal decompression (removal of nonviable, infarcted tissue [that is, in the case of malignant MCA infarction, temporal lobectomy]). The two can be combined [109,110]. In theory, resection of the temporal lobe may reduce the risk of uncal herniation. However, this has never been proven consistently by clinical studies, which show similar results as series using external decompression [111,112]. Resection of infarcted tissue is more complicated, and it is difficult to distinguish between already infarcted and potentially salvageable tissue. Therefore, in most institutions, external decompressive surgery (consisting of a large hemicraniectomy and dura-plasty) is performed: In short, a large (reversed) question mark-shaped skin incision based at the ear is made. A bone flap with a diameter of at least 12 cm (including the frontal, parietal, temporal, and parts of the occipital squama) is removed. Additional temporal bone is removed so that the floor of the middle cerebral fossa can be explored. Then the dura is opened and an augmented dural patch, consisting of homologous periost and/or temporal fascia, is inserted (usually, a patch of 15 to 20 cm in length and 2.5 to 3.5 cm in width is used). The dura is fixed at the margin of the craniotomy to prevent epidural bleeding. The temporal muscle and the skin flap are then reapproximated and secured. In surviving patients, cranioplasty usually is performed after 6 to 12 weeks, using the stored bone flap or an artificial bone flap (Figures 1 and 2). Complications occur rarely and include postoperative epidural and subdural haemorrhage and hygromas or wound and bone flap infections [77,109]. These can be recognized easily and usually do not contribute to perioperative mortality. A more common and far more serious problem is a hemicraniectomy that is too small. Because the proportion of brain tissue to be allowed to shift outside the skull is closely related to the diameter of the bone flap (which is removed), small hemicraniectomies not only are insufficient but may lead to herniation through the craniectomy defect [113]. Ventriculostomy is not recommended; although it may help to decrease ICP by allowing drainage of cerebrospinal fluid, it promotes brain tissue shifts at the same time and therefore may be detrimental.

Bottom Line: Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%.The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%.However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany. eric.juettler@med.uni-heidelberg.de

ABSTRACT
The treatment of patients with large hemispheric ischaemic stroke accompanied by massive space-occupying oedema represents one of the major unsolved problems in neurocritical care medicine. Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%. Therefore, the term 'malignant brain infarction' was coined. Because conservative treatment strategies to limit brain tissue shift almost consistently fail, these massive infarctions often are regarded as an untreatable disease. The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%. However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability. Due to the lack of conclusive evidence of efficacy from randomised trials, controversy over the benefit of these treatment strategies remained, leading to large regional differences in the application of this procedure. Meanwhile, data from randomised trials confirm the results of former observational studies, demonstrating that hemicraniectomy not only significantly reduces mortality but also significantly improves clinical outcome without increasing the number of completely dependent patients. Hypothermia is another promising treatment option but still needs evidence of efficacy from randomised controlled trials before it may be recommended for clinical routine use. This review gives the reader an integrated view of the current status of treatment options in massive hemispheric brain infarction, based on the available data of clinical trials, including the most recent data from randomised trials published in 2007.

Show MeSH
Related in: MedlinePlus