Is decompressive craniectomy for malignant middle cerebral artery infarction of any worth?

Is decompressive craniectomy for malignant middle cerebral artery infarction of any worth? first-author corresp ‡Corresponding Author ‡Corresponding Author †E-mail:yu_yao03@126.com †E-mail:yu_yao03@126.com yu_yao03@126.com Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China Objective: 2 Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients presenting malignant MCA infarction compared with those receiving medical treatment alone. Methods: 2 Patients with malignant MCA infarction treated in our hospital between January 1996 and March 2004 were included in this retrospective analysis. The National Institute of Health Stroke Scale (NIHSS) was used to assess neurological status on admission and at one week after surgery. All patients were followed up for assessment of functional outcome by the Barthel index (BI) and modified Rankin Scale (RS) at 3 months after infarction. Results: 2 Ten out of 24 patients underwent decompressive craniectomy. The mean interval between stroke onset and surgery was 62.10 h. The mortality was 10.0% compared with 64.2% in patients who received medical treatment alone ( P < 0.001). The mean NIHSS score before surgery was 26.0 and 15.4 after surgery ( P < 0.001). At follow up, patients who underwent surgery had significantly better outcome with mean BI of 53.3, RS of 3.3 as compared to only 16.0 and 4.60 in medically treated patients. Speech function also improved in patients with dominant hemispherical infarction. Conclusion: 2 Decompressive craniectomy in patients with malignant MCA infarction improves both survival rates and functional outcomes compared with medical treatment alone. A randomized controlled trial is required to substantiate those findings. Decompressive craniectomy Cerebral infarction Middle cerebral artery (MCA) INTRODUCTION 1 The management of ischemic stroke has improved greatly over the past two decades in terms of stroke treatment. Large multicentre trials and studies provide many evidences of the value of intravenous thrombolysis with rtPA, anticoagulants, antiplatelet agents, and so on. There is strong evidence that outcomes after stroke can be improved and that death or disability from stroke can be reduced with appropriate treatment (Adams et al., 2003 2003 ; Hack et al., 2003 2003 ). Despite these advances, there is still a subset of patients who deteriorate rapidly after hospital admission for cerebral infarction, with a mortality approaching 80% when treated conservatively (Berrouschot et al., 1998 1998 ; Heinsius et al., 1998 1998 ; Wijdicks and Diringer, 1998 1998 ). This occurs in 10% to 15% of supratentorial infarction cases (Hacke et al., 1996 1996 ) and is involved in the entire middle cerebral artery (MCA) territory. This “malignant” MCA infarction suffers from progressive clinical deterioration because of increasing brain swelling, raised intracranial pressure (ICP), and brain herniation. This patient subpopulation constitutes a particularly difficult challenge for those charged with their cases. Considering the high mortality yielded by conservative treatment, therapy of malignant MCA infarction should be more aggressive. Decompressive craniectomy was first described by Kocher for the treatment of post traumatic brain edema (Bayir et al., 2003 2003 ; Mussack et al., 2003 2003 ; Ziai et al., 2003 2003 ). The rationale for decompressive surgery is to reduce ICP and the vicious circle of extensive edema and further infarction. But the role of surgical decompression in malignant MCA infarction is still controversial and needs to be clearly defined further (Adams et al., 2003 2003 ; Hack et al., 2003 2003 ). We report a series of patients with malignant MCA infarction who underwent decompressive craniectomy because they showed signs of transtentorial herniation despite appropriate medical therapy. PATIENTS AND METHODS 1 Patient selection 2 From January 1996 to March 2004, 24 patients with malignant MCA infarction were treated in our hospital. The criteria of malignant MCA infarction was as following: (1) infarction of more than 50% of the MCA territory as defined by computed tomography (CT) and/or magnetic resonance imaging (MRI) with an acute onset of corresponding clinical signs and symptoms; (2) neuroradiological evidence of local brain swelling such as midline shift of 5 mm or more indicating space occupying edema. We excluded patients with small size infarctions, as they usually were treated successfully by conservative methods. All these 24 patients were first treated using standardized conservative management included controlling good blood pressure, hyperosmolar treatment, hypertonic saline solution, hyperventilation and so on (Steiner et al., 2001 2001 ). Decompressive craniectomy was used as second line treatment in case of significant neurological deterioration and informed consent obtained from the patients’ relatives. Twenty-four patients in this study were divided into 2 groups. Group A ( n =10) included patients who received decompressive craniectomy. Group B ( n =14) underwent medical control. Patients whose relatives did not consent to surgery were also enrolled in Group B. Operative technique 2 Decompressive craniectomy was done by removing parts of the frontal, parietal, temporal, and occipital squama, resulting in a large bone flap (diameter > 12 cm) (Schwab et al., 1998 1998 ). A cruciate durotomy was then opened centered on the flap. In order to protect major vessels cross the dural margins from compression, we used absorbable gelatin with biomedical mucilage on its bone surface to create a “vascular tunnel”. And this may provide free circulation to the herniated brain substance (Fig. 1 1 ). Dural patch or homologous temporal fascia was placed into the incision for volume-enlarged dural repair. Cranioplasty was done about three months after discharge. Patient evaluation 2 Clinical status was rated on admission and at operation or surgical decision time using the National Institute of Health Stroke Scale (NIHSS) which was repeated one week after surgery. Conscious levels of two groups were checked one week after surgery. Month mortality was defined as patient death 30 d after onset. Patients were assed three months after surgery and the outcome was quantified on Barthel Index (BI) and the modified Rankin scale (RS). Statistical analysis 2 SPSS 11.5 for Windows package was used for statistical analysis. All values are expressed as means± SD . Paired T test was applied to analysis the difference of NIHSS change perioperation in Group A. Mann-Whitney U non-parametric tests and T tests were used to compare means between groups. Rates were compared by Fisher’s exact test. Statistical significance was assigned to P value of < 0.05. RESULTS 1 Ten patients with malignant MCA infarction underwent decompressive craniectomy (for summarized data, Table 1 1 ); fourteen medically treated patients’ characteristics are summarized in Table 2 2 . There were no statistical differences between age, sex and initial NIHSS among patients in the two groups. One patient with decompressive craniectomy is described in Fig. 1 1 . Note: L.MCA: left MCA; R.MCA: right MCA; NA: Not applicable Patient died after x days P < 0.001, between NIHSS at operation and NIHSS a week after surgery, paired T test 2 Patient No. 2 Sex/age 2 Location of infarction 2 Infarction reason 3 NIHSS 2 Hours between onset and operation 3 Follow up At admission At operation * * After surgery Time BI RS 1 F/19 L.MCA Takayasu arteritis 13 20 11 140 3 months 90 1 2 M/46 R.MCA Thrombosis 16 28 9 54 3 months 85 2 3 M/50 R.MCA+ACA Thrombosis 17 27 15 40 3 months 75 3 4 F/56 L.MCA+ACA Thrombosis 17 27 15 71 3 months 40 4 5 M/59 R.MCA Embolism 17 22 10 34 3 months 70 3 6 F/65 R.MCA+ACA Thrombosis 15 29 25 111 ↓ ↓ 8 d NA NA 7 F/70 L.MCA Embolism 13 22 19 32 3 months 40 4 8 M/73 R.MCA+ACA Embolism 19 29 16 39 3 months 40 4 9 F/74 R.MCA+PCA Embolism 17 28 15 31 3 months 40 4 10 M/75 R.MCA+PCA Embolism 17 28 19 69 3 months 0 5 Note: L.MCA: left MCA; R.MCA: right MCA; NA: Not applicable Patient died after x days 2 Patient No. 2 Sex/age 2 Location of infarction 2 Infarction reason 2 NIHSS 3 Follow up At admission At surgical decision time Time BI RS 1 M/54 R.MCA Embolism 10 24 3 months 0 5 2 M/54 L.MCA+ACA Thrombosis 16 29 ↓ ↓ 5 d NA NA 3 M/55 L.MCA+ACA Embolism 17 27 3 months 40 4 4 F/61 R.MCA+ACA Embolism 19 27 ↓ ↓ 3 d NA NA 5 M/63 L.MCA Thrombosis 18 28 ↓ ↓ 3 d NA NA 6 F/64 L.MCA+ACA Thrombosis 19 29 ↓ ↓ 10d NA NA 7 M/68 R.MCA+ACA Thrombosis 15 26 3 months 0 5 8 M/69 R.MCA+PCA Embolism 17 29 3 months 0 5 9 M/70 L.MCA Embolism 17 28 ↓ ↓ 21 d NA NA 10 M/71 R.MCA+ ACA Thrombosis 18 27 ↓ ↓ 3 d NA NA 11 F/71 R.MCA Embolism 13 27 3 months 40 4 12 M/74 L.MCA Embolism 17 29 ↓ ↓ 3 d NA NA 13 M/74 R.MCA Thrombosis 18 28 ↓ ↓ 9 d NA NA 14 F/75 R.MCA+ACA Thrombosis 17 29 ↓ ↓ 2 d NA NA The age of the patients on operate was 58.7±17.3 years. Four patients had ischemic infarction restricted to the MCA territory; others had additional ACA (anterior cerebral artery) or PCA (posterior cerebral artery) infarction. The average interval between infarction and surgery was 62.1±37.0 h (range 31~140 h). NIHSS at operation was 26.0±3.3 (range 20~29) and 15.4±4.8 (9~25) at one week after surgery ( P < 0.001). One patient died after 111 h. She had delayed surgery because she was sent to our hospital late and her family members refused surgical treatment at first time. She died of heart failure at 8 d after surgery. The age of the 14 medically treated patients was 65.9±7.5 years. Nine of these patients (64.2%) died of transtentorial herniation in the first days after infarction. The results for two groups are shown in Table 3 3 . There were no statistical differences in NIHSS between the two groups during admission and surgical decision time ( P > 0.05). The mortality in Group A was 10.0% (1/10), while that in Group B was 64.2% (9/14) ( P < 0.001). The percent of patients able to obey commands at one week after surgery (or surgical decision) was 70.0% in Group A and 0% in Group B ( P < 0.001). At 3 months of onset, there were significant differences between Group A and Group B in both BI and RS ( P < 0.05). P < 0.01, Group A versus Group B, Fisher’s exact test P < 0.001, Group A versus Group B, Fisher’s exact test P > 0.05, Group A versus Group B, T test P > 0.05, Group A versus Group B, T test P < 0.05, between Group A and Group B, Mann-Whitney U non-parametric test P < 0.05, between Group A and Group B, Mann-Whitney U non-parametric test Group A Group B Mortality 10.0% * * 64.20% Consciousness recovery 70.0% ** ** 0% NIHSS at admission 16.1±1.9 Δ Δ (13~19) 16.5±2.4 (10~19) NIHSS at a week after surgery 26.0±3.3 ΔΔ ΔΔ (20~29) 27.6±1.4 (24~29) BI 53.3±28.8 a a (0~90) 16.0±21.9 (0~40) RS 3.3±1.2 b b (1~5) 4.6±0.5 (4~5) DISCUSSION 1 Decompressive craniectomy with durotomy is usually performed as a last resort in patients with malignant brain edema because of infarction or trauma (Mitchell et al., 2004 2004 ; Messing-Junger et al., 2003 2003 ; Schwab et al., 1998 1998 ). However, in the setting of cerebral ischemia, the indications are still controversial, although it is clear that with even the best conservative therapy, the mortality rates are approximately 80% (Berrouschot et al., 1998 1998 ; Heinsius et al., 1998 1998 ; Wijdicks and Diringer, 1998 1998 ). A more aggressive therapeutic method is therefore necessary to reduce mortality in these patients. Even though decompressive craniectomy for supratentorial infarction has been done in a few patients sporadically over four decades, it is only in the last two decades that the treatment has been studied systematically (Uhl et al., 2004 2004 ; Morley et al., 2002 2002 ; Steiner et al., 2001 2001 ; Schwab et al., 1998 1998 ). A recent review, however, revealed no evidence from the extant literature of solid basis for the use of this approach (Morley et al., 2002 2002 ). Our study, support previous findings that suggest mortality, may be better after surgery. In Group A, only one patient died (mortality 10.0%); 8 d after operation because of failure of heart function, not because of herniation. The mortality rates in previous reports varied from 0%~35% (Schwab et al., 1998 1998 ; Rieke et al., 1995 1995 ; Kalia and Yonas, 1993 1993 ). In Group A, NIHSS significantly decreased with exciting consciousness recovery rate (70.0%). Patients who received decompressive craniectomy had mean BI of 53.3 and RS of 3.3. Our results accorded with data published by Pranesh et al.( 2003 2003 ) and Schwab et al.( 1998 1998 ). It was often thought that decompressive craniectomy must be offered only to patients with non-dominant hemispherical strokes because the speech function is unaffected and outcome would be better (Carter et al., 1997 1997 ). In Group A, we found speech function improved most in patients with dominant hemispherical infarction. This is consistent with Schwab et al.( 1998 1998 )’s report. Decompressive surgery can reduce ICP, secondary ischemia, edema and can also significantly decrease infarction size. However, this procedure can allow bulge of brain tissue through the defect. This frequently results in compression of vessels by the dural margin with further congestion, edema, ischemia and hemorrhage in the bulged brain tissue. The method of creating a vascular tunnel was first reported by Csokay ( 2001 2001 ) in traumatic brain swelling, here we newly applied this technique in malignant MCA infarction to help to prevent vascular compression and ischemia of brain bulging through the defect. Volume-enlarged dural repair can help to prevent cortex conglutination and possible shift of the brain after surgery. We also found in Group A that patients more than 60 years had relative bad RS (4 patients’ RS≥4 out of 5 patients). But “younger” patients achieved good RS (one patient’s RS>3 among 5 patients). 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