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Hemicraniectomy for Massive Middle Cerebral Artery Infarction: A Review

Published online by Cambridge University Press:  02 December 2014

Dulka Manawadu ,
Ahmed Quateen  and
J. Max Findlay
Dulka Manawadu
Affiliation:
Division of Neurology, Division of Neurosurgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
Ahmed Quateen
Affiliation:
Division of Neurology, Division of Neurosurgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
J. Max Findlay*
Affiliation:
Division of Neurology, Division of Neurosurgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
*
Rm. 2D 102 Mackenzie Centre, University Hospital, 8440 112 Street, Edmonton, Alberta T6G 2B7
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Abstract

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Hemicraniectomy and opening underlying dura mater permits the expansion of infarcted, swollen brain outwards, reversing dangerous intracranial pressure elevations and the risk of fatal transtentorial temporal lobe or diencephalic herniation. Recently published randomized controlled trials have proven this procedure a powerful life-saving measure in the setting of malignant middle cerebral artery infarction and allayed concerns that a reduction in mortality is accompanied by an unacceptable increase in patients suffering severe neurological impairments. Appropriate patients are relatively young, in the first five decades of life, suffering infarction of a majority of the middle cerebral artery (MCA) territory in either hemisphere, and decompression should be performed prior to progression to coma or two dilated, fixed pupils. Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider and discuss surgical intervention. Families and, when possible, patients themselves, should be informed of the certainty of at least moderate to mild permanent deficits, and the possibility of worse. To be successful decompression must be extensive, targeting a bone flap measuring 14 cm from front to back, and extending 1 to 2 cms lateral to the midline sagittal suture to the floor of the middle cranial fossa at the level of the coronal suture. An augmentation duraplasty is mandatory.

Résumé:

RÉSUMÉ:

L'hémicrâniectomie et l'ouverture de la dure-mère sous-jacente permettent l'expansion du cerveau infarcisé et oedématié, diminuant ainsi la pression intracrânienne et le risque de hernie transtentorielle temporale ou diencéphalique fatale. Des études randomisées, contrôlées, publiées récemment ont montré que cette procédure était un outil puissant pour sauver la vie dans le contexte d'un infarctus massif du territoire de l'artère cérébrale moyenne (ACM) et dissiper la crainte qu'une diminution de la mortalité ne soit accompagnée par une augmentation inacceptable de déficits neurologiques sévères chez ces patients. Les patients qui peuvent en bénéficier sont relativement jeunes, soit dans les cinq premières décennies de vie et présentent un infarctus de la majorité du territoire de l'ACM de l'un ou l'autre hémisphère. La décompression devrait être effectuée avant que le patient ne soit dans le coma ou que ses deux pupilles ne soient dilatées et fixes. La léthargie associée à un déplacement médian et une hernie de l'uncus à la neuroimagerie sont des signaux indiquant qu'on doit envisager cette intervention et en discuter. La famille et le patient lui-même si possible devraient être informés de la certitude de déficits permanents de légers à modérés ou pire. La décompression doit être extensive pour être efficace. Le volet osseux doit mesurer 14 cm d'avant en arrière et s'étendre latéralement de 1 à 2 cm de la suture sagittale médiane jusqu'au plancher de la fosse cérébrale moyenne au niveau de la suture coronale. Une plastie durale d'augmentation est essentielle.

Type
Review Article
Information
Canadian Journal of Neurological Sciences , Volume 35 , Issue 5 , November 2008 , pp. 544 - 550
Copyright
Copyright © The Canadian Journal of Neurological 2008

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