Decompressive Craniectomy: the Right Call at the Right Moment

Abstract

Introduction:Massive intracerebral hemorrhages and large internal carotid artery infarcts may cause early death due to severe cerebral edema with elevated intracranial pressure, despite maximal medical therapy. Decompressive craniectomy may be of benefit to these patients in terms of survival and even functional outcome. The aim of our paper is to present two cases that illustrate the use of decompressive craniectomy both in ischemic and hemorrhagic stroke, followed by a discussion on the indication and right timing of the intervention, but also on the outcome of these patients.

Materials and methods: We present the cases of a 38-year-old man with a right lenticular and capsular hemorrhage who underwent decompressive craniectomy in the first 24 hours from onset of symptoms and a 64-year-old patient with an ischemic stroke in the territory of the left carotid artery with a decompressive craniectomy performed at more than 72 hours from the beginning. For each of the two cases, we analyzed the following parameters: neurologic status, Glasgow Coma Scale, aspect of the cerebral computed tomography before and after surgery, in-hospital complications and modified Rankin Scale at discharge.

Outcomes: While the intervention was life-saving in both cases, the procedure had different functional outcomes.

Conclusion: Decompressive craniectomy may be a life-saving procedure for patients with both hemorrhagic or ischemic strokes complicated with massive edema and increased intracranial pressure. When performed in the first 48 hours, especially in patients with ischemic stroke aged less than 60, it may also improve the functional outcome compared to conservative treatment.

Keywords:decompressive craniectomy, ischemic stroke, intracerebral hemorrhage.

INTRODUCTION

Massive intracerebral hemorrhages and large internal carotid artery infarcts may cause severe cerebral edema with elevated intracranial pressure. Conservative treatment has limited efficacy in these patients, while decompressive craniectomy may be life-saving, but it is to be mentioned that the decision is not always easy.

MATERIALS AND METHODS

We present the cases of two patients, one with hemorrhagic stroke and the other one with ischemic stroke, both undergoing decompressive surgery. For each case, we analyzed the neurologic status, Glasgow Coma Scale, aspect of the cerebral computed tomography before and after surgery, in-hospital complications and modified Rankin Scale at admission and discharge.

Case 1

A 38-year-old man presented to the Emergency Room of our hospital for sudden onset of motor weakness affecting his left limbs, left facial asymmetry and severe dysarthria. The patient had a medical history of arterial hypertension, for which he received antihypertensive treatment, as well as intracerebral hemorrhage (located in the left basal ganglia) eight months prior to admission. His modified Ranking Scale score at admission was 0, with no cognitive impairments.

At time of admission to our clinic, the patient had a Glasgow Coma Scale score of 9. The neurological examination revealed left hemiplegia, left central facial palsy, Babinski sign on his left side and severe dysarthria.

Cerebral computed tomography (CT) performed at admission showed a right lenticular and capsular hemorrhage of 55/29 mm, with moderate edema and a 10 mm shift of the medial line. The patient was immediately transferred to the Neurosurgery Department, where a right fronto-temporo-parietal decompressive craniectomy was performed at about eight hours from symptom onset.

The initial postoperative clinical status was severely impaired. He was transferred in the Intensive Care Unit of our hospital. The cerebral CT scan performed after the intervention revealed herniation of the cerebral structures through the surgical breach. The size of the hemorrhage was stationary, being surrounded by significant edema, with a 10 mm shift of the medial line.

He developed acute respiratory insufficiency, needing an emergency tracheostomy, which was complicated with a respiratory tract infection with Serratia spp. He had severe dysphagia, so he needed a nasogastric tube. He also developed an urinary tract infection because of the urinary catheterization.

Under treatment with antibiotherapy and osmotic diuretics his evolution was gradually favorable. After one month his tracheostoma was removed. He was able to breath, speak and eat, with no residual dysphagia. He was transferred back to our clinic, with a Glasgow Coma Scale of 15 points.

Serial cerebral CT scans showed progressive remission of the edema, shrinkage of the hemorrhage and the reversion of the medial structures to the right position (Figures 1 and 2).

The patient was discharged one month and a half after the craniectomy. At the time of discharge, he presented with left hemiparesis and slight dysarthria and was oriented in time and space, with a modified Rankin Scale score of four points.

Case 2

A 64-year-old man was transferred to our clinic from a regional hospital, where he had been admitted three days before for motor deficit in his right limbs and global aphasia. The patient had a medical history of arterial hypertension, for which he received antihypertensive treatment. His prior modified Rankin Scale Score was 0, with no cognitive impairments.

The neurological examination showed right hemiplegia, right central facial palsy, right homonymous hemianopsia and global aphasia, with a Glasgow Coma Scale of 13 points.

The cerebral CT scan at admission showed an extensive hypodensity in the left cerebral hemisphere, suggestive for an ischemic stroke in the territory of the left carotid artery, with moderate edema and a medial structural shift of 4 mm. Also, a Doppler ultrasonography of the cervical and cerebral arteries was performed, which revealed occlusion of the left internal carotid artery.

The patient received antiplatelet therapy with aspirin and osmotic diuretics, but his clinical evolution was unfavorable and his neurological status got worse. Three days later, his Glasgow Coma Scale score was eight points. Another cerebral CT scan was performed at that moment and a massive diffuse edema in the left hemisphere with an 8 mm displacement of the medial line structures was observed. The patient was transferred to the Neurosurgery Clinic, where he underwent left fronto-temporo-parietal left decompressive craniectomy.

After surgery, the patient continued to receive antiplatelet therapy and osmotic diuretics. The only in-hospital complication was a urinary tract infection with a common germ due to urinary catheterization, which was managed with antibiotic therapy.

Repeated cerebral CT scans showed the presence of frontal, temporal, parietal, insular and lenticulo-capsular left hypodensity, with minimal herniation of the cerebral structures through the craniectomy breach, with progressive resolution of the edema and remission of the medial line shift (Figures 3 and 4).

The neurological status improved slowly. At discharge, the patient still presented hemiplegia but only a slight mixed aphasia, with the predominance of expressive aphasia and a Glasgow coma Scale of 15 points. His modified Rankin Scale score was 4.

DISCUSSION

There are some questions that make the decision of performing a decompressive craniectomy a difficult one: which patients are eligible, what is the right timing, and which will be the outcome?

Occlusion of the internal carotid artery results in large ischemic strokes, associated with massive edema leading to severe intracranial pressure, herniation syndromes and even death (1).

Conservative treatment based on osmotic diuretics, hyperventilation and barbiturates did not show any benefit (2), mortality being as high as 80% in these patients, despite maximal medical therapy (3).

Decompressive craniectomy has been shown to be superior in terms of survival in such cases. Three randomized controlled studies (DESTINY, DECIMAL, HAMLET) proved a clear benefit in patients under the age of 60, with a survival rate increased up to 50% compared to conservative approach (4-6). DESTINY II trial showed an increase in the survival rate for patients aged over 60 as well (7).

One of the ethical issues that emerges when such high survival rates are considered is whether these patients have a favorable functional outcome, which in most of the studies is defined as a modified Rankin Scale (mRS) of 3 or less. While when evaluating patients under the age of 60 it was observed that there was a non-significant increase in the number of those with severe morbidity compared to the medical treated group, half of subjects aged over 60 had a mRS score ≥4. Among patients with the age of 60 or higher, only 5% had a mRS score of 3 and none of them less than 3. Thus, decompressive craniectomy may be considered a life-saving but invalidating procedure for older patients (8, 9).

Another important matter in question is the right timing of the intervention. While the studies mentioned above had a period of maximum 48 hours from the onset of symptoms as an inclusion criterium, one recent study that enrolled 1301 participants showed that decompressive craniectomy was beneficial when performed before herniation of the intracranial structures. The same study concluded that the risk of unfavorable outcome was increased when the procedure had been performed after more than 72 hours (10). This was also the case for our ischemic stroke patient. As the patient was transferred to our clinic at 72 hours from symptom onset, our first choice was to treat him conservatively. Because of the alteration of his neurological status under antithrombotic and osmotic treatment, we have decided to perform decompressive craniectomy at six days after onset.

Some clinical scores such as DASH (the risk of developing malignant middle cerebral artery infarction) (11) or EDEMA (Enhanced Detection of Edema in Malignant Anterior Circulation Stroke) (12) include a series of radiologic and laboratory variables, and can therefore be used to predict the risk of development of malignant infarction (9).

Guidelines state that, for patients under the age of 60 whose neurological status worsen in the first 48 hours despite maximal medical therapy, decompressive craniectomy is reasonable. For those older than 60, surgery may be considered, but families should be informed regarding the high risk of major disability and should be part of the decisional team (13).

While decompressive craniectomy has proved to be beneficial in terms of survival and even functional outcome in selected patients with malignant middle cerebral artery infarction, the benefit for those with spontaneous intracerebral hemorrhage is still debatable. Intracerebral hemorrhage accounts for up to 20% of all strokes, but the rates of mortality (54% mortality at one year) and disability (only 12 to 39% of patients being functionally independent) are higher than in patients with ischemic stroke (14). For our patients, the modified Rankin Scale at discharge was the same. However, there were some significant differences in terms of in-hospital complications. While the patient with ischemic stroke only developed urinary tract infection with a common germ, in the case of hemorrhagic stroke there were multiple and more severe complications and disabilities. He has also developed urinary tract infection due to urinary catheterization, presented dysphagia, needing a nasogastric tube, and developed acute respiratory failure. An emergency tracheostomy was performed, complicated with a respiratory infection with Serratia spp.

Conservative treatment includes intensive measures of lowering the blood pressure and osmotic or hypertonic saline agents for patients with increased intracranial pressure (15).

The STICH and STICH II trials failed to demonstrate the superiority of early hematoma removal over conservative medical treatment (16, 17). A systematic review published in February 2018 showed that decompressive craniectomy reduced mortality and might even improve functional outcome in patients with spontaneous intracerebral hemorrhage. However, larger studies are needed to confirm these findings (18). SWITCH (Swiss Trial of Decompressive Craniectomy versus Best Medical Treatment of Spontaneous Supratentorial Intracerebral Hemorrhage) is an ongoing randomized controlled trial that aims to demonstrate the superiority of the best medical therapy associated to decompressive craniectomy compared to best medical therapy alone in patients with acute intracerebral hemorrhage. The results will be available in 2021 and will probably shed some light on the subject (19). Both our patients received medical therapy associated to craniectomy.

According to guidelines, decompressive craniectomy may be performed in patients with supratentorial intracerebral hemorrhage and midline shift or increased intracerebral pressure refractory to medical treatment (13).

CONCLUSONS

Decompressive craniectomy may be a lifesaving procedure for patients with both hemorrhagic or ischemic strokes complicated with massive edema and increased intracranial pressure. When performed in the first 48 hours, especially in patients with ischemic stroke aged less than 60, it may also improve the functional outcome compared to conservative treatment. Although we expected that the patient with ischemic stroke would have a better functional outcome, this was probably due to the fact that he was over 60 years old and the intervention was performed after more than 48 hours from onset.

Conflict of interests: none declared

Financial support: none declared.

FIGURE 1.

Cerebral CT scan performed at 24 hours after decompressive craniectomy

FIGURE 2.

Cerebral CT scan performed at 4 weeks after decompressive craniectomy

FIGURE 3.

Cerebral CT scan performed at 24 hours after decompressive craniectomy

FIGURE 4.

Cerebral CT scan performed at 10 days after decompressive craniectomy