An overview of Decompression hemicraniectomy in patients with large hemispheric infarctions. The presentation touches upon definition, pathophysiology, medical management, rationale for surgery, mortality, functional outcomes of DHC, and complications in a nutshell.

1. Decompressive Hemicraniectomy for
Large Hemispheric Infarction
Naresh Mullaguri MD
Cerebrovascular Case Management
Conference

2. Objectives
• Definition and Epidemiology
• Medical management for LHI and
rationale of DCH
• Selection of patients and surgical timing of
DCH?
• DCH RCTs and meta-analysis on mortality
and functional outcomes
• Complications of DCH

3. Definition
Large hemispheric infarction(LHI) is the term
used to describe rapid neurological
deterioration due to space occupying cerebral
edema following acute ischemic stroke.

4. Epidemiology
• LHI represent 10% of supratentorial acute
ischemic strokes with mortality as high as
78%.
• Annual incidence is 10-20/100,000.
• Female sex predominance. Young people
at more risk.
• Clinical features manifest between 24-96
hours.
Kumar KR, Kleinig T “Malignant” ischaemic stroke of an entire cerebral hemisphere"
Journal of Neurology, Neurosurgery & Psychiatry 2009;80:87.

5. Pathophysiology
• Cytotoxic edema (minutes to hours)
• Vasogenic edema (hours to days)
• Midline shift
• Increased intracranial pressure
• Herniation

7. Clinical and Radiological predictors of poor outcome following LHI
Treadwell SD; Postgraduate Medical Journal 2010; Torbey, MT Evidence based guidelines for the management of LHI, Neurocritical care 2015
Clinical Predictors Radiological Predictors
History of heart failure Multiple vascular territory infarction (OR 3.34)
History of hypertension Pineal gland displacement/septum pellucidum >
5mm Midline shift (OR 10.9)
Higher NIHSS score (>18, OR 4.4) > 50% MCA ischemic change/basal ganglia
involvement, ASPECTS < 7 on CT (OR 6.1)
Depressed conscious level MRI DWI >82 cc @ 6hrs / > 145 cc lesion volume
(predicts herniation).
Early nausea and vomiting Transtentorial herniation
Pupil asymmetry Poor collaterals (CS<2, OR 7.3), failed
recanalization
Higher body temperature Distal ICA/Proximal MCA occlusion on angio
Elevated white cell count Flumazenil PET/SPECT/Xenon CT
(<15ml/100gm/min) showing reduced CBF**

8. Prediction tool for malignant brain edema
Jo K, Bajgur SS, Kim H, Choi HA, Huh PW, Lee K., PLoS One 2017

9. Biomarkers
• S-100
• Cellular Fibronectin
• Microdialysis –
• Excitatory neurotransmitters - Glutamate, Aspartate
• Anaerobic metabolites – Lactate and Pyruvate
* Not used in any DCH trials. Still experimental.

10. Medical management??
• No proven medical management for LHI.
• Osmotherapy, hyperventilation,
THAM buffers, barbiturate and steroids
are ineffective and some of them are even
detrimental.
• Hypothermia??
(Bardutzky et al., stroke 2007)

11. Hypothermia trials
• North American trials so far did safety
and feasibility pilot studies which are not
powered to assess efficacy.

12. Hypothermia trials – Cochrane review 2010
• 5 pharmacological temperature reduction
trials + 3 physical cooling trials (1998-
2007)
• N=423 – No statistically significant effect
• OR 0.9 (95% CI 0.6-1.4) for reducing death
or dependency
• OR 0.9 (95% CI 0.5-1.5) for death

13. Hypothermia as an alternative to
DHC in Elderly patients (age > 60)
• Korean study (n=11)
• Patients enrolled between 02/2011-08/2012.
• DHC was the first choice but for patients who declined
the surgery were consented for TTM at 33C.
• Median time of initiation 30.3(SD 23) hours.
• Median time of TTM was 76.7 (SD 57.1) hours.
• Mean mRS @ 3 months was 4.9 for
all patients and 4.7 for survivors.
• 1/11 (9%) achieved mRS of 3.
• 2/11 died (18%).
• No patients with pineal gland shift > 1cm survived.

14. Rationale for DHC
• Given the poor prognosis
despite best medical
management, DHC was found
to be a life saving treatment.
• It decreases intracranial
pressure; reverses midline
shifts and prevents herniation.
• Over the past 30 years,
enthusiasm for this procedure
fluctuated.

15. Decompressive Hemicraniectomy

16. Historical account of
DHC
• First described by Harvey Cushing
in 1905
• Scarcella first described operative
procedure specifically in massive
cerebral infarction in 1956.

17. DHC
resolving
midline shift

19. Effects of DCH on CBF, CBV, brain tissue oxygenation & metabolism
Lazaridis C.; Neurocritical care 2012

20. Randomized controlled
Trials
• AMERICAN study -
Hemicraniectomy and Durotomy
upon deterioration from infarction
related swelling trial
(HEADDFIRST)
• FRENCH study - DEcompressive
Craniectomy In Malignant middle
cerebral artery infarcts (DECIMAL)
• GERMAN study - DEcompressive
Surgery for the Treatment of
malignant Infarction of the middle
cerebral artery (DESTINY I and II)
• DUTCH study - Hemicraniectomy
After Middle cerebral artery
infarction with Life-threatening
Edema Trial (HAMLET)

25. 14 RCTs and 11
Observational
studies on DHC

26. Good
functional
outcome (mRS
<3 or GOS >4)
at 3,6,12 and
36 months

28. Survival with moderately severe disability (mRS =4)

29. Survival with severe disability for all ages at 6 and 12 months

30. MORTALITY @ 1, 3, 12 and 36 months
Improvement in NIHSS
Improvement in Barthel index

31. Subgroup
analysis –
Age (<60 vs
>60)
GFO <60 vs. >60 = 38.94% vs 9.65%

32. Mortality higher in pts> 60 with DHC vs < 60 = 35.8% vs. 16.85%Pts > 60 have higher risk of having mRS 4-5

33. Surgical timing of DHC
• Prophylactic DHC: DESTINY and DECIMAL
offered it with in 24 hrs.
• with reduced mortality, rate of herniation and
ICU time.
• Improved neurological outcome at 6 and 12
months.
• Decreased final infarct volume. Some showed
increased disability.
• Rapid infarcters with early neurological decline
underwent early DHC. Reperfusion, collateral
status and rate of infarct growth matters in
predicting these patients.
• RESCUE DHC: Worse outcomes are reported if
performed after patients showed signs of
herniation**. **Maramattom BV; Neurology 2004
**Malm; Acta Neurologica 2006

34. Surgical timing (<48 vs >48 hours)
Good functional outcome – No difference
Mortality – Trend towards early DHC

35. Operation technique and prognosis
• Suboptimal DHC (AP diameter < 12 cm) -
increased cerebral complications and
decreased survival. ( Venous congestion
& hemorrhage)
Unanswered questions:
• Temporalis muscle resection? Duraplasty
(reduces ICP by 53%).
• Temporal lobe resection (helps with
herniation)?? Strokectomy??
• Timing of Cranioplasty, storage of bone
flap, autologous vs synthetic flap??
• Large RCTs are needed.
Wagner S, et al., Journal of neurosurgery 2001
Park J, et al., Journal of neurosurgery 2009

36. DHC for Dominant vs Non-dominant
hemisphere
• No difference in outcomes. No evidence to withhold
DCH for dominant hemisphere infarcts.
• Reasons:
• Smaller number of patients with dominant hemisphere
• Aphasia may have a smaller consequence compared to
hemiplegia. (A study showed 13/14 pts improved @ 1
year – Kastrau F et al., Stroke 2005)
• Non-dominant hemisphere stroke leads to depression,
abulia, neglect states that interfere with rehab.
• Global disability scales like BI, mRS, GOS emphasize
mobility than aphasia.
• Our understanding of patients’ view of acceptable
outcome is poor. (Patients and their family members
retrospectively consented for DHC).
• Assessments of patients at risk of stroke have shown –
disabling hemiplegia is often viewed worse than aphasia
and death.

37. QoL after LHI
• Secondary end-points in RCTs: No significant difference
between CT vs. DHC (HAMLET and DECIMAL)
• Depression is prevalent.
• All survivors were able to acknowledge that ”Life is
worth living”.

38. Differences
among stroke
neurologists and
neurosurgeons
regarding DHC
recommendation

39. Basu P, et al., world neurosurgery 2017

40. Complications of DHC
• Hydrocephalus (10% approx. Finger
et al., Clin. Neurol and Neurosurg.
2017)
• External brain tamponade
• Infections
• Seizures
• Sinking flap syndrome (11% in
DECIMAL @ 3-5 months)
• Paradoxical herniation (Neurological
emergency)

41. Future perspectives
•DHC +
Hypothermia?
•Anti-edema
treatments
•Multimodal
monitoring

42. Thank you