Decompressive Craniotomy for Acute Ischemic Stroke

1. Decompressive craniectomy for
acute ischemic stroke
“...To do or not to do...
That is the question...”
By Sanjeewa Malinda

2.  MCA is the largest cerebral artery.
 It is the vessel most commonly affected by strokes.
 (approximately 90% of infarcts and two thirds of all first strokes)
 MCA supplies most of the outer convex brain surface, nearly all the basal ganglia, and the
posterior and anterior internal capsules
 Vast distribution of this vessel lead to diverse neurologic sequelae
 Neurologic complications include
i. Cerebral edema
ii. Hemorrhagic transformation of cerebral infarction
iii. Seizures
iv. Hydrocephalus
v. Increased intracranial pressure
Background

3. The medical interventions that have been shown to improve outcomes after
stroke...
• Treatment in a stroke unit
• Intravenous rtPA therapy administered within 3-4.5 hours of onset to patients with ischemic
stroke
• Mechanical thrombectomy
• Antiplatelet therapy, including aspirin administered within the first 48 hours of stroke
Chinese Acute Stroke Trial (CAST).
• Antihypertensives are typically deferred
• High-dose statins for secondary stroke prevention.
• Presenting within 6 hours of stroke onset with a stroke affecting a proximal, anterior
circulation vessel, endovascular thrombectomy may improve outcomes

4. • Carotid endarterectomy - Recommended for the secondary prevention of
stroke for patients with internal carotid artery stenosis of 70-99%, and for some
patients with 50-69% stenosis.
• The Carotid Revascularization Endarterectomy versus Stenting Trial
(CREST) compared the two and the outcomes appeared to be similar
• But during the periprocedural period
• carotid stenting resulted in a higher risk of strokeand
• carotid endarterectomy resulted in a higher risk of myocardial infarction
The medical interventions that have been shown to improve outcomes
after stroke cnt...

5. Decompressive Hemicraniectomy for
Large Hemispheric Infarction
Large hemispheric infarction (LHI) is a severe form of ischemic stroke affecting the
majority of or complete middle cerebral artery (MCA) distribution area with or
without anterior cerebral artery and posterior cerebral artery involvement and
characterized by the development of life-threatening cerebral edema

6. Pathophysiology
Cerebral edema develops shortly after interruption of perfusion and evolves in stages
 Cytotoxic edema - evolves over minutes to hours after the event, declines within 1 day,
and is characterized by an intact BBB and swelling of the cellular elements of the brain
(neurons, glia) owing to failure of ATP-dependent ion (Na+ and Ca2+) transport
 Ionic edema - an early phase of endothelial dysfunction—forms immediately following
cytotoxic edema and precedes vasogenic edema development by ≈6 hours
 Vasogenic edema - develops secondary to the BBB breakdown, which leads to
extravasation of fluid and intravascular proteins into the parenchymal extracellular
space peaking ≈24 to 48 hours after onset
 Midline shift  Increased intracranial pressure  Herniation

10. Medical management?
No proven medical management for LHI
• Osmotherapy, Hyperventilation, THAM buffers, No proven medical
management for LHI
• Barbiturate and steroids are ineffective and sometimes even detrimental
• Hypothermia?

11. What is the rationale of Decompressive Hemi-Craniectomy (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
 Prevents herniation
.

12. Life-saving treatment by DHC
has been available for >25
years.
Pooled major trials show a
marked effect in reducing
mortality and the most severe
dependency in patients aged
<60

13. The number-needed-to-treat is striking: in patients
aged <60 years, number-needed-to-treat is 2 in
reduction of mortality and 4 in reduction of severe
disability

14. Guidelines (AHA/ASA)
 Selected patients, including those able to handle an aggressive rehabilitation
program, may benefit from decompressive craniectomy; younger patients may
benefit most, and surgery is not recommended for patients older than 60 years
 In patients with swollen supratentorial hemispheric ischemic stroke, who continue to
deteriorate neurologically, decompressive craniectomy with dural expansion should
be considered
 In patients with swollen cerebellar stroke who deteriorate neurologically, suboccipital
craniectomy with dural expansion should be performed

15. Guidelines (NICE)
1.9.5. Consider decompressive hemicraniectomy (which should be performed within
48 hours of symptom onset) for people with acute stroke who meet all of the
following criteria:
 Clinical deficits that suggest infarction in the territory of the middle cerebral
artery, with a score above 15 on the National Institutes of Health Stroke Scale
(NIHSS)
 Decreased level of consciousness, with a score of 1 or more on item 1a of the
NIHSS
 Signs on CT of an infarct of at least 50% of the middle cerebral artery territory:
- with or without additional infarction in the territory of the anterior or
posterior cerebral artery on the same side, or
- with infarct volume greater than 145 cm3, as shown on diffusionweighted MRI scan

16. NICE further elaborates...
Discuss the risks and benefits of decompressive hemicraniectomy with
people or their family members or carers (as appropriate), taking into
account their functional status before the stroke, and their wishes and
preferences

17. • 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)
Some land mark trials on DHC for malignant middle cerebral artery infarction

19. DECIMAL trial (2007)
• Prospective, MC RCT from France
• n=38
• data safety monitoring committee terminated the trial because of slow recruitment
• Protocol outcome 1: Mortality at 6months and 1 year, 2: Functional outcome at
90days
• Outcome: ARR 52.8% in mortality favouring the decompressive craniectomy
group (75% vs 22% survival)

21. DESTINY trial (2007)
• Prospective, MC RCT from Germany
• n=32 (projected sample size calculated to be n-188)
• Protocol outcome 1: mortality at 6months and 1year, 2: FOC at 90days
• steering committee terminated the trial early as a statistically significant
mortality reduction was found at this stage in comibnation with the results
of the other European decompressive craniectomy trials
• Outcome: 88% vs 47% survival in favour of decompressive craniectomy

23. DESTINY II Trial (2014)
• studied patients aged >60 years:
• n = 112 patients >60 years of age (median age was 70)
• Protocol outcome 1: Mortality at define, 2: Functional outcome
at 90days, 3: QoL at define
• Primary outcome measure was survival without severe disability
• 38% in the hemicraniectomy group vs 18% in the control group
• Secondary outcomes:
• Overall mortality was lower in the surgery group (33% vs 70%)
• Almost none of the survivors has an outcome as good as an mRS score of 3;
almost all post-operative survivors were severely disabled

25. HAMLET trial (2009)
• Prospective, MC RCT from the Netherlands
• n=64
• Outcome: ARR 38% in mortality favouring the decompressive
craniectomy group

33. Decompressive craniectomy for
acute ischemic stroke
“...To do or not to do...
That is the question...”

34.  Given the poor prognosis, despite best
medical management, DHC was found
to be a life saving treatment
 Secondary endpoints  no significant
difference in functional outcome
(DECIMAL and HAMLET)
 Depression prevalent
 All survivors were able to acknowledge
that life is worth living