Neurosurgical management of ischemic stroke

Neurosurgical Management of
CVAs and sICH
Presenter: Kedir.D
Moderator: Dr. Eyob, Neurosurgeon.

Acute Ischemic stroke=Cerebral infarction
TIA=>: Transient neuronal dysfunction secondary to focal ischemia (of brain, spinal
cord, or retina) without (permanent) acute infarction(note: obsolete ~24HRS)
10–15% of patients with TIA have a stroke within 3 months, 50% of which occur
within 48 hours; ABCD*2(1-3=>1%, 4-5=>4%, 6-7=>8%)
Stroke=>Permanent (i.e., irreversible) death of neurons caused by inadequate perfusion
of a region of the brain or brainstem.
Watershed Infarct=> Ischemic infarction in a territory located at the periphery of two
bordering arterial distributions due to a disturbance in flow in one or both of the arteries.

Basics
Cerebral blood flow(CBF)
CVR and AR
CVR is affected by the PaCO2
CBF increase linearly PaCO2 = 20–80 mm Hg.
CMRO2
3-3.8 ml/100 gm tissue/min
The coupling ratio(CBF/CMRO2) in the quiescent brain is 14:18.
With focal cortical activity, local CBF increases 30% while CMRO2 increases 5%.
CVR/R(Diamox Challenge)
TYPE:I=>Normal Baseline CBF =>30-60%’ed
TYPE:II=>low Baseline CBF, blunted response: less than 10%,10ml/100g/min
Type: III=> Low baseline CBF, Dced CBF following ACZ=>Steal phenomenon.

Clinical presentation & Evaluation
History and physical
examination
NIHSS score
Clinical syndromes
of cerebral ischemia
-IX-CBC ,OFT ,RBS,OFT
Coagulation Profile,ECG,
CHEST X-RAY
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IMAGING
CT/+C
Time dependent
<6hrs, 24hr, 1-2wks, 3wks
CTA, high NIHSS=>No delay
CTP: CBF/CBV Mismatch
MRI: MRI+C, MRP
4 patterns of enhancement: IV(1-3d), Meningeal(1-3d), Transitional(3-6d),
parenchymal(1wk)

Imaging
• CT SCAN
• ASPECTS
• CTA
• MRI
• MRA
• MR PERFUSION
STUDIES
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Surgical Management of IS.
Revascularization of an occluded cerebral vessel is necessary
to achieve optimal clinical outcomes in patients suffering an
acute ischemic stroke
Clinical symptoms develop immediately after vessel occlusion,
whereas ischemic brain tissue progresses to infarction only after
several hours.

Limitation: MEDICAL RX:IV-tPA
1. Majority of patients do not reach medical attention within the time window (upto 4.5 hours). (only 4% in
2003 to 7% in 2011)
2. Numerous exclusion criteria for IV thrombolysis
3. Proximal occlusions(e.g. proximal M1 and ICA) are more refractory to IV thrombolysis .
-Revascularization rates of 71% in the coronary arteries vs 32% in the cerebral arteries.
4. Recanalization can take several hours to days.
-Interventional Management of Stroke (IMS) I and II Trials confirmed a 10% reduced likelihood of good
outcomes after each 30 minute delay in treatment time for IV or IA therapy.
-An advantage of IA therapy is the ability to achieve recanalization rapidly using newer mechanical
strategies.

Etiology
Large artery atherosclerotic infarction
Small vessel disease
Cardiogenic Embolism
Non atherosclerosis vasculopathy
Dissections
Trauma
Radiation Vasculopathy
Moyamoya
Fibromuscular Dysplasia
Inflammatory Vasculitides
• Infections
• Drug Abuse
• Systemic Vasculitides
• Migraine
• Inherited disorders
• Hypercoagulable disorders

Atherosclerotic carotid artery disease
Atherosclerotic plaques begin to form in the carotid artery at 20
yrs of age.
In the extracranial cerebral circulation, plaques typically start on
the back wall of the common carotid artery (CCA).
The risk of stroke correlates with the degree of stenosis and with
certain types of plaque morphology, and is also increased in
hypercoagulable states and with increased blood viscosity.

“Vulnerable” plaques are atherosclerotic plaques likely to cause
thrombotic complications, or those that tend to progress rapidly.
Criteria for vulnerable plaques include: intimal thickening, plaque
fissure, lipid/necrotic core with thin fibrous cap, calcification,
thrombus, intraplaque hemorrhage, and outward remodeling.

CF
Symptomatic(lateralizing) or Asymptomatic (bruit)
The majority (80%) of carotid atherothrombotic strokes occur without
warning symptoms.
Asymptomatic bruit==>prevalence increases with age (2.3% in ages 45–
54 yrs, 8.2% at 75).
Accuracy of a bruit in predicting ICA stenosis==>50–83% and Sensitivity
is as low as 24%

Sxic CAS
May present as a TIA, RIND, or stroke with any of the following findings;
1. Retinal insufficiency or infarction (CRA is a branch of the ophthalmic artery)=> IMB
a) May be temporary: Amaurosis fugax, Or( TMB).
Four types: embolic, flow related, vasospastic, miscellaneous
b) Blindness may be permanent
2. MCA Sxs
a) Contralateral motor or sensory TIA(UE>LE),LTS
b) Language deficits if dominant hemisphere involved

SCREENING
The U.S. Preventive Services Task Force (USPSTF) currently recommends against
screening for carotid stenosis in the adult general population
(Grade D recommendation: moderate or high certainty that the service has no net
benefit or that the harm outweighs the benefit)
The AHA Primary Prevention of Stroke Guidelines does not recommend screening for
asymptomatic carotid stenosis
The American Society of Neuroimaging advised that screening should be considered
only for age 65 years with 3 or more cardiovascular risk factors.
The Society of Vascular Surgery recommends ultrasonography screening for age 55
years with cardiovascular risk factors, such as HTN, diabetes, smoking,
hypercholesterolemia, or known cardiovascular disease.

NASCET
SXIC and 70-90%
ECST
Sxic and >80%
% stenosis by ECST= 0.6 % stenosis by NASCET+ 40% Angiography
also affords the opportunity to perform endovascular intervention if
indicated.

CTA
CTA involves ionizing radiation (X-rays) and IV iodinated contrast, limiting its use in
patients with dye allergies and renal dysfunction.
Results are comparable to MRA and Doppler.
CTA can be performed within a few seconds and yields high-resolution images of all
vessels from the aortic arch through the intracranial/extracranial vessels as well as the
surrounding soft tissues
In a meta-analysis, sensitivity and specificity for detection of a 70% to 99% stenosis were
85% and 93%, respectively.
CTA is still evolving and may help detect vulnerable plaques.
Another potential advantage: ability to obtain CT-perfusion studies at the same time.

Summary
In patients with an abnormal screening test, a common strategy is to
obtain a second confirmatory noninvasive test to evaluate the carotid
bifurcation before intervention.
The combination of carotid ultrasound and MRA has proved cost-
effective with good interobserver reliability.
If 2 noninvasive tests are discordant, catheter angiography should be
considered before intervention.

ACAS
Natural history: reveals low stroke rate (2%/yr), half of which are not
disabling
Large randomized trials have revealed moderate surgical benefit versus
medical management for asymptomatic stenosis > 60%
Treatment selection criteria depend on patient’s age, gender, and
comorbidities (and therefore life expectancy), and on perioperative
complication rate.

Management
A. Best Medical Management: Anti-plt, HTN mgt, DM mgt…
B. Endovascular techniques: (combined angioplasty and stenting (±
distal embolus protection)
C. Open Surgery=>CEA

Level-I: CEA is reasonable in asymptomatic patients with > 70% ICA
stenosis if risk of perioperative stroke, MI, and death is low(6%)
Level-II: It is reasonable to choose CEA over CAS when
revascularization is indicated in older patients especially when the
anatomy is unfavorable for endovascular intervention
Level -II: It is reasonable to choose CAS over CEA when
revascularization is indicated in patients with anatomy unfavorable for
surgery

Level II: prophylactic CAS may be considered in highly selected patients
with asymptomatic ICA stenosis ( 60% by angiography, > 70% by
validated Doppler ultrasound), but the effectiveness compared to medical
therapy alone is not well-established
Level II: In patients with high risk of complications by either CEA or CAS
(includes: age > 80 years, NYHA heart failure class II or IV, LVEF < 30%,
class III or OV angina pectoris, left main or multivessel CAD, need for
cardiac surgery within 30 days, MI within 4 weeks, and severe chronic
lung disease), the effectiveness of revascularization over medical therapy
alone is not well-established

Ipsilateral hemodynamic symptoms in the setting of ipsilateral ICA occlusion and
contralateral ICA stenosis may benefit from contralateral ICA revascularization to
ameliorate hemodynamic insufficiency.
Ipsilateral embolic symptoms in the setting of ipsilateral ICA occlusion and
ipsilateral external carotid occlusion (ECA) stenosis may be treated with ipsilateral
ECA revascularization to eliminate the source of embolization, which occurs via
enlarged ECA collaterals;
Ligation of the ipsilateral ICA also eliminates a source for embolization.
Finally, ipsilateral hemodynamic symptoms in the setting of a patent contralateral
carotid system, ipsilateral ICA occlusion, and ipsilateral ECA stenosis indicate
ipsilateral ECA revascularization to improve ipsilateral hemodynamic flow.

CEA,NASCET
The (NASCET) found that for patients with a hemispheric or retinal TIA or a mild
(non-disabling) stroke within 120 days and ipsilateral high-grade stenosis (> 70%),
that(CEA) reduced the rate of fatal and non-fatal strokes (by 17% at 18 months)
and death from any cause (by 7% at 18 months) when compared to BMM
When surgery was performed with perioperative risk of stroke or death of 5.8%).
Results were twice as good for patients with stenosis from 90–99% than for those
with 70–79%.
Furthermore, with CEA the frequency of major functional impairment was reduced
at 2 years.

Pre-op management (carotid endarterectomy)
ASA 325 mg TID for at least 2 days, preferably 5 days pre-op
(NB: patients should be kept on their ASA for surgery, and if not on ASA they should be started, in order to reduce risks
of MI and TIA
Post-op management (carotid endarterectomy):
patient monitored in ICU with A-line
keep patient well hydrated (run IVF 100 cc/hr for most adults)
SBP ideally 110–150 mm Hg (higher pressures are permitted in patients with chronic severe HTN)
HYPOTENSION:
check EKG – R/O cardiogenic shock
if mild, start with fluids (crystalloid or colloid)
phenylephrine (Neo-Synephrine®) for resistant hypotension

Hypertension: Nicardipine (Cardene®) is the agent of choice.
Avoid rebound hypotension
Avoid antiplatelet drugs for 24–48 hrs post-op (causes oozing); may start
these 24–72 hrs post-op (note: ASA 325 mg + dipyridamole 75 mg TID
have been shown not to reduce the rate of restenosis after
endarterectomy
Optional: reverse half of heparin with protamine 10 minutes after closing
arteriotomy

Emergency CAE
Emergency CEA indications include crescendo TIAs , stroke in evolution and post t-PA residual
critical carotid stenosis
A Recent meta-analysis of emergent CEA has shown that the pooled stroke and stroke/death
rates after CEA for crescendo TIA in 176 patients were 6.5% and 9.0%, respectively.
For those with stroke in evolution, the overall stroke and stroke/death rates in 114 patients were
16.9% and 20.0%, respectively.
However, the Efficacy of immediate surgical removal of obstruction is controversial and
unproven.
In one early study, over 50% of patients suffered fatal intracranial hemorrhage within 72 hours of
emergency carotid endarterectomy.

For emergency surgery, it is essential that blood pressure be stable
In patients with complete occlusion, ICA is not occluded intra-op (to avoid breaking up thrombus,
if present)
If thrombus is present
a) attempt spontaneous extrusion using back pressure
b) if this fails, attempt to remove with smoothened suction catheter
c) if this fails, pass balloon embolectomy catheter as far as base of skull (caution: avoid injury to
distal ICA that could cause CCF)
d) obtain intra-op angiogram unless thrombus emerges and backflow is excellent
e plicate ICA(avoid creating a blind pouch at origin)if there is good back flow or if satisfactory

Operative technique
9/16/2022 29

Carotid Angioplasty/Stenting
There is a paucity of randomized control trials comparing carotid
angioplasty/stenting with CEA, and many nonrandomized registries.
However, data from multicenter randomized trials showing that carotid
angioplasty/stenting is as safe over the short term or as efficacious over
the long term as CEA in average-risk symptomatic patients are lacking.
Published trials are heterogeneous (clinically and methodologically), too
small to provide robust and convincing data, and limited in long-term
follow-up.

Only the SAPPHIRE study comparing CEA with stenting (using a distal
embolic protection device) for moderate to severe carotid stenosis with
comorbidities that might increase the risk of CEA (high-risk patients), found
that angioplasty/stenting was not inferior (risk within 3%, P = 0.004) to CEA
(based on a composite primary end point of stroke, death, or MI within 30
days, or death from neurologic causes or ipsilateral stroke between 31 days
and 1 year). However, the study methodology has been criticized.
A 2007 Cochrane review concluded that available data on carotid
angioplasty/stenting are difficult to interpret and does not support a change
in clinical practice away from recommending CEA as the treatment of choice
for suitable carotid artery stenosis.

INDICATION
Severe vascular and cardiac comorbidities:
a)CHF (NYHA III/IV)and/or known severe left ventricular dysfunction
b) Open heart surgery needed within 6weeks
c) Recent myocardial infarction (< 24 hours and > 4 weeks)
d) Unstable angina (Canadian Cardiovascular Society classIII/IV)
e) Contralateral carotid occlusion

Specific conditions:
a) Contralateral laryngeal nerve palsy
b) Radiation therapy to the neck
c) previous CEA with recurrent restenosis
d) High cervical internal carotid/below the clavicle common carotid lesions
e) Severe tandem lesions
f) Age > 80 years
g) Severe pulmonary disease

CREST-2=>https://vimeo.com/240664061
The 2009 European Society for Vascular Surgery (ESVS) Guidelines state that carotid
angioplasty/ stenting is indicated in cases of: Contralateral laryngeal nerve palsy,
Previous radical neck dissection or cervical XRT, prior CEA (re-stenosis), high bifurcation
or intracranial extension of a carotid lesion, provided that the peri-interventional stroke or
death rate is not higher than that accepted for CEA (Class C recommendation).
AHA Guidelines state that angioplasty/stenting might be a reasonable alternative to CEA
in asymptomatic high-risk patients.
However, they stress that it remains uncertain whether this group of patients should have
either procedure.

AIS Evaluation and Management
In the complete absence of blood flow, neuronal death occurs within 2–3
minutes from exhaustion of energy stores.
However, in most strokes, there is a salvageable penumbra (tissue at
risk) that retains viability for a period of time through suboptimal perfusion
from collaterals.
Local cerebral edema from the stroke results in compromise of these
collaterals and progression of ischemic penumbra to infarction if flow is
not restored and maintained.

EMERGENCY SURGERY IN AS
Herniation from subdural hematoma
Suboccipital craniectomy for progressive neurologic deterioration due to brainstem
compression from cerebellar hemorrhage or infarction
Decompressive craniectomy for malignant MCA territory stroke.
Carotid endarterectomy for high-grade carotid stenosis ipsilateral to fluctuating neuro
deficit;

Management Review
AHA a goal of “door-to-needle” (DTN) time of à 60 minutes in 50% of AIS patients being treated with tPA
(Level I1), with a DTN of à 45 minutes being a reasonable secondary goal (Level II1).
Post. Circ > Ant. Circ.

Endovascular Treatment
Recent trials favor rapid endovascular intervention in acute ischemic
stroke with proximal vessel occlusion, small infarct core, and moderate to
good collateral circulation.

Thrombolytic Rx.
Intravenous (IV) tissue plasminogen activator (tPA) remains the only approved medical
treatment for ischemic stroke;
However, even highly optimized care centers report that <25% of patients qualify for
administration, and rates of revascularization approach only 32%.
More favorable recanalization rates are observed in the absence of a large vessel occlusion.
Intra-arterial (IA) tPA can be considered a second-line treatment for patients within 6 hours of
ictus who are not candidates for IV tPA or who have evidence of a large thrombus and major
neurological deficit (National Institutes of Health Stroke Scale [NIHSS] score ≥10) and are not
candidates for endovascular thrombectomy.

Endovascular RX.
On the basis of the available literature supporting IA thrombolytic therapy (AHA/ASA)
provided similar statements in 2005 and 2013 (class I, level of evidence B),
recommending IA thrombolytics for appropriately selected patients with evidence of an
MCA occlusion within 6 hours of ictus unless they are candidates for IV tPA.
Previously reported indications include patients excluded from receiving IV tPA or those
with severe neurological deficits (National Institutes of Health Stroke Scale [NIHSS]
score ≥10) with imaging consistent with a large thrombus or proximal vessel occlusion.
Notably, the AHA/ASA 2018 guidelines clearly defined IA tPA as the second-line
therapy when treatment can be achieved by endovascular thrombectomy.

Mechanical Thrombectomy-MT
MT with stent retriever is recommended when all criteria met (Level I1):
(modified Rankin Score (mRS) of 0–1
Causative occlusion of ICA or M1 segment of MCA
Age 18 years +
NIHSS score >/= 6
ASPECTS >/= 6

MT
Mechanical thrombectomy (MT) represented a major shift in interventional stroke management
and has now become the standard of care for acute ischemic stroke related to large vessel
occlusion.
MT techniques can be classified into four major divisions based on the method of clot disruption:
(1) Stent retriever, (2) Coil retriever, (3) Aspiration, or (4) Ultrasonic/Thermoablative clot
disruption.
Coil retriever and ultrasonic/Thermoablative techniques did not provide effective Recanalization;
However, stent retriever and aspiration technologies have evolved to become the current
standard of care.

Mechanical thrombectomy (MT) with a stent retriever is indicated for
large vessel occlusion with a NIHSS score ≥6 and Alberta Stroke
Program Early CT score ≥6, in which time from ictus to treatment is
within 6 hours and up to 16 hours when a perfusion mismatch is
identified.
Recanalization of an occluded middle cerebral artery (MCA) M1 or
internal carotid artery (ICA) is indicated, and it is reasonable to consider
intervention for patients with M2, M3, anterior cerebral artery, vertebral
artery, basilar artery, or posterior cerebral artery occlusion.

To summarize the second-generation trials, a meta-analysis of the first five phase 3 trials evaluating
MT with stent retriever devices (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT)
was completed and indicated consistent and clear evidence that MT improves reperfusion and
functional outcome at 90 days compared with standard medical therapy (OR, 2.22 [95% CI, 1.66–
2.98]; P < .001).
The THRACE trial included multiple MT techniques but demonstrated clear evidence supporting MT
intervention.
The THERAPY trial included only aspiration thrombectomy and was terminated before becoming
sufficiently powered to detect effectiveness of the therapy.
Overall, these trials provided a framework for patient selection and established MT as standard of care
for patients with large vessel occlusion.
Further investigation and refinement were necessary to refine patient selection parameters, including
the inclusion of advanced imaging modalities, timing of intervention, and ideal MT device selection.

The AHA/ASA guidelines, published in 2018, provided a
recommendation for MT with stent retriever devices for patients with an
ASPECT score of 6 or greater;
This recommendation was based on data from MR CLEAN, SWIFT
PRIME, EXTEND-IA, ESCAPE, REVASCAT, and THRACE.
This indicates the clear benefit for a small core infarct, reflecting the
greater likelihood for meaningful recovery.

In summary, the 2018 AHA/ASA guidelines provided a class I evidence
recommendation for MCA M1 and ICA occlusion and a class IIb evidence
recommendation for M2, M3, anterior cerebral artery, vertebral artery,
basilar artery, or posterior cerebral artery occlusion.
The recommendation stated that although benefit is uncertain, it is
reasonable to pursue this intervention in carefully selected patients.

In summary, the AHA/ASA 2018 publication continued to support the
previously described class I indication for MT intervention within 6 hours
of ictus in large vessel occlusion but added a class I recommendation for
MT intervention in select patients within 6 to 16 hours of ictus and a
class IIa recommendation for intervention between 16 and 24 hours after
onset.
The existing evidence therefore supports selecting patients along the
line of the inclusion criteria of the DAWN and DEFUSE 3 trials for
interventions undertaken in patients with wake-up strokes or more than 6
hours after onset.

UNCERTAIN BENEFITIS :MT
Mechanical thrombectomy may be reasonable for (Level II1)carefully
selected patients with causative occlusion of M2 or M3 segment of MCA,
or anterior cerebral, vertebral, basilar, or posterior cerebral arteries
Prestroke mRS > 1, ASPECTS < 6 and causative occlusion of ICA or M1
segment; however, additional randomized trials are needed
When treatment can be initiated (groin puncture) à 6 hours after onset

Mechanical thrombectomy is recommended for selected patients 6–16
hours from onset with large vessel occlusion (LVO) in the anterior
circulation who meet other DAWN or DEFUSE-3 eligibility criteria (Level
I1).
Mechanical thrombectomy is reasonable in selected patients 16–24 hours
from onset with anterior circulation LVO who meet other DAWN eligibility
criteria (Level II1).
The goal of thrombectomy should be reperfusion to a mTICI =>2b/3
angiographic result and to minimize the time to treatment in order to
maximize the chances of good functional outcome (Level I1).

a DAWN & DEFUSE-3 are the only randomized controlled trials that
showed benefit of mechanical thrombectomy > 6 hours from onset.
CTP, DW-MRI, or MRI perfusion can aid in patient selection when
RCT eligibility criteria are strictly met.
DEFUSE-3 used perfusion/core mismatch & maximum core size (< 70
ml) to select patients 6–16 hrs from onset.
DAWN: used clinical/imaging mismatch (combination of NIHSS score
and imaging findings on CTP or DWI-MRI) to select patients 6–24 hrs
from onset.

TECHNIQUES
From a technical standpoint, thrombectomy is being performed using three predominant
techniques:
(1) a direct aspiration first-pass technique (ADAPT), (2) stent retriever thrombectomy, and (3)
stent retriever–assisted manual aspiration thrombectomy (SMAT or SOLUMBRA).
The main second-generation trials for MT primarily used stent retriever technology, with the
exception of THERAPY.
More recent investigations have sought to compare each technique. A systematic review and
meta-analysis of the literature in 2017 suggested that ADAPT achieved higher rates of
complete revascularization (89.4% versus 71.7%; P < .001) but similar clinical outcomes
relative to stentreiver thrombectomy.

Given the cost discrepancy between the two technologies and favorable results,
several studies advocate that ADAPT should be considered as a standard first-line
therapy, followed by stent retriever use for refractory cases.
The COMPASS (Comparison of Direct Aspiration Versus Stent Retriever as a First
Approach) trial was a randomized study published in 2019 that included 270
patients and demonstrated comparable rates of TICI 2b/3 reperfusion and
noninferior functional outcomes at 90 days in comparing ADAPT versus stent
retriever.
Aspiration can be considered as a first-line therapy for thrombectomy with an
added benefit of being more cost effective and potentially faster than stent
retriever alone or SMAT

Direct-Revascularizatio: EC-IC
The EC/IC bypass, pioneered by Donaghy and Yasargil in 1967, plummeted in popularity after
publication of the international cooperative EC/IC bypass study in 1985.
The EC/IC trial randomized 1,377 patients with symptomatic ICA or MCA stenosis to either STA-
MCA bypass or medical therapy with ASA.
Despite a graft patency rate of 96%, surgical patients suffered more and earlier fatal and nonfatal
strokes.
Patients with severe MCA stenosis and those with persistent symptoms following ICA occlusion
fared especially worse with bypass.
Critique: inclusion criteria failed to distinguish between hemodynamic vs. thromboembolic(doest
improve) causes of stroke.

Imaging +CVR/R to see flow-dependent ischemia.
As CPP decreases in severe atherosclerotic occlusive disease, cerebral
autoregulation is unable to maintain adequate CBF to meet metabolic demands.
This is “misery perfusion,” where oxygen extraction fraction (OEF) of
available blood flow will increase.
Abnormal OEF, as quantified by PET, is an independent predicator of
subsequent stroke
Patients with abnormal response to acetazolamide challenge and/or with
elevated OEF are therefore potential candidates for cerebral revascularization

JET/COSS Trial
The Japanese EC-IC Bypass Trial (JET) and Carotid Occlusion
Surgery Study (COSS) were designed to stratify candidates
according to hemodynamic criteria.
JET: 169 patients, study period of almost 4 years, 2-year
follow-up. A significant reduction of the
primary and secondary stroke was observed after surgery.

COSS: halted after inclusion of 195 patients due to high 30-day event rate and no significant benefits on
the overall outcome of the surgical patients.
The high event rate (14.4%) was dramatically higher than that of the 1985 EC-IC bypass study.
Furthermore, the COSS data demonstrated a clear postoperative reduction of ipsilateral ischemic
events beyond the 30-day perioperative period.
Conclusion: EC-IC bypass remains an option in carefully selected patients with ischemic cerebrovascular
disease, limited to interdisciplinary and specialized high-volume centers and within the framework of
controlled studies.
Recently, the Japanese Adult Moyamoya Trail (JAM) reported the preventative effect of direct bypass
against rebleeding in adult patients with moyamoya disease who had experienced intracranial
hemorrhage.

Types
The type of graft used depends on preoperative determination of amount
of flow augmentation necessary, the size of the recipient graft, and the
availability of donor vessel:
1. Pedicled arterial grafts:=> STA, occipital artery
a) low-flow(15–25ml/min)
b) only one anastomosis required
c) 95% graft patency in superficial temporal artery-middle cerebral artery
(STA-MCA) bypasses

Radial artery graft:
a) Moderate to highflow(40–70ml/min)
b) Advantages:physiological conduit for arterial blood; constant location
makes it easy to harvest; lumen size closely approximates that of M2 or P1
and reduces flow mismatch with subsequent flow turbulence and graft
thrombosis
c) Disadvantages: risk of vasospasm (reduced with pressure distension
technique)
d) > 90% graft patency at 5 years

Saphenous vein graft:
a) Highflow (70–140ml/min)
b) Advantages: easy accessibility; longer length
c) Disadvantages: risk of thrombosis at distal anastomosis due to flow
mismatch and turbulence; lower graft patency rates
D) 82% graft patency at 5years

DHC for AIS
Occlusion of the internal carotid artery (ICA) or MCA leads to significant cerebral ischemic
infarction, accounting for approximately 10% of supratentorial ischemic stroke cases.
Hypodensity of more than 50–75% of the MCA territory including the basal ganglia,
involvement of additional vascular territories, and cerebral midline shift of more than 4 mm
at the level of the pineal gland in the initial 48 h indicate life-threatening infarct volume, i.e.,
malignant cerebral infarction
Neurological deterioration occurs within 5 days, with the highest frequency of deaths due to
Transtentorial herniation and subsequent brain death on day 3 after the ictus.
The mortality of malignant MCA infarction is around 80% without neurosurgical intervention

Summary
In the surgical arm, the probability of survival increased from 30 to 80%, albeit with a tenfold increase in the
probability of surviving with a modified Rankin Scale (mRS) score of 4, meaning moderately severe disability
requiring assistance from care-givers.
However, the probability of surviving with a mRS of ≤ 3 (i.e., slight or moderate disability) doubled and the
risk of surviving with a mRS of 5 (i.e., severe disability) remained stable compared to conservative treatment.
The pooled analysis of all RCTs providing information on mortality at 12 months follow-up shows a consistent
and significant benefit of DC with a risk reduction of almost 50%.
Cho and co-workers published a small retro-spective analysis of patients undergoing ultra-early DC within a
mean time of 4.25 h after stroke onset
The mortality in this ultra-early group was only 8%, comparing favorably to 38% observed in those treated
later, i.e., within a mean time of 68.25 h.

SUMMARY
There is clear class I evidence for the benefit of early DHC in reducing mortality in
patients under 60 years of age with malignant edema secondary to unilateral
ischemic stroke, regardless of laterality.
Given these data, the United Kingdom nationalized health service has adopted the
recommendation that patients <60 years old with MCA infarct volume >145 cc and
NIHSS score >15 be referred for DC within 24 hours, and for surgery to be
performed within 48 hours.
For patients not fulfilling these criteria, the decision should be individualized,
bearing in mind that the data suggest poorer outcomes

ICP post DHC IN MMCAI
Sauvigny and co-workers analyzed ICP data after DC for malignant MCA infarction and
demonstrated a significant difference in mean ICP values between the subgroups with good
(mRS ≤ 4, mean ICP 11.7 mmHg) and poor out-come (mRS 5 + 6, mean ICP 18.7 mmHg)
The therapeutic consequences of elevated ICP can be variable:
Paldor and co-workers reported frequent episodes of intracranial hypertension after DC, which
were treated with intensive care measures such as drainage of cerebrospinal fluid, modification
of sedation, hyperosmotic therapy, cooling, head elevation, and moderate hyperventilation.
Schwake and co- workers as well as Kürten and co-workers raised ICP after DC even triggered
secondary debridement of infarcted tissue, and this intervention was found to at least reduce
case fatality rates

Cerebellar stroke
The pattern of arterial occlusion found in cerebellar ischemic stroke is
more variable.
However, 20% of patients suffer from malignant cerebellar stroke with
clinical deterioration due to edema, brainstem compression, upward and
downward herniation, and occlusive hydrocephalus
In severe cases, bilateral cerebellar infarction, occlusion of the posterior
inferior cerebellar artery (PICA), and additional brainstem infarction are
typically found

CEREBELLAR INFARCTION =SMgt.
The surgical management of cerebellar infarct has not been subjected to a randomized controlled
trial because of a lack of clinical equipoise.
A systematic review of the literature in 2018 revealed that studies have been largely limited to
small retrospective series but that reported clinical outcomes from the study population of 283
patients are often poor, with unfavorable outcomes observed in 28% and mortality reported in
19.9%.
However, overall outcomes are better than those among patients who require decompressive
craniectomy for supratentorial ischemia.
The systematic review concluded that several factors were associated with favorable outcomes:
age <60 years, higher preoperative Glasgow Coma Scale score, performance of suboccipital
decompressive craniectomy within 48 hours of ictus, concomitant external ventricular drain
placement, and performance of strokectomy at time of decompression.

PFDC FOR ITS
Jauss and co-workers conducted a prospective multicenter observational study exploring the best
medical care, external ventricular drainage, and suboccipital DC.
The study design does not allow for direct comparison of treatment options, as the groups are
imbalanced with regard to the severity of cerebellar infarction.
In the DC cohort, 50% of patients were comatose, surgery was performed at a mean time of 62 h
after admission, and poor outcome (mRS > 2) was reported in 35%.
Clinical deterioration occurred most commonly at day 3 after stroke onset.
No comatose patients were enrolled in the medical treatment arm, preventing direct comparison.
The only reasonably comparable subgroups in this study are patients classified as
somnolent/stuporous, but no difference in the outcome becomes evident when comparing medical
care and DC.

Kim and co-workers published results of a retrospective matched case-
control study.
The surgical patients were treated with suboccipital DC and additionally
50% received an external ventricular drain (EVD) and 57% a
debridement of infarcted tissue.
Poor outcome (mRS > 2) was reported in 49% in the medical and 33% in
the surgical cohort, indicating a significant benefit of DC.

The largest case series was published by Pfefferkorn and co-workers
They included 57 patients in their monocentric retrospective analysis, of which 82% received an
EVD and 56% a debridement of infarcted tissue in addition to DC.
Poor outcome (mRS >2) was observed in 60% of patients and in 76% in the subgroup with additional
brainstem infarction.
Mortality was 40% and 58%, respectively.
Surgical complications occurred in 18% of cases, comprising CSF leaks and meningitis/ ventriculitis
Two aspects of this study are worth mentioning:
Age above 60 years as well as the timing of DC did not appear to influence the outcome
Quality of life (SF-36 questionnaire) was moderately impaired, and 96% of survivors
retrospectively consented to suboccipital DC

Notably, the data justifying these recommendations are heterogeneous
and lack significant statistical backing.
A retrospective matched case-control study was published in 2016 in
which 28 patients underwent suboccipital decompressive craniectomy
and 56 patients received observation with medical management.
Outcomes indicated that suboccipital decompressive craniectomy
provided an improvement in favorable clinical outcomes (mRS score, ≤2;
OR, 4.8; P < .01), compared with the control group, in the absence of
brainstem infarction.

STROKECTOMY
Strokectomy, or resection of infarcted brain, has been suggested as a potential surgical option for both
dominant and nondominant malignant MCA infarcts.
Kostov and colleagues demonstrated that patients with malignant MCA infarcts who underwent craniotomy
with resection of ischemic frontotemporal cortex and anterior temporal lobectomy with bone flap
replacement had similar mortality and functional outcomes compared with matched patients who underwent
hemicraniectomy.
Strokectomy and temporal lobectomy have also been performed in concert with hemicraniectomy in
patients with mass effect that remains significant despite extensive bony decompression and dural opening.
Critics of this technique cite functional MRI evidence of functional recovery in the peri-infarct tissues and
the difficulty in identifying the boundary of infracted cortex to suggest that resection of infarcted brain
should be minimized.

SICH
Role of surgery is still under investigation(Late 19th C-Late 21st)
However , approximately 6000 to 7000 patients undergo operative removal of ICH
annually.
In Recent study 15% of ICH and 30% of cases benefiting from drainage of associated
IVH
The goal of surgery in ICH and IVH:
To decrease the size of the clot,
Reduce any mass effect, limit increases in ICP
Minimize the neurotoxic effects of blood-degradation products.

In 1989, 2 RCT of End. Ev of ST-ICH suggested the potential usefulness
of minimally invasive approaches for ICH.
The First trial N=52, BMM VS EndoS=>no significant difference in
mortality or 6-month functional outcome.
Mortality Benefit for stuporous pt(GCS=7-10)

By comparison, Auer and colleagues, N= 100 BMM VS MIS, found both
functional and survival benefits associated with MIS(Endoscopic)
Subgroup analysis demonstrated that hematoma size and location were
important factors in patient outcomes.
Patients with subcortical hemorrhage <50 mL vs >50cc/6months
Functional outcome benefit vs mortality benefit

Meta-analysis of RCT in 2000=Surgery for ICH=>death and dependency,
specially pre-CT
In 2008, meta-analysis of 10 RCT, N=2059 surgery was associated with
a reduction in mortality and improved functional outcomes.
However, this conclusion was limited because of heterogeneity within
the data.
Acted as rationale for Devt of STICH trials

In 1989 Auer and colleagues MM versus endoscopic evacuation in 100 patients with SICH.
Subgroup analysis based on GCS, age, location, size, and side of the hematoma.
Outcome: At least 50% clot removal in alls, with 15%=> > 90% of the hematoma evacuated.
Endoscopic evacuation achieved better outcome than those in the medically treated group.
1wk Mortality=14% vs 28%(Endoscopic vs MM)
6-month mortality=>42% endoscopic versus 70% in the medical group.
Age(<60), clinical presentation(coma<10%), and hematoma size(<50cc) were critical factors in
determining outcomes.
The data show endoscopic evacuation of ICH to be a safe procedure that may lead to
decreased mortality and improved functional recovery in carefully selected patients.

Miller and colleagues (2008) randomized patients to medical treatment or endoscopic evacuation.
The study was limited by a small sample size; however, mortality was significantly lower in the endoscopic
group (20%) versus the medical group (50%).
Furthermore, endoscopic intervention resulted in an 80% reduction in hematoma volume within 24 hours of the
procedure, whereas medically managed patients experienced an overall expansion in hematoma size in the
same time period.
Unfortunately, the surgical arm did not demonstrate significant improvement in functional outcomes at 90 days.
Kuo and colleagues (2011), in a retrospective analysis, reported a 93% overall clot evacuation rate, with a 1.5%
rebleeding rate.
Nagasaka and colleagues retrospectively compared clinical outcomes in patients undergoing hematoma
evacuation performed endoscopically versus through craniotomy.
The endoscopy group demonstrated a significantly higher evacuation rate (99% versus 95.9%), higher GCS
scores at 1 week, and a greater improvement in GCS score from admission.

STICH TRIAL
2005, for ST-ICH
EARLY SURGERY(<24HR)+MM VS MM
GCS>5, SIZE>2CM
outcome=> GOS at 6 months.
1000pt, 529->Conservative Mgt—->26%—>surgery
The authors found no significant difference in the percentage of patients achieving a favorable outcome
at 6 months (26% early surgery, 24% initial conservative management).
Mortality=>groups differed by only 1% (36% early surgery, 37% initial conservative management)
Hematoma with in 1 cm have better surgical prognosis(early surgery)

STICH-II, n=601
Subgroup analysis of STICH FOR <1CM FROM CORTEX
10-100CC: Early Surgery+MM/12hrs vs MM==>21% cross over
Primary outcome : DICHOTOMIZED=> favorable vs unfavorable based on EGOS @6mo
Good vs poor prognosis :26.7cc (</>)
Based on the EGOS score, 123 (41%) of 297 patients in the early surgery group had a favorable
outcome at 6 months VS 108 (38%) of 286 patients in the medical treatment group.
59% OF early surgery group had an unfavorable outcome versus 62% of patients in the initial medical
treatment group.
The 6-month mortality rates were 18% in the surgery group and 24% in the medical group.
Recent post hoc analyses have suggested potential benefit in STICH II patients who had GCS levels of
9 to 12—neither too poor nor too good to benefit from surgery.

TAKE HOME MESSAGE!
Current evidence suggests that patients with a lobar ICH <1 cm from the
cortical surface without IVH or patients with a poor prognosis based on
age, Glasgow Coma Scale score, and hematoma volume should be
considered for surgical intervention.

DHC with/out Hematoma Evacuation
Intraparenchymal hemorrhage initiates a cascade of events leading to the loss of autoregulation and edema
formation.
As a result, effective hematoma evacuation alone may not resolve the problem of elevated ICP.
Therefore hemicraniectomy has been explored, both in addition to and without hematoma evacuation, as a treatment
option for spontaneous ICH.
This has been examined in a meta-analysis regarding hemicraniectomy plus clot evacuation and hemicraniectomy
alone.
152 Of 185 patients undergoing hemicraniectomy plus hematoma evacuation, 75 (41%) achieved a good outcome
based on a multitude of outcome scales used across studies.
28% of patients had died during various follow-up periods.
3 studies reported a significant improvement in functional outcome or mortality compared with control groups that
underwent only hematoma evacuation, and one study reported no significant difference.

DHC without clot evacuation has also been investigated as a surgical management
option for patients with supratentorial ICH.
Two small prospective studies with matched control groups have compared DHC
without clot evacuation Vs BMM, and both demonstrated nonsignificant benefits in
mortality and long-term outcome.
A systematic review in 2013 that included nine studies and 226 surgical cases (191
cases in which hematoma evacuation was performed) concluded that DHC with
hematoma evacuation might improve outcome, but significant additional investigation
is necessary.
Therefore, in summary, further work is necessary to refine the indications and
appropriate technique for this practice in supratentorial ICH.

Because of concerns regarding exacerbation of tissue damage during the removal of large hematomas,
hemicraniectomy without clot evacuation has been explored as an alternate treatment.
This option is of particular interest in the treatment of deep-seated lesions (e.g., basal ganglia and thalamus) and in
large dominant hemisphere lesions.
Ramnarayan and colleagues reported on 23 patients with large putaminal hemorrhages who were treated with
DHC
15(65%) patients achieved a good clinical outcome of good recovery or moderate disability, and the 1-month
mortality rate was 13%.
Fung and colleagues treated 12 basal ganglia or lobar hemorrhages with an average volume of 61 mL with DHC
Patients had a median GCS score of 8 at presentation.
33% of patients had a favorable outcome, and there was a 25% mortality rate at 6-month follow-up.
Functional outcome was improved compared with the medical treatment control group.
The systematic review reported a pooled favorable out-come in 53%.

Retrospective case series demonstrate that DHC is safe and feasible.
The majority of studies examine patients in a coma (GCS score <8), with hematomas
>30 mL, or with ICP that did not normalize with medical management.
Many include patients within 24 hours of hemorrhage.
Overall, the studies suggest that surgery may improve mortality compared with medical
management.
Both a meta-analysis and a systematic review suggest that DHC may offer mortality
benefits in the setting of supratentorial ICH.
The systematic review (1 RCT, 8 retrospective studies) included only patients who
underwent DC without clot evacuation and reported a mortality rate of 26%

There is a perceived lack of equipoise DHC for ST-ICH
SWITCH trial (Decompressive Hemicraniectomy in Intracerebral
Hemorrhage) will investigate these questions (ClinicalTrials.gov
NCT02258919).
GAP:
Time window, patient selection, size of hematoma
Size of the craniotomy flap and its effect on ICP.

SWITCH TRIAL=>The trial was conducted in 35 hospitals in Switzerland
and enrolled 201 patients with ICH.
Patients were randomized to either DHC or BMM
The primary outcome of the trial was mortality at 6 months..
The SWITCH trial was the largest and most rigorous trial of DHC for ICH
to date.
The results of the trial suggest that DHC may improve functional
outcomes for patients with ICH, but it does not reduce mortality.

MISTIE-TRIAL
N=506, ICH:>30 mL (MISTIE-255 patients; 50%) or MM(251 patients; 50%).
The Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for
Intracerebral Hemorrhage Evacuation (MISTIE) protocol
=>stereotactic placement of a sheath into the hematoma cavity followed by immediate
intraoperative aspiration.
A ventricular catheter was then placed through the sheath along the long axis of the
hematoma, and tPA was instilled into the hematoma every 8 hours for a total of nine doses or
until the clinical end point of 80% reduction in clot volume (or hematoma volume <15 mL) was
reached.
In a phase 2 trial using this technique, a 46% reduction in clot volume was observed, compared
with a 4% reduction over the same duration with use of traditional medical management.

Many small RCTs of MIS show a functional outcome benefit from MIS
compared with standard medical care at follow-up times of 3 months to 1
year.
In the MISTIE III trial, stereotactic aspiration plus irrigation with alteplase did
not improve functional outcomes at 1 year compared with standard medical
care in patients with ICH volume >30 mL.(45 vs 41%), BUT better
Mortality=6-8%
A significant association between extent of clot removal and both mortality
and lower mRS score (0–3), for EOT clot size ≤15 mL or >70% evacuation
Meta-analyses =>Supported functional benefit of MIS..
One meta-analysis: clot=25 and 40 mL and with a GCS score ≥9 faired better

The Artemis system, formerly known as the Apollo system, is an
aspiration-irrigation system that has been used with or without
endoscopic guidance.
Neuroendoscope using cone-beam CT guidance through a 19-French
sheath (∼7- mm diameter).
Craniotomy= 15 mm diameter.
In Early 3-pts, all clot evacuation and better FOS(NIHSS score improved
from 19 to 5.7).
The MIND trial (Minimally Invasive Neuro Evacuation Device) Ongoing

The NICO system uses a frameless stereotactic-guided introduction of a
13.5-mm endoport sheath for direct visualization of clot evacuation,better
evacuation and reduced ICP
Craniotomy of 20 mm diameter.
hematoma volume reduction of 87%, 1-fatal ICH.

The INVEST (Minimally Invasive Endoscopic Surgical Treatment With
Apollo Versus Medical Management for Supratentorial ICH) trial is a
phase 2 evaluation of the Apollo system, which is currently enrolling
patients.
The NICO BrainPath system is also being evaluated in the Early
Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial.
This is a multicenter, randomized, phase 3 analysis that is currently
enrolling patients

Meta-analysis MIS RCTs in 2018 that included 15 RCTs and 2152
patients treated with endoscopic surgery, stereotactic aspiration,
stereotactic thrombolysis, and combined approaches.
The results: MIS benefit to both survival and functional outcomes for
select patients compared with conventional medical and open craniotomy
approaches for treatment (OR, 0.46 [95% CI, 0.36–0.57] and 0.59 [5%
CI, 0.45– 0.76], respectively).

RCTs comparing MIS with craniotomy have included patients
with ICH volume >25 mL and time interval to surgery from <6 to
72 hours after presentation.
In the early surgery study, MIS showed a functional outcome
benefit compared with craniotomy only if the CTA spot sign was
positive but also showed a higher risk of rebleeding.

RCTs of MIS =Didn't answer timing of surgery and intent to stabilize
ICH before surgery and which type of device;
Although a functional outcome benefit of MIS compared with
conventional craniotomy is reported for many RCTs, a mortality benefit
is uncertain and may reflect the practice to perform craniotomy but not
MIS in deteriorating patients.
Ongoing RCTs will add useful data to these questions.

For most patients, craniotomy for spontaneous ICH remains of uncertain benefit compared with medical
management alone.
RCT results have been inconclusive.
Early data were mixed, with 2 large RCTs finding no benefit in functional outcome or mortality.
However, the most recent of these large RCTs identified a trend toward a mortality benefit, despite a
substantial medical-to-surgical crossover rate.
In addition, a recent smaller single-center RCT demonstrated a mortality benefit.
Therefore, limited data suggest that it is reasonable to consider craniotomy as lifesaving procedure in
deteriorating patients.
A knowledge gap exists concerning the timing of craniotomy for ICH.

Craniotomy for ICH of volume >10 mL in patients with significant
neurological deficit remains of uncertain benefit compared with
conservative management.
A patient-level data meta-analysis performed contemporaneously
suggested that certain cohorts might benefit and a smaller (n=108)
single-center RCT found that craniotomy improved functional outcome.
3 meta-analyses published in 2020 provide mixed results: 2 meta-
analyses suggest a benefit in functional outcome and mortality with any
surgery, and 1 meta-analysis found no benefit in functional outcome or
mortality.

Cerebellar ICH
Hematoma size=??3cm,4cm,14cc,15cc
Hematoma size alone might not unilaterally predict poor outcome and should not necessarily lead
to prophylactic surgery in patients with good neurological condition;
However, neurological deterioration, brainstem compression, and hydrocephalus are predictors of
poor out-come and are considered indications for surgery.
Kirollos and colleagues found that medical management can lead to good outcomes in patients
with good neurological examination results, even in the face of a large hemorrhage, as long as the
fourth ventricle was not completely effaced.
This study suggested that patients with good neurological examination results and total
effacement of the fourth ventricle should undergo clot evacuation prior to decompensation to
maximize outcomes.

Spontaneous cerebellar hemorrhage is frequently associated with hydrocephalus, brainstem compression, and herniation in the
confined space of the posterior fossa.
Therefore, hematoma evacuation is often recommended despite a lack of randomized evidence.
The present guideline is based primarily on data from a large individual-patient data meta-analysis with propensity score matching,
systematic reviews and several retrospective studies.
As a primary recommendation, urgent surgical hematoma evacuation with or without EVD is recommended compared with
conservative management to reduce mortality in patients with cerebellar ICH who are deteriorating neurologically, have brainstem
compression and/or hydrocephalus from ventricular obstruction, or have cerebellar ICH volume ≥15 mL.
The efficacy of surgical evacuation for improving functional outcomes, however, is uncertain and has not been demonstrated in
retrospective studies.
For patients with cerebellar ICH and clinical hydrocephalus, EVD alone is, in theory, potentially harmful, especially if the basal cisterns
are compressed.
EVD alone may be insufficient when intracranial hypertension impedes blood supply to the brainstem.

CICH without brainstem extension, hematoma evacuation was not significantly associated with
improved functional outcomes at 3 months but was associated with survival benefit at both 3 and 12
months.
Mortality benefit occurred for patients with larger hematoma volumes (>15 mL), whereas volumes
<12 mL were associated with lower likelihood of good outcome with surgery.
A systematic review of 41 studies (37 retrospective and 4 prospective) reported no significant
association of surgical evacuation with either mortality or functional outcomes at 6 months
A large retrospective review found that pooled mortality rates were lower in patients treated with
surgery compared with conservative treatment but functional outcomes were more favorable with
nonsurgical management.
Most studies support a lifesaving benefit from surgery under conditions of a deteriorating clinical
examination, impending brainstem compression, clinical hydrocephalus with fourth ventricle
obstruction, and radiographic obliteration of basal cisterns

ENRICH-TRIAL(2016-2022/23)
The primary endpoint of the trial was the utility-weighted modified Rankin Scale (UWmRS) at 180 days.
The UWmRS is a scale that measures disability and quality of life, with higher scores indicating better outcomes.
The results of the trial showed that patients who underwent MIPS had a statistically significant and clinically
meaningful improvement in UWmRS at 180 days compared to those who received standard medical
management. The mean UWmRS score was 0.458 in the MIPS group and 0.374 in the medical management
group.
The trial also found that MIPS was safe and overall mortality at six months was 21.7% (20% for MIPS, 23.3% in
the medical management group).
The ENRICH trial is the first randomized clinical trial to demonstrate the superiority of surgical treatment over
medical management for the treatment of supratentorial ICH.
It demonstrated Bayesian posterior probability of superiority of 0.9813, indicating the superiority of MIPS over
standard guideline-based medical management for improving outcomes of patients with ICH.

IVH-Clear-III Trial
Intraventricular hemorrhage occurs in 45% of patients with ICH, and it is an independent predictor of poor long-term
outcome.
Despite control of hydrocephalus through external ventricular drainage, clinical outcomes remain poor.
Intraventricular administration of fibrinolytic agents has been shown to speed the resolution of intraventricular blood
clots in a dose-dependent fashion when compared with ventricular drainage alone.
The CLEAR III (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) trial compared
ventricular drainage with saline irrigation (n = 251) versus ventricular drainage and alteplase administration (n =
249).
The results indicated that administration of alteplase did not significantly improve functional outcome.
The alteplase group did demonstrate a more rapid time to open ventricles and lower IVH volume at the end of
therapy.
VPS rates were comparable between the two groups.

Patient outcomes were reported as an intention-to-treat analysis, but crossover occurred commonly; 26% of patients
randomized to the medical management arm eventually had surgery (85% craniotomy, with a mean of 60 hours
between ictus and surgery).
Subgroup analysis showed a benefit for surgery among patients with small lobar hemorrhages <1 cm from the cortical
surface as well as among those without intravascular hemorrhage (IVH).
The design of the STICH II trial was based on these data to test the hypothesis that patients with isolated supratentorial
lobar ICH <1 cm from the cortical surface and without associated IVH would benefit from early surgery compared with
medical management.
Overall results among 601 patients in STICH II were similar to those for STICH, with no functional outcome or survival
benefit found among patients randomized to the early surgical group.
A prespecified subgroup analysis suggested a functional outcome benefit to early surgery for patients predetermined to
have a poor prognosis on the basis of their age, Glasgow Coma Scale score at presentation, and hematoma volume.
The STICH II authors also performed an updated meta-analysis that included 3366 patients and favored surgical
intervention, but this conclusion was also limited by significant heterogeneity within the study population and surgical
techniques

4 types of plaque(s)
type I: predominantly hemorrhage, lipid, cholesterol, and
proteinaceous material
type II: dense fibrous connective tissue with >50% volume of
hemorrhage, lipid, cholesterol, and proteinaceous material
type III: dense fibrous connective tissue with <50% volume of
hemorrhage, lipid, cholesterol, and proteinaceous material
type IV: dense fibrous connective tissue

PRE-OP RISK
NASCET and ACAS: age > 80 years, prior ipsilateral CEA, prior contralateral CEA within 4 months,
prior neck XRT, tandem lesion larger than target lesion, other conditions that could cause symptoms
(atrial fibrillation, prior stroke with persistent major deficit, valvular heart disease), major organ
failure, uncontrolled hypertension or diabetes mellitus, and significant coronary artery disease.
The SAPPHIRE Trial (Stenting and Angioplasty with Protection in Patients at High-Risk for
Endarterectomy): patients with clinically significant cardiac disease (CHF, abnormal stress test, or
need for open-heart surgery), severe pulmonary disease, contralateral carotid occlusion,
contralateral laryngeal-nerve palsy, previous radical neck surgery or neck XRT, recurrent stenosis
after endarterectomy, and age>80 years.
The ARCHeR Trial (ACCULINK for Revascularization of Carotids in High-Risk patients) also
included patients with tracheostomy, spinal immobility, and dialysis-dependent renal failure.

The following should also be checked:
1.Change in neurologic status due to cerebral dysfunction, including:
a) pronator drift (R/O new hemiparesis). b) signs of dysphasia (especially for left-sided surgery)
c) mimetic muscle symmetry (assesses facial nerve function)
2. pupil diameter and reaction (R/O stroke, Horner syndrome)
3. Severe H/A (especially unilateral) > may indicate hyperperfusion syndrome
4. STA pulses (R/O external carotid occlusion)
5. Tongue deviation (R/O hypoglossal nerve injury)
6. Symmetry of lips (R/O weakness of lower lip depressors due to retraction of marginal mandibular
branch of facial nerve against mandible, usually resolves in 6–12 wks, must di!erentiate from
7. Central VII palsy due to stroke) 8.check for hoarseness (R/O recurrent laryngeal nerve injury)
9. assess for hematoma in operative site: note any tracheal deviation, dysphagia

Between 2007 and 2009, the results from the first three RCT (DESTINY, DECIMAL, and HAMLET)
were published and a pooled analysis of patients aged between 18 and 60 years undergoing DC
within 48 h after stroke onset was performed.
This pooled analysis revealed a significant benefit in all predefined subgroups (e.g., age above and
below 50 years, time to randomization above and below 24 h, and dominant versus non-dominant
hemisphere) with a number needed to treat of 4 for the prevention of poor outcome (i.e., mRS 4 to 6)
and of 2 for survival.
In the surgical arm, the probability of survival increased from 30 to 80%, albeit with a tenfold increase
in the probability of surviving with a modified Rankin Scale (mRS) score of 4, meaning moderately
severe disability requiring assistance from caregivers.
However, the probability of surviving with a mRS of ≤ 3 (i.e., slight or moderate disability) doubled and
the risk of surviving with a mRS of 5 (i.e., severe disability) remained stable compared to conservative
treatment. The pooled analysis of all RCTs providing information on mortality at 12 months follow-up
shows a consistent and significant benefit of DC, with a risk reduction of almost 50%

The Decompressive Craniectomy in Malignant MCA Infarction (DECIMAL) trial randomized 38
patients younger than 55 years with >50% MCA territory ischemia, >145-mL diffusion-weighted
imaging infarct volume, and an NIHSS score of ≥16.
Patients enrolled in the medical arm underwent standard early medical management to reduce
ICP.
Patients randomized to surgery underwent ipsilateral decompressive hemicraniectomy within 30
hours of symptom onset.
Although the study was stopped early because of slow recruitment, a significant reduction in
mortality (52.8% absolute reduction) was observed in the surgical group.
Assessment of functional outcomes at 1 year demonstrated that the surgical group experienced a
non–statistically significant increase in mRS scores of 3 or less (50% versus 22%) and a non–
statistically significant increase in scores of ≥4 (25% versus 0%), suggesting that
hemicraniectomy may increase the number of survivors with both good and poor functional
outcomes.

The Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY)
trial allowed for older patients (age <60 years) with a larger stroke burden (ischemia of two-thirds of the MCA
territory and NIHSS scores >18 for the non dominant hemisphere and >20 for the dominant hemisphere) than the
DECIMAL trial did, but it reached similar conclusions.
The surgical group demonstrated a significant reduction in mortality at 12 months compared with the conservative
treatment group (mortality, 18% versus 53%), with a nonsignificant increase in survival among those patients with
an mRS score of 3 or less (survival, 47% versus 27%) and no significant increase in comatose survivors.
The follow-up DESTINY II trial examined the efficacy of hemicraniectomy in an older population.
A total of 112 patients older than 60 years were assigned to hemicraniectomy or conservative management within
48 hours of symptom onset.
Hemicraniectomy improved the proportion of patients who survived without severe disability (38% versus 18%),
defined as mRS score of 0 to 4; this was driven by lower mortality in the surgical group than in the medical group
(33% versus 70%).
In fact, the majority of survivors required assistance with most bodily needs, with 32% in the surgical group and
15% in the medical group having moderately severe disability.

The Hemicraniectomy After Middle Cerebral Artery Infarction With Life-
Threatening Edema (HAMLET) trial differed from DESTINY in its
inclusion of patients treated up to 96 hours after symptom onset.
Nevertheless, the HAMLET trial demonstrated that decompressive
hemicraniectomy significantly reduced mortality (absolute risk reduction,
38%) but failed to reduce poor functional outcomes in survivors.

A Cochrane meta-analysis and a pooled analysis of the initial European trials (DECIMAL,
DESTINY, and HAMLET) demonstrated that decompressive hemicraniectomy led to a
significant reduction in mortality, a twofold increase in Rankin scores of 3 or less, and a 10-
fold increase in Rankin scores of 4 or less without a significant increase in patients with
severe disability.
A systematic analysis of six randomized controlled trials of decompressive hemicraniectomy
for malignant cerebral edema following MCA infarction concluded that surgical intervention
was associated with decreased mortality and a significant increase in the number of patients
with an mRS score of 2 (OR, 4.51 [95% CI, 1.06–19.24]) and 4 (OR, 4.43 [95% CI, 2.27–
8.66]) in the decompressive surgery group compared with the standard medical management
group.
Clearly, the results present a dichotomy to the neurosurgeon, given that the intervention
carries a higher likelihood for favorable outcomes but also for outcomes with higher
morbidity.

A randomized controlled trial from China that enrolled 47 subjects (age
range, 18–80 years) had similar results that suggested reduction in
mortality at 6 months (12.5% in the surgical group versus 60.9% in the
medical group) and fewer patients with severe disability (mRS score >4
after surgery; 33.3% in the surgical group versus 82.6% in the medical
group).
A subgroup analysis concluded that patients 60–80 years of age
experienced a benefit comparable to that for the entire study population
following the intervention.

MISTIE-Trial
Explored the safety, efficacy, technique, dose optimization, and outcome of image-guided cannula aspiration, followed by catheter placement
for delivery of r-tPA and passive drainage of a hematoma in a recent phase 3 trial.
Enrollment criteria ST-ICH volume ≥30 mL, clot stability for 6 hours, absence of obstructive IVH, no clinical herniation syndrome, and negative
etiology screen for occult pathologies.
Manual aspiration was accomplished through a cannula inserted in the ICH, followed by placement of a soft catheter for thrombolytic
administration and drainage, until a final hematoma volume of <15 mL was reached or nine doses of drug were administered.
The dose 1.0 mg was tested in the phase 2 MISTIE study, with higher or more frequent doses tested in the CLEAR study causing greater
symptomatic bleeding.
An r-tPA dosage of 1.0 mg every 8 hours for up to nine doses (up to 72 hours) showed the best clearance rates without increasing hemorrhagic
complications.
In order to determine the possibility of achieving a good functional outcome at 1 year with a prespecified end-of-treatment (EOT) volume, a
phase 3 trial was completed.
The patients were randomly assigned to guideline-based medical management with or without the MISTIE procedure.
The benefits of a catheter-based procedure were based on the theoretical drawbacks of the STICH trials by providing less operative trauma for
the patient, less time in the operating room, shortened healing time, less pain and scarring, and shorter intensive care unit and hospital stays
with lower associated costs.

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