Impact of timing of cranioplasty on hydrocephalus after decompressive hemicraniectomy in malignant middle cerebral artery infarction (2022)

Table of Contents
Clinical Neurology and Neurosurgery Abstract Objective Patients and methods Results Conclusion Introduction Section snippets Methods Results Discussion Conclusion Conflict of interest Funding Ethical approval References (39) Med. Hypotheses J. Physiother. Arch. Phys. Med. Rehabil. J. Clin. Neurosci. J. Clin. Neurosci. J. Clin. Neurosci. J. Clin. Neurosci. Clin. Neurol. Neurosurg. Lancet Neurol. Lancet Neurol. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial Stroke Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial) Stroke Surgical decompression for space-occupying cerebral infarction: outcomes at 3 years in the randomized HAMLET trial Stroke Decompressive craniectomy is not an independent risk factor for communicating hydrocephalus in patients with increased intracranial pressure Neurosurgery Hydrocephalus following decompressive craniectomy for ischemic stroke Acta Neurochi. Suppl. Postoperative hydrocephalus in patients undergoing decompressive hemicraniectomy for ischemic or hemorrhagic stroke Neurosurgery Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management Neurocrit. Care Syndrome of the trephined (sinking skin flap syndrome) with and without paradoxical herniation: a series of case reports and review Del. Med. J. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction Stroke Cited by (7) Cranioplasty for patients with disorders of consciousness Decompressive hemicraniectomy in ischemic stroke Role of comprehensive nursing care in improving the prognosis and mood of patients with secondary cerebral infarction after craniocerebral injury Presence of Propionibacterium acnes in patients with aseptic bone graft resorption after cranioplasty: preliminary evidence for low-grade infection Massive Brain Swelling after Cranioplasty: A Case Report Recommended articles (6) Videos
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Clinical Neurology and Neurosurgery

Volume 153,

February 2017

, Pages 27-34

Abstract

Objective

Patients with malignant middle cerebral artery infarction frequently develop hydrocephalus after decompressive hemicraniectomy. Hydrocephalus itself and known shunt related complications after ventriculo-peritoneal shunt implantation may negatively impact patientś outcome. Here, we aimed to identify factors associated with the development of hydrocephalus after decompressive hemicraniectomy in malignant middle cerebral artery infarction.

Patients and methods

A total of 99 consecutive patients with the diagnosis of large hemispheric infarctions and the indication for decompressive hemicraniectomy were included. We retrospectively evaluated patient characteristics (gender, age and selected preoperative risk factors), stroke characteristics (side, stroke volume and existing mass effect) and surgical characteristics (size of the bone flap, initial complication rate, time to cranioplasty, complication rate following cranioplasty, type of implant, number of revision surgeries and mortality).

Results

Frequency of hydrocephalus development was 10% in our cohort. Patients who developed a hydrocephalus had an earlier time point of bone flap reimplantation compared to the control group (no hydrocephalus=164±104days, hydrocephalus=108±52days, p<0.05). Additionally, numbers of revision surgeries after cranioplasty was associated with hydrocephalus with a trend towards significance (p=0.08).

(Video) Webinar on Cranioplasty

Conclusion

Communicating hydrocephalus is frequent in patients with malignant middle cerebral artery infarction after decompressive hemicraniectomy. A later time point of cranioplasty might lead to a lower incidence of required shunting procedures in general as we could show in our patient cohort.

Introduction

Over last years the treatment of patients with space occupying middle cerebral artery infarctions has fundamentally changed. More and more early surgical decompressive hemicraniectomies are performed to prevent increased intracranial pressure due to developing cerebral edema. This change of paradigm was necessary due to the poor outcome of conservative treatment in these patients with mortality rates of up to 78%. Several large prospective randomized trials have clearly demonstrated a significant reduction of mortality and improvement of patient outcome after hemicraniectomy [1], [2], [3], [4]. In particular patients between 18 and 60 years, an infarct volume exceeding 145cm3, an initial NIHSS score of >15 taken to surgery within the first 48h after symptom onset benefit from a decompressive hemicraniectomy. An absolute risk reduction of 50% concerning mortality and 42% concerning a modified Ranking Score ≥4 after 12 months can be achieved [3]. The benefit of the initial surgical treatment can still be found 3 years after hemicraniectomy [5]. However, despite these promising results, some patients develop complications that are solely related to the hemicraniectomy. The influence of those surgical complications on the long term outcome is insufficiently recognized and discussed.

Besides the classical surgical complications (wound infections, meningitis, cerebral abscess formation, hematomas, cerebrospinal fluid (CSF) fistulas etc.) there is a certain spectrum of complications that can be attributed to a wrong allocation of CSF, impaired CSF circulation and malabsorption of CSF following decompressive hemicraniectomy. Development of hydrocephalus and subsequent increase of intracranial pressure (ICP) is probably one of the more frequent complications in this spectrum. Numbers up to 47,8% have been reported [6], [7], [8], [9]. There seems to be evidence that the development of hydrocephalus after decompressive hemicraniectomy may have a negative influence on the neurological outcome [10]. On the other hand, reports of the sinking skin flap syndrome describe paradoxical herniation as a possible result of a reduced intracranial pressure [11], [12]. In a small prospective patient cohort 26% of the patients developed a sinking skin flap syndrome radiographically, only 11% had relevant clinical symptoms [13]. Further the development of extra-axial fluid collections is yet another CSF related complication that has been reported with an incidence of 18% in these patients [14], [15] while its clinical relevance is insufficiently understood. Ropper et al. could show that all the extra-axial fluid collections in patients after decompressive hemicraniectomy because of a malignant middle cerebral artery infarction resolved spontaneously [15].

Beyond decompressive craniectomy for treatment of malignant middle cerebral artery infarction of course decompressive surgery as well is performed following severe traumatic brain injury [16], [17]. As shown in a review by Stiver et al. development of post-cranioplasty hydrocephalus is a common complication [18]. A recent retrospective study reviewing the data of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid haemorrhage, epidural hematoma, subdural hematoma, and trauma reported an incidence of 13,5% for post-cranioplasty hydrocephalus [19]. In contrast, only 1% of patients with head injury and without craniectomy develop hydrocephalus, while up to 30% develop hydrocephalus following aneurysmal SAH [20], [21]. Hydrocephalus itself is associated with a poorer neurological outcome following traumatic brain injury [22], [23].

In this retrospective study, we aimed to elucidate the incidence of the development of hydrocephalus after decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction. It is known that the development of hydrocephalus in these patients has a negative influence on the outcome. The outcome is even further impaired by well-known surgery and shunt related complications [10]. However, so far this group of patients is insufficiently recognized and characterized. We therefore tried to identify risk factors that may allow the clinician to anticipate the development of hydrocephalus in certain patients and possibly find ways to further decrease the incidence.

Section snippets

Methods

Clinical data was collected by a chart review approved by the local ethics committee (reference number: EA2/169/13). A total of 99 consecutive patients were included in this retrospective analysis. All patients had the diagnosis of a large middle cerebral artery infarction with an infarct volume exceeding 145cm3 with the indication for decompressive hemicraniectomy. Excluded were patients with other underlying conditions being the cause for a decompressive hemicraniectomy (e.g. intracerebral

Results

Patient, stroke and surgical characteristics are summarized in Table 1, Table 2, Table 3. In total, we evaluated 99 patients with a mean age of 53 years ±11 years with a gender distribution of 62% male and 38% female patients. All patients had malignant middle cerebral artery infarction and were operated within the first 72h after symptom onset. In our patient cohort 10 of the 99 patients developed a hydrocephalus with the need for the implantation of a ventriculo-peritoneal shunt (VP-Shunt) (

Discussion

This study has the following main findings: 1) The incidence for development of hydrocephalus in patients following hemicraniectomy due to a malignant middle cerebral artery infarction is 10%. 2) An earlier time point of cranioplasty was the only factor predisposing a patient towards the development of hydrocephalus. 3) Patients who were reimplanted within the first 100days after the initial decompression developed a hydrocephalus 4.2 times more likely compared to patients that were operated on

Conclusion

Communicating hydrocephalus is a serious complication that can arise after decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction. Our data demonstrate that the incidence of clinically relevant hydrocephalus with the need for a shunting procedure appears to be lower than previously assumed. A later time point of cranioplasty correlated with a lower incidence of required shunting procedure in our patient cohort. Prospective randomized trials are warranted to

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed

Funding

Vincent Prinz is participant in the Charité Clinical Scientist Program funded by the Charité – Universitätsmedizin Berlin and the Berlin Institute of Health.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Clinical data was collected by a chart review approved by the local ethics committee (reference number: EA2/169/13).

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    (Video) Traumatic Intracranial Hypertension Seminar 4 Grand Rounds Update Decompressive Craniectomy for TBI

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  • Cited by (7)

    • Decompressive craniectomy in malignant middle cerebral artery infarction: family perception, outcome and prognostic factors

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      El pronóstico en los infartos malignos de un hemisferio siembra dudas entre los neurocirujanos a la hora de indicar una hemicraniectomía descompresiva. ¿Qué resultados a corto y medio plazo se obtienen? ¿Están las familias satisfechas con la cirugía una vez el enfermo se encuentra en su domicilio? En el presente trabajo analizamos nuestra experiencia en esta materia en los últimos 13 años.

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      La edad demostró estar directamente relacionada con la mRS (r=0,56; p=0,035) y en el 37,5% se obtuvo un buen resultado (mRS≤3). El 78,9% de los familiares entrevistados repetirían la decisión quirúrgica tomada.

      Aportamos un grupo de 21 pacientes intervenidos mediante craniectomía descompresiva por infarto maligno donde los mejores resultados funcionales se han dado entre los <60 años. Las graves secuelas neurológicas en pacientes con infarto maligno intervenidos mediante hemicraniectomía descompresiva fueron toleradas y aceptadas por la mayoría de familias a favor de su supervivencia. No debemos dejar que esta satisfacción familiar camufle el pronóstico, teniendo que contextualizarla dentro de la situación real ambulatoria de los pacientes.

      The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years.

      In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS).

      Patient age was shown to be directly related to the mRS (r=0.56; p=0.035) and 37.5% achieved a good outcome (mRS≤3); 78.9% of the interviewed relatives would repeat the surgical decision.

      We present a 21 patients group where the best outcome was achieved in patients ≤60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients.

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