What are the indications for hemicraniectomy in hemorrhagic Cerebrovascular Accident (CVA)?

Indications for Hemicraniectomy in Hemorrhagic CVA

Hemicraniectomy should be considered in patients with hemorrhagic stroke who demonstrate significant mass effect, midline shift, or elevated intracranial pressure refractory to medical management, as it is a life-saving measure that can significantly reduce mortality in appropriately selected patients. 1

Patient Selection Criteria

Primary Indications

• Deteriorating neurological status despite maximal medical therapy 1
• Large hematoma volume with significant mass effect 1
• Midline shift >5mm 2
• Elevated intracranial pressure (ICP) refractory to medical management 1
• Cerebellar hemorrhage ≥15 mL with brainstem compression or hydrocephalus 1

Specific Anatomical Considerations

• Cerebellar hemorrhage: Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal as soon as possible (Class I; Level of Evidence B) 1
• Lobar hemorrhage: Consider for superficial hemorrhages extending to within 1 cm of cortical surface 1
• Basal ganglia/deep hemorrhage: Generally less responsive to surgical intervention unless causing significant mass effect 3

Timing of Intervention

• Early intervention (within 24-48 hours) is associated with better outcomes 2
• Surgery should be performed before progression to coma or development of fixed, dilated pupils 4
• Lethargy combined with midline shift and uncal herniation on neuroimaging is an appropriate trigger to consider surgical intervention 4

Preoperative Considerations

Medical Management Prior to Decision for Surgery

1. Blood pressure control: Target SBP <140 mmHg within 6 hours of ICH onset 1
2. Correction of coagulopathy: All coagulation disorders should be corrected before craniectomy 5
   • For patients on anticoagulants: immediate reversal is critical 1
   • For patients on antiplatelet therapy: consider platelet transfusion 5
3. ICP management: Consider osmotherapy with mannitol or hypertonic saline 5
4. Maintain cerebral perfusion pressure (CPP) >60 mmHg 5

Imaging Requirements

• Non-contrast CT to confirm hemorrhage and assess volume, location, and mass effect 1
• CT angiography to evaluate for underlying vascular malformations or aneurysms 1

Surgical Technique

For Supratentorial Hemorrhage

• Fronto-parieto-temporo-occipital craniectomy up to the midline with a diameter of at least 12 cm 5
• Durotomy and enlargement duroplasty are performed 5
• Removing ischemic brain tissue is not recommended, but evacuation of hematoma may be considered 5

For Cerebellar Hemorrhage

• Craniectomy up to the transverse sinus and opening of the foramen magnum 5
• Durotomy, enlargement duroplasty, and removal of hemorrhagic cerebellar tissue 5
• In case of concomitant hydrocephalus, an external ventricular drainage should be considered 5

Postoperative Management

• ICP and CPP monitoring with treatment of intracranial hypertension 5
• Control CT after 24 hours or earlier if signs of intracranial hypertension are present 5
• Thromboembolic prophylaxis with subcutaneous low-dose heparin from the second postoperative day 5
• Early rehabilitation should be initiated in the ICU 5

Expected Outcomes and Prognosis

• Decompressive craniectomy is primarily a life-saving procedure 2
• Functional outcomes are variable:
  • Better outcomes observed in younger patients (<60 years) 2
  • Early intervention (within 24-48 hours) associated with improved functional outcomes 2
  • Patients should be informed of the certainty of at least moderate to mild permanent deficits 4

Special Considerations

Cerebral Venous Thrombosis with Hemorrhagic Infarction

• Decompressive hemicraniectomy can be life-saving in patients with cerebral venous thrombosis and impending brain herniation 6
• Prospective data show good clinical outcomes in 60% of patients with severe cerebral venous thrombosis treated with hemicraniectomy 6

Common Pitfalls to Avoid

1. Delayed intervention: Waiting until brainstem herniation occurs significantly worsens outcomes 4
2. Inadequate decompression: Bone flap must be sufficiently large (14 cm from front to back) 4
3. Failure to perform duraplasty: Augmentation duraplasty is mandatory for effective decompression 4
4. Inappropriate patient selection: Patients with small, deep hemorrhages without significant mass effect may not benefit 3
5. Neglecting family discussions: Families should be informed about potential outcomes and disability 1

By following these guidelines, clinicians can appropriately select patients with hemorrhagic stroke who would benefit from hemicraniectomy, potentially saving lives while optimizing functional outcomes.