From the Guidelines
Decompressive hemicraniectomy is recommended for patients with malignant middle cerebral artery (MCA) infarction causing life-threatening brain swelling, particularly in patients under 60 years old within 48 hours of stroke onset. This recommendation is based on the results of three major randomized controlled trials (DESTINY 1, HAMLET, and DECIMAL) which demonstrated a significant reduction in mortality and improved outcomes in patients undergoing decompressive hemicraniectomy 1. The procedure involves removing a large portion of the skull on the side of the stroke to allow the swollen brain to expand outward, reducing intracranial pressure and preventing herniation.
Key considerations for patient selection include:
- Age: patients under 60 years old tend to have better outcomes
- Pre-existing disability: patients with no pre-existing disability tend to have better outcomes
- Timing: surgery should be performed before clinical deterioration becomes severe, ideally when the patient shows early signs of elevated intracranial pressure but before coma develops
Following surgery, intensive care management is crucial and includes:
- Maintaining adequate cerebral perfusion pressure
- Controlling intracranial pressure
- Preventing complications The bone flap is typically stored and replaced during a second surgery (cranioplasty) after brain swelling resolves, usually 1-3 months later. While the procedure increases survival rates, patients should be counseled that survivors may have significant disability, though many achieve functional independence with rehabilitation 1.
From the Research
Decompressive Hemicraniectomy
- Decompressive hemicraniectomy is a surgical procedure used to reduce intracranial pressure (ICP) in patients with severe brain injury or stroke 2, 3.
- The procedure involves removing part of the skull to allow the brain to expand and reduce pressure 2.
- Decompressive hemicraniectomy has been shown to be effective in reducing mortality and improving functional outcomes in patients with malignant middle cerebral artery ischemic stroke and traumatic brain injury 2, 3.
Indications and Outcomes
- The decision to perform decompressive hemicraniectomy should be made on a case-by-case basis, taking into account the individual patient's preferences and quality of life expectations 2.
- Studies have shown that decompressive hemicraniectomy can be beneficial in patients with traumatic brain injury, particularly those with severe intracranial hypertension refractory to medical management 4, 5.
- However, the procedure is not without risks, and patients may experience complications such as wound infections, cerebral abscess, and meningitis 5.
Surgical Techniques
- Different surgical techniques can be used to perform decompressive hemicraniectomy, including the standard trauma flap and the Kempe incision 6.
- The Kempe incision has been shown to be a safe and effective alternative to the standard trauma flap, with comparable outcomes and reduced risk of wound complications 6.
Clinical Evidence
- Numerous studies have investigated the use of decompressive hemicraniectomy in patients with severe brain injury or stroke, including randomized controlled trials and retrospective cohort studies 2, 3, 4, 5.
- The evidence suggests that decompressive hemicraniectomy can be a lifesaving procedure in selected patients, but further research is needed to fully understand its benefits and risks 2, 3, 4, 5.