PURPOSE: To discuss the therapeutic possibilities for treatment of malignant infarction by occlusion on M1 portion of the MCA.
MATERIAl AND METHODS: The study was performed in a 35-year-old patient with acute ischemic stroke and left sided hemiparesis one hour before hospitalization. Intravenous t-PA was performed regarding the inclusion/exclusion criteria by protocol.
RESUlTS: By reason of progression of neurological deficit and loss of consciousness MRI was performed in the next 24 hours. On MRI and MRI angiography ischemic stroke with haemorrhagic transformation in the right MCA and dislocation on the left were seen. The patient was treated by decompressive craniectomy. A converse development of focal neurological symptoms to mild central left-sided hemiparesis was reported with present good results.
DISCUSSION: The presentation of this clinical case shows that some of the patients with acute ischemic stroke may benefit from a decompressive craniectomy. The timing and indications for this potential lifesaving procedure are still debated, there are no well-defined selection criteria for performing the surgery in case of supratentorial infarctions.
Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eis enberg HM: Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neu rosurg. 2006;104:469-479.
Albanese J, Leone M, Alliez JR, Kaya JM, Antonini F, Alliez B, et al: Decompressive craniectomy for severe traumatic brain injury: evaluation of the effects at one year. Crit Care Med. 2003;31:2535-2538.
Akins PT, Guppy KH. Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care. 2008;9:269-276.
Baussart B, Cheisson G, Compain M, Leblanc PE, Tadie M, Benhamou D, et al: Multimodal cerebral monitoring and the compressive surgery for the treatment of severe bacterial men ingitis with increased intracranial pressure. Acta Anaes.
;50:762-765
Berrouschot J, Sterker M, Bettin S, Koster J, Schneider D: Mortality of space-occupying (`malignant`) middle cerebral artery infarction under conservative intensive care. Intensive Care Med. 1998;24:620-623.
Bounds JV, Wiebers DO, Whisnant JP, Okazaki H: Mechanisms and timing of deaths from cerebral infarction. Stroke, 1981;12:474-477.
Bullock MR, Chesnut RM, Clifton G, Ghajar J, Marion DW, Na rayan RK, et al: Management and Prognosis of Severe Traumatic Brain Injury. New York: Brain Trauma Foundation. 2000.
Buschmann U, Yonekawa Y, Fortunati M, Cesnulis E, Keller E: Decompressive hemicraniectomy in patients with subarachnoid hemorrhage and intractable
intracranial hypertension. Acta Neurochir. 2007;149:59-65.
Carter BS, Ogilvy CS, Candia GJ, Rosas HD, Buonanno F: One-year outcome after decompressive surgery for massive nondominant hemispheric infarction. Neurosurgery (1997) pp. 40: 1168-1176 Chang V, Hartzfeld P , Langlois M, Mahmood A, Seyfried Outcomes of cranial repair after craniectomy. J Neurosurg. 2010;112:1120-1124.
Chen CC, Cho DY, Tsai SC: Outcome of and prognostic factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Clin Neurosci. 2007;14:317-321.
Curry WT Jr, Sethi MK, Ogilvy CS, Carter BS: Factors associated with outcome after hemicraniectomy for large middle cerebral artery territory infarction.
Neurosurgery. 2005;56:681-692.
Dierssen G, Carda R, Coca JM: The influence of large decompressive craniectomy on the outcome of surgical treatment in spontaneous intracerebral haematomas. Acta Neurochir 1983;69:53-60.
Doerfler A, Forsting M, Reith W, Staff C, Heiland S, Schabitz WR, et al: Decompressive craniectomy in a rat model of `malignant` cerebral hemispheric
stroke: experimental support for an aggressive therapeutic approach. J Neurosurg. 1996;85:853-859.
Engelhorn T, Doerfler A, Kastrup A, Beaulieu C, de Crespigny A, Forsting M, et al: Decompressive craniectomy, reperfusion, or a combination for early treatment of acute `malignant` cerebral hemispheric stroke in rats? Potential mechanisms studied by MRI. Stroke.1999;30:1456-1463.
Erban P, Woertgen C, Luerding R, Bogdahn U, Schlachetzki F, Horn M: Long-term outcome after hemicraniectomy for space occupying right hemispheric MCA infarction. Clin Neu rol Neurosurg. 2006;1 384-387.
Fandino J, Keller E, Barth A, Landolt H, Yonekawa Y, Seiler RW: Decompressive craniotomy after middle cerebral artery infarction. Retrospective analysis of patients treated in three centres in Switzerland. Swiss Med Wkly. 2004;134:423-429.
Forsting M, Reith W, Schaebitz WR. Decompressive craniectomy for cerebral infarction: an experimental study in rats. Stroke. 1995;26:259-264.
Georgiadis D, Schwarz S, Aschoff A, Schwab S: Hemicraniectomy and moderate hypothermia in patients with severe ischemic stroke. Stroke 33 (2002) pp. 1584-1588.
Greenwood J Jr: Acute brain infarctions with high intracranial pressure: surgical indications. Johns Hopkins Med J. 1968;122:254-260
Hacke W, Schwab S, Horn M , Spranger M, De Georgia M, von Kummer R. Malignant middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53:309-315.
Harscher S, Reichart R, Terborg C, Hagemann G, Kalff R, Witte OW. Outcome after decompressive craniectomy in patients with severe ischemic stroke. Acta Neurochir (Wien). 2006;148(1):31-7.
Heros RC. Surgical treatment of cerebellar infarction. Stroke. 1992;23:937-938.
Hofmeijer J, van der Worp HB, Kappelle LJ: Treatment of space-occupying cerebral infarction. Crit Care Med. 2003;31:617-625.
Kilincer C, Asil T, Utku U, Hamamcioglu MK, Turgut N, Hic donmez T, et al: Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a pro spective cohort study. Acta Neurochir. 2005;147:587-594.
Koh MS, Goh KY, Tung MY, Chan C: Is decompressive craniectomy for acute cerebral infarction of any benefit? Surg Neurol. 2000;53:225-230.
Kunze E, Meixensberger J, Janka M, Sorensen N, Roosen K: Decompressive craniectomy in patients with uncontrollable in tracranial hypertension. Acta Neurochir Suppl. 1998;71:16-18.
Meier U, Zeilinger FS, Henzka O: The use of decompressive craniectomy for the management of severe head injuries. Acta Neurochir Suppl. 2000;76:475-478.
Reddy AK, Saradhi V, Panigrahi M, Rao TN, Tripathi P, Meena AK: Decompressive craniectomy for stroke: indications and results. Neurol India. 2002;50(Suppl):S66 -S69.
Ziai WC, Port JD, Cowan JA, Garonzik IM, Bhardwaj A, Rigamonti D. Decompressive craniectomy for intractable cerebral edema: experience of a single center. J Neurosurg Anesthesiol.2003;20:25-3.
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