Objectives: To evaluate surgical results, then propose some prognostic factors for large supratentorial cerebral infarction. Subjects and methods: A prospective, uncontrolled interventional study on 75 patients who were diagnosed and performed the decompressive craniectomy due to cerebral infarction at Cho Ray Hospital from May 2003 to September 2016.
Journal of military pharmaco-medicine no4-2018 DECOMPRESSIVE CRANIECTOMY FOR LARGE SUPRATENTORIAL INFARCTION IN CHO RAY HOSPITAL Truong Da*; Bui Quang Tuyen** SUMMARY Objectives: To evaluate surgical results, then propose some prognostic factors for large supratentorial cerebral infarction Subjects and methods: A prospective, uncontrolled interventional study on 75 patients who were diagnosed and performed the decompressive craniectomy due to cerebral infarction at Cho Ray Hospital from May 2003 to September 2016 Results: The decompressive craniectomy was conducted within 48 hours after stroke for 40% patients (30/75) without mortality; within 60 hours after stroke for 19 patients (1 death); 13 patients within 72 hours after stroke (2 deaths) and 10 patients (60%) within 96 hours after stroke (6 deaths) The largest open skull portion size was 16 x 12 cm (no mortality in a total of 17 cases); the smallest size was 12 x 12 cm (8 out of 26 cases deaths) Postoperative complications occurred in 15/75 cases (20%), of which: small bleeding scattered in the infarction area for 2/75 (2.6%); incision infection was the most common complication seen in 8/75 cases (10.6%); local seizures for 3/75 (4%) and cardiovascular disorders for 2/75 cases (2.6%) Conclusion: The later the operation, the higher the mortality rate The smaller the open skull portion size, the higher the mortality rate (p < 0.0001) Postoperative complications occurred in 15/75 cases All cases were under internal medicine treatment and there were deaths due to cardiovascular disorders, acute stroke * Keywords: Decompressive craniectomy; Large supratentorial cerebral infarction; Cho Ray Hospital INTRODUCTION In 1956, Scarcella was the first person to describe a cranial opening for cerebral infarction to reduce intracranial pressure and prevent brain from herniating According to Klaus Zweckberger et al (2014), stroke due to complete occlusion of mesencepohalon artery for which internal medical treatment is used, the mortality rate can be up to 80% [3] Thus, Demitre Staykov (2011), Gupta R et al (2004), Desiree J.L (2000), Erdem Gresher (2011) and many other neurosurgeons supposed that decompressive craniectomy for large and malignant cerebral infarction is effective in reducing mortality and restricting neurological sequelae [1] In the past 10 years, Neurological Surgery Department, Cho Ray Hospital has done the decompressive craniectomy for some patients with large cerebral infarction in the cerebral hemisphere that has brought some good results, * Cho Ray Hospital ** 103 Military Hospital Corresponding author: Bùi Quang Tuyển (buiquangtuyenb9@gmail.com) Date received: 10/01/2018 Date accepted: 02/04/2018 200 Journal of military pharmaco-medicine no4-2018 saved the patient’s life Therefore, we have conducted this study aiming to: Evaluate the surgical results of decompressive craniectomy, then propose some prognostic factors and surgical indications for large supratentorial cerebral infarction after surgery, family did not agree to participate in the study; unable to follow-up after - months Methods A prospective, uncontrolled interventional study * Research indicators: SUBJECTS AND METHOD - Surgery time: Time from onset to decompressive hemicraniectomy Subjects 75 patients were diagnosed and operated to decompress due to large supratentorial cerebral infarction at Cho Ray Hospital from May 2003 to September 2016 - Size of the open skull portion: Anterior: frontal to mid-pupillary line; posterior: cm posterior to external auditory canal; superior: superior sagital sinus The smallest size was 12 x 12 cm * Selection criteria: Patients were diagnosed to have large supratentorial cerebral infarction, indicated for a surgery and were operated to decompress - Postoperative complications (if any): Bleeding in the infarction area, incision infection, facial muscular seizures, cardiovascular complication * Exclusion criteria: Patient did not have enough medical records before and Data entered and processed by SPSS 16.0 Statistically significant when p < 0.05 RESULTS Time for craniectomy Table 1: Time for decompressive craniectomy Number of patient Time Total Alive Dead ≤ 48 hours 30 30 ≤ 60 hours 19 20 ≤ 72 hours 13 15 ≤ 96 hours 10 Total 66 75 The highest mortality rate (60%) when the surgery time ≤ 96 hours (with deaths in 10 cases) 201 Journal of military pharmaco-medicine no4-2018 Sizes of open skull portion Table 2: Open skull portion Results Open skull portion area (cm ) No of patients Alive Dead 16 x 12 192 17 17 14 x 12 168 32 31 12 x 12 144 26 18 Size (cm) The mortality rate was very high (30.8% = 8/26 cases) if the size of the skull opening was 12 x 12 cm but the mortality rate was very low (2% = 1/49 case) if the size of the skull opening was more than 12 x 12 cm Complications after decompressive craniectomy Table 3: Post-operative complications Complications Treatment results No of patients Alive Bleeding in the infarction area 2 Incision infection 8 Facial muscular seizures (local epilepsy) 3 Cardiovascular complication Total 15 Dead 13 Common complications after surgery occurred in 15/75 cases (accounting for 20%) The most common complication after surgery was incision infection (8/75 = 10.66%) but this complication was quite shallow There was no case of deep infection There were cases of cardiovascular complication, both of whom were dead; mainly due to acute vasodepressor DISCUSSION The surgery time Schwab S (1998) studied the effects of skull opening in 63 patients with largescale cerebral infarction The results showed that the mortality rate for early surgery (21 hours) was 16% and 34% for late surgery (39 hours) Early surgery would reduce the rate of brain herniation 202 (encephalocele) to only 13% compared with 75% in late surgery [3] Cho D.Y et al (2003) studied 12 patients who underwent ultra-early decompressive craniectomy within hours of stroke, found that a mortality rate was 8.3% compared with 36.7% in late surgery and 80% in conservative treatment [3] Journal of military pharmaco-medicine no4-2018 Xiao Cheng Lu (2014) suggested that early decompressive craniectomy within 48 hours of stroke reduce mortality rate and improve neurologic recovery in patients with malignant middle cerebral artery infarction [8] We realized that when performing surgery ≤ 48 hours for 30 patients, there was no death Whereas, late surgery ≤ 96 hours for 10 patients, the number of death was Comparison was statistically significant with p < 0.001 These findings are also consistent with those by foreign authors Early surgery will save patients, reduce mortality rate and improve postoperative neurologic recovery ability The skull portion size margin of the defect bone edge to the middle skull pit was 1.8 ± 1.3 cm The difference between the alive and the dead patient was the size of the open skull portion and the distance to middle skull pit Thus, the authors concluded that decompressive craniectomy is an effective treatment, which can reduce mortality rate and improve neurological recovery ability in patients with spaceoccupational cerebral infarction if the skull portion size is opened wide enough [4] William T Curry et al (2005) recommended that the skull opening size in adults was at least 13 cm for aheadbehind dimension and cm for superoinferior dimension which allowed the release of the hemisphere [6] Compared to foreign documents, our open cranium piece size is smaller; perhaps the skull of a foreigner is bigger than the Vietnamese skull In fact, the area of the injured skull was larger than the area of the normal skull area, as we continued to cut the skull toward the temporal bone in the preauricular pit, down to the skull base to prevent brain herniation and temporal lobe herniation into the fissure of Bichat Skull bone portion is stored in the tissue bank of Cho Ray Hospital, preserved at an extreme cold temperature of -500C Chung J et al (2011) found that the maximal decompression size > 14 - 16 cm or > 399 cm2 compared to a large size > 12 cm or 308 cm2 would increase the recovery rate months after stroke [4] According to Kristian R.W et al (1997) [4] among 43 decompressive craniectomy cases for space-occupational hemispheric infarction treatment, it was found that the survival rates was 72.1% and no patient was under vegatative state The average size of the open skull portion was 84.3 ± 16.5 cm2 and average distance from the Among the 75 cases in the study, we performed decompressive craniectomy for 17 cases with the largest size of 16 x 12 cm (192 cm2) and there was no death Of 32 cases with the size of 14 x 12 cm (168 cm2), the number of alive patients was 31 and number of death was Of 26 cases with the size of 12 x 12 cm (144 cm2) the Klaus Zweckberger (2014) revealed that the skull opening size of less than 12 cm was the cause of cortical damage and increased the mortality rate Some studies also supposed that the diameter of the open skull portion of even more than 14 cm, or including the superior sagittal sinus, is preferable for good recovery prognosis without any complications [4] 203 Journal of military pharmaco-medicine no4-2018 number of alive patients was 18 and number of death was From these data, we realized that the skull portion size of 12 x 12 cm caused much higher mortality rate than size of 16 x 12 cm and 14 x 12 cm (p < 0.0001) other diseases (24 operations) Some complications occurred as following: incision infection 12/341 (3.5%); abscess 9/341 (2.6%); CSF fistula 2/341 (0.6%); epidural and subdural hematoma 7/341 (2.1%) and hygroma 1/341 (0.3%) [2] In our study, there was no case performed the skull opening with the size of over 200 cm2 In some cases of size > 399 cm2 and 308 cm2 as described above, it was likely that these authors must open the skull through the superior sagittal sinus With the such large sizes, surely that the proportion of patients who survive after the surgery will increase dramatically The authors found that the complication rate of 78 cranioplasty operations due to cerebral infarction included: incision infection 6/78 (7.7%) and cerebral abscess 6/78 (7.7%) These rates were much higher than those of operated cranioplasty due to other causes, namely: incision infection 7.7% compared to 2.3%, p = 0.03, OR 3.6, 95%CI 1.1 - 11.4 Cerebral abscess: 7.7% compared to 1.1%, p = 0.005, OR 7.2, 95%CI: 1.7 - 29.6 [2] Surgical complications Tyler J Kenning (2012) performed decompressive craniectomy for 19 cases Its complication was as followed: 11 cases (58%) had subdural hygroma; case (5%) suffered from contralateral mass lesion development; cases (11%) developed hydrocephalus Reoperation: cranioplasty 17/17 (100%), no cranioplasty 7/19 (37%); progressive hematoma 11/18 (61%); incision infection 5/19 (26%) The author only presents statistically significant complications and does not address the course and treatment outcome for these complications [5] Erdem Güresir et al (2011) [2] reoperated cranioplasty 341 times for 318 patients, including: postoperative patient with defective skull (137 operations); subarachnoid bleeding (79 operations); bleeding in the brain (23 operations); cerebral infarction (78 operations) and 204 Wolf-Dieter Heiss (2016) [7] found that postoperative complications include: hematoma; meningitis and incision infection Epidural bleeding and brain parenchyma lesions were rare Seizures occurred between 11% and 66% The so-called “sinking skin flap syndrome” may be the consequence of paradoxical herniation, headaches, convulsions, and neurologic deficits Some authors suggested that the “sinking skin flap syndrome” may be due to small size of the skull opening portion In addition, 62% of patients developed extra-axial fluid collection Hydrocephalus following stroke may be 30% or 47.8% The appearance of pre-or post-cranioplasty hydrocephalus showed no neurologic recovery ability and maybe there needed to combine the skull opening of a 2.5 cm towards the midline Journal of military pharmaco-medicine no4-2018 In a study of 75 cases with middle cerebral artery infarction who were performed decompressive craniectomy, we found that 15/75 cases (20%) occurred postoperative complications, i.e.: bleeding in the infarcted area 2/75 (2.6%); incision infection 8/75 (10.6%) - the most common complication; seizures 3/75 (4%) and cardiovascular disorders 2/75 (2.6%) Of the 15 complication cases, conservative treatment saved 13 lives and two remaining cases were dead due to cardiovascular disorders, acute stroke Out of cases of scattered bleeding in infarction area, no case required to be operated but medicine treatment only, then small hematoma was absorbed and patients recovered CONCLUSION - The mortality rate was 12% - Time for surgery: The highest mortality rate (60%) when the surgery time ≤ 96 hours The later the surgery, the higher the mortality rate - Size of the skull opening: The mortality rate was very high (30.8%) if the size of the skull opening was 12 x 12 cm, but the mortality rate was very low (2%) if the size of the skull opening was more than 12 x 12 cm The smaller the size, the higher the mortality rate (p < 0.0001) - Postoperative complications occurred in 15/75 cases (20%), of which: small bleeding scattered in the infarction area 2/75 (2.6%); incision infection 8/75 (10.6%) - the most common complication; local seizures 3/75 (4%) and cardiovascular disorders 2/75 (2.6%) All cases were under internal medicine treatment, there were deaths due to cardiovascular disorders, acute stroke REFERENCE Desiree J.L, Giuseppe L Decompressive craniectomy for space occupying supratentorial infarct: rational, indication and outcome Neurosurg Focus 2000, (5) Erdem Gűresir, Hartmut Vatter et al Rapid closure technique in decompressive craniectomy J Neurosurg 2011, April, Vol 114, pp.954-960 Klaus Zweckberger, Eric Juetler et al Surgical aspects of decompressive craniectomy in malignant stroke: Review Cerebrovasc Dis 2014, 38, pp.313-323 Kristian Reiner Wirtz, Thorsten Steiner et al Hemicraniectomy with dural augmentation in medically uncontrollable hemispheric infarction Neurosurgical Focus 1997, (5), Article Tyler J Kenning, Gooch M.R et al Cranial decompression for the treatment of malignant intracranial hypertension after ischemic cerebral infarction: decompressive craniectomy and hinge craniotomy J Neurosurg 2012, Vol 116, Jun, pp.1289-1298 William T Curry, Manish K Sethi et al Factors associated with outcome after hemicraniectomy for large middle cerebral artery territory infarction Neurosurgery 2005, 56, pp.681-692 Wolf-Dieter Heiss Malignant MCA infarction: Pathophysiology and imaging for early diagnosis and management decisions Cerebrovasc Dis 2016, 41, pp.1-7 Xiao Cheng Lu, Bao Sheng Huang et al Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery 2014 205 ... 341 times for 318 patients, including: postoperative patient with defective skull (137 operations); subarachnoid bleeding (79 operations); bleeding in the brain (23 operations); cerebral infarction. .. complications include: hematoma; meningitis and incision infection Epidural bleeding and brain parenchyma lesions were rare Seizures occurred between 11% and 66% The so-called “sinking skin flap syndrome”... combine the skull opening of a 2.5 cm towards the midline Journal of military pharmaco-medicine no4-2018 In a study of 75 cases with middle cerebral artery infarction who were performed decompressive