Decompressive craniectomy for large supratentorial infarction in cho ray hospital

Nội dung text: Decompressive craniectomy for large supratentorial infarction in cho ray hospital

1. Journal of military pharmaco-medicine n o4-2018 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 2 deaths due to cardiovascular disorders, acute stroke. * Keywords: Decompressive craniectomy; Large supratentorial cerebral infarction; Cho Ray Hospital. INTRODUCTION Gresher (2011) and many other In 1956, Scarcella was the first person neurosurgeons supposed that to describe a cranial opening for cerebral decompressive craniectomy for large and infarction to reduce intracranial pressure malignant cerebral infarction is effective and prevent brain from herniating. in reducing mortality and restricting According to Klaus Zweckberger et al neurological sequelae [1]. (2014), stroke due to complete occlusion In the past 10 years, Neurological of mesencepohalon artery for which Surgery Department, Cho Ray Hospital internal medical treatment is used, has done the decompressive craniectomy the mortality rate can be up to 80% [3]. for some patients with large cerebral Thus, Demitre Staykov (2011), Gupta R infarction in the cerebral hemisphere et al (2004), Desiree J.L (2000), Erdem that has brought some good results, * Cho Ray Hospital ** 103 Military Hospital Corresponding author: Bùi Quang Tuy ển (buiquangtuyenb9@gmail.com) Date received: 10/01/2018 Date accepted: 02/04/2018 200
2. Journal of military pharmaco-medicine n o4-2018 saved the patient’s life. Therefore, we after surgery, family did not agree to have conducted this study aiming to: participate in the study; unable to follow-up Evaluate the surgical results of after 3 - 6 months. decompressive craniectomy, then propose 2. Methods. some prognostic factors and surgical A prospective, uncontrolled interventional indications for large supratentorial cerebral study. infarction. * Research indicators: SUBJECTS AND METHOD - Surgery time: Time from onset to 1. Subjects . decompressive hemicraniectomy. 75 patients were diagnosed and - Size of the open skull portion: operated to decompress due to large Anterior: frontal to mid-pupillary line; supratentorial cerebral infarction at Cho posterior: 4 cm posterior to external Ray Hospital from May 2003 to September auditory canal; superior: superior sagital 2016. sinus. The smallest size was 12 x 12 cm. * Selection criteria: Patients were - Postoperative complications (if any): diagnosed to have large supratentorial Bleeding in the infarction area, incision cerebral infarction, indicated for a surgery infection, facial muscular seizures, and were operated to decompress. cardiovascular complication. * Exclusion criteria: Patient did not Data entered and processed by SPSS have enough medical records before and 16.0. Statistically significant when p < 0.05. RESULTS 1. Time for craniectomy. Table 1: Time for decompressive craniectomy. Number of patient Time Total Alive Dead ≤ 48 hours 30 0 30 ≤ 60 hours 19 1 20 ≤ 72 hours 13 2 15 ≤ 96 hours 4 6 10 Total 66 9 75 The highest mortality rate (60%) when the surgery time ≤ 96 hours (with 6 deaths in 10 cases). 201
3. Journal of military pharmaco-medicine n o4-2018 2. Sizes of open skull portion. Table 2: Open skull portion Open skull portion area No. of Results (cm 2) patients Alive Dead Size (cm) 16 x 12 192 17 17 0 14 x 12 168 32 31 1 12 x 12 144 26 18 8 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. 3. Complications after decompressive craniectomy. Table 3: Post-operative complications. Treatment results Complications No. of patients Alive Dead Bleeding in the infarction area 2 2 Incision infection 8 8 Facial muscular seizures (local epilepsy) 3 3 Cardiovascular complication 2 2 Total 15 13 2 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 2 cases of cardiovascular complication, both of whom were dead; mainly due to acute vasodepressor. DISCUSSION (encephalocele) to only 13% compared with 75% in late surgery [3]. 1. The surgery time. Schwab S (1998) studied the effects of Cho D.Y et al (2003) studied skull opening in 63 patients with large- 12 patients who underwent ultra-early scale cerebral infarction. The results decompressive craniectomy within showed that the mortality rate for early 6 hours of stroke, found that a mortality surgery (21 hours) was 16% and 34% for rate was 8.3% compared with 36.7% in late surgery (39 hours). Early surgery late surgery and 80% in conservative would reduce the rate of brain herniation treatment [3]. 202
4. Journal of military pharmaco-medicine n o4-2018 Xiao Cheng Lu (2014) suggested that margin of the defect bone edge to the early decompressive craniectomy within middle skull pit was 1.8 ± 1.3 cm. The 48 hours of stroke reduce mortality rate difference between the alive and the dead and improve neurologic recovery in patient was the size of the open skull patients with malignant middle cerebral portion and the distance to middle skull artery infarction [8]. pit. Thus, the authors concluded that We realized that when performing decompressive craniectomy is an surgery ≤ 48 hours for 30 patients, there effective treatment, which can reduce was no death. Whereas, late surgery mortality rate and improve neurological ≤ 96 hours for 10 patients, the number of recovery ability in patients with space- death was 6. Comparison was statistically occupational cerebral infarction if the skull significant with p < 0.001. These findings portion size is opened wide enough [4]. are also consistent with those by foreign William T. Curry et al (2005) authors. Early surgery will save patients, recommended that the skull opening size reduce mortality rate and improve in adults was at least 13 cm for ahead- postoperative neurologic recovery ability. behind dimension and 9 cm for superoinferior dimension which allowed 2. The skull portion size. the release of the hemisphere [6]. Compared to foreign documents, our Klaus Zweckberger (2014) revealed open cranium piece size is smaller; that the skull opening size of less than 12 cm perhaps the skull of a foreigner is bigger was the cause of cortical damage and than the Vietnamese skull. In fact, the increased the mortality rate. Some studies area of the injured skull was larger than also supposed that the diameter of the the area of the normal skull area, as we open skull portion of even more than 14 cm, continued to cut the skull toward the or including the superior sagittal sinus, is temporal bone in the preauricular pit, preferable for good recovery prognosis down to the skull base to prevent brain without any complications [4]. herniation and temporal lobe herniation Chung J et al (2011) found that the into the fissure of Bichat. Skull bone maximal decompression size > 14 - 16 cm portion is stored in the tissue bank of Cho or > 399 cm 2 compared to a large size Ray Hospital, preserved at an extreme > 12 cm or 308 cm 2 would increase the cold temperature of -50 0C. recovery rate 3 months after stroke [4]. According to Kristian R.W et al (1997) Among the 75 cases in the study, we [4] among 43 decompressive craniectomy performed decompressive craniectomy for cases for space-occupational hemispheric 17 cases with the largest size of 16 x 12 cm infarction treatment, it was found that the (192 cm 2) and there was no death. Of survival rates was 72.1% and no patient 32 cases with the size of 14 x 12 cm (168 was under vegatative state. The average cm 2), the number of alive patients was 31 size of the open skull portion was 84.3 ± and number of death was 1. Of 26 cases 16.5 cm 2 and average distance from the with the size of 12 x 12 cm (144 cm 2) the 203
5. Journal of military pharmaco-medicine n o4-2018 number of alive patients was 18 and other diseases (24 operations). Some number of death was 8. From these data, complications occurred as following: we realized that the skull portion size of incision infection 12/341 (3.5%); abscess 12 x 12 cm caused much higher mortality 9/341 (2.6%); CSF fistula 2/341 (0.6%); rate than size of 16 x 12 cm and 14 x 12 cm epidural and subdural hematoma 7/341 (p < 0.0001). (2.1%) and hygroma 1/341 (0.3%) [2]. In our study, there was no case The authors found that the complication performed the skull opening with the size rate of 78 cranioplasty operations due to 2 of over 200 cm . In some cases of size cerebral infarction included: incision infection > 399 cm 2 and 308 cm 2 as described 6/78 (7.7%) and cerebral abscess 6/78 above, it was likely that these authors (7.7%). These rates were much higher must open the skull through the superior than those of operated cranioplasty due to sagittal sinus. With the such large sizes, other causes, namely: incision infection surely that the proportion of patients who 7.7% compared to 2.3%, p = 0.03, OR survive after the surgery will increase 3.6, 95%CI 1.1 - 11.4. Cerebral abscess: dramatically. 7.7% compared to 1.1%, p = 0.005, 3. Surgical complications. OR 7.2, 95%CI: 1.7 - 29.6 [2]. Tyler J. Kenning (2012) performed Wolf-Dieter Heiss (2016) [7] found that decompressive craniectomy for 19 cases. postoperative complications include: Its complication was as followed: 11 cases hematoma; meningitis and incision (58%) had subdural hygroma; 1 case infection. Epidural bleeding and brain (5%) suffered from contralateral mass parenchyma lesions were rare. Seizures lesion development; 2 cases (11%) occurred between 11% and 66%. developed hydrocephalus. Reoperation: cranioplasty 17/17 (100%), no cranioplasty The so-called “sinking skin flap syndrome” 7/19 (37%); progressive hematoma 11/18 may be the consequence of paradoxical (61%); incision infection 5/19 (26%). The herniation, headaches, convulsions, and author only presents statistically neurologic deficits. Some authors suggested significant complications and does not that the “sinking skin flap syndrome” may address the course and treatment be due to small size of the skull opening outcome for these complications [5]. portion. In addition, 62% of patients Erdem Güresir et al (2011) [2] reoperated developed extra-axial fluid collection. cranioplasty 341 times for 318 patients, Hydrocephalus following stroke may be including: postoperative patient with 30% or 47.8%. The appearance of pre-or defective skull (137 operations); post-cranioplasty hydrocephalus showed subarachnoid bleeding (79 operations); no neurologic recovery ability and maybe bleeding in the brain (23 operations); there needed to combine the skull cerebral infarction (78 operations) and opening of a 2.5 cm towards the midline. 204
6. Journal of military pharmaco-medicine n o4-2018 In a study of 75 cases with middle disorders 2/75 (2.6%). All cases were cerebral artery infarction who were under internal medicine treatment, there performed decompressive craniectomy, were 2 deaths due to cardiovascular we found that 15/75 cases (20%) occurred disorders, acute stroke. postoperative complications, i.e.: bleeding REFERENCE in the infarcted area 2/75 (2.6%); incision infection 8/75 (10.6%) - the most common 1. Desiree J.L, Giuseppe L . Decompressive complication; seizures 3/75 (4%) and craniectomy for space occupying supratentorial cardiovascular disorders 2/75 (2.6%). Of infarct: rational, indication and outcome. Neurosurg Focus. 2000, 8 (5). the 15 complication cases, conservative treatment saved 13 lives and two 2. Erdem G űresir, Hartmut Vatter et al . Rapid closure technique in decompressive remaining cases were dead due to craniectomy. J Neurosurg. 2011, April, Vol. cardiovascular disorders, acute stroke. 114, pp.954-960. Out of 2 cases of scattered bleeding in 3. Klaus Zweckberger, Eric Juetler et al . infarction area, no case required to be Surgical aspects of decompressive craniectomy operated but medicine treatment only, in malignant stroke: Review. Cerebrovasc Dis. then small hematoma was absorbed and 2014, 38, pp.313-323. patients recovered. 4. Kristian Reiner Wirtz, Thorsten Steiner et al . Hemicraniectomy with dural augmentation CONCLUSION in medically uncontrollable hemispheric infarction. - The mortality rate was 12%. Neurosurgical Focus. 1997, 2 (5), Article 3. - Time for surgery: The highest mortality 5. Tyler J. Kenning, Gooch M.R et al . rate (60%) when the surgery time ≤ 96 hours. Cranial decompression for the treatment of malignant intracranial hypertension after The later the surgery, the higher the ischemic cerebral infarction: decompressive mortality rate. craniectomy and hinge craniotomy. J. - Size of the skull opening: The Neurosurg. 2012, Vol 116, Jun, pp.1289-1298. mortality rate was very high (30.8%) if the 6. William T. Curry, Manish K. Sethi et al . size of the skull opening was 12 x 12 cm, Factors associated with outcome after but the mortality rate was very low (2%) if hemicraniectomy for large middle cerebral the size of the skull opening was more artery territory infarction. Neurosurgery. 2005, than 12 x 12 cm. The smaller the size, the 56, pp.681-692. higher the mortality rate (p < 0.0001). 7. Wolf-Dieter Heiss . Malignant MCA infarction: Pathophysiology and imaging for - Postoperative complications occurred early diagnosis and management decisions. in 15/75 cases (20%), of which: small Cerebrovasc Dis. 2016, 41, pp.1-7. bleeding scattered in the infarction area 8. Xiao Cheng Lu, Bao Sheng Huang et al . 2/75 (2.6%); incision infection 8/75 Decompressive craniectomy for the treatment (10.6%) - the most common complication; of malignant infarction of the middle cerebral local seizures 3/75 (4%) and cardiovascular artery. 2014. 205