Article
Decompressive hemicraniectomy (DHC) for malignant cerebral infarction: Any change in the perioperative risk profile after systemic, local or mechanical recanalization treatment?
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Authors
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Walid Albanna
- Neurochirurgische Klinik, Universitätsklinikum der RWTH Aachen, Germany
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Mohamed Alzaiyani
- Neurochirurgische Klinik, Universitätsklinikum der RWTH Aachen, Germany
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Marc Brockmann
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum der RWTH Aachen, Germany
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Hans Clusmann
- Neurochirurgische Klinik, Universitätsklinikum der RWTH Aachen, Germany
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Johannes Schiefer
- Neurologische Klinik, Universitätsklinikum der RWTH Aachen, Germany
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Gerrit Schubert
- Neurochirurgische Klinik, Universitätsklinikum der RWTH Aachen, Germany
| Published: | June 8, 2016 |
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Outline
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Objective: New data advocates early mechanical recanalization in addition to intravenous or intraarterial lysis for acute, intracranial large vessel occlusion. For those few cases still requiring decompressive hemicraniectomy (DHC) for impending malignant cerebral infarction thereafter, the influence of presurgial recanalization treatment (lysis and/or thrombectomy) on the perioperative complication rate is unclear and is therefore the purpose of this study.
Method: A total of 82 patients (age 52.6 ± 10.3yrs) with complete clinical data sets undergoing DHC for malignant cerebral infarction between 2005 and 2015 were included for this retrospective analysis. With comparable demographic data (age, sex, GCS and NIHSS at admission), the following outcome parameters were analyzed after dichotomization for DHC with or without pre-surgical treatment (IV lysis, IA lysis, thrombectomy or combination of treatments): duration of surgery, intraoperative blood loss, transfusion requirement, any postoperative hemorrhage (any intracranial or subgaleal hyperdensity on postop CT), need for revision surgery and overall outcome (GOS) after three months.
Results: A total of 40 patients (48.8%) received pre-surgical treatment such as IV lysis, IA lysis, thrombectomy or a combination of treatments. When compared to patients without preceding treatment, there was no statistically significant difference in the need for preoperative reversal of coagulopathy or anticoagulation (52.5% vs 35.7%, ns), duration of surgery (101 ± 42mins vs 97.4 ± 37.2mins, ns), intraoperative blood loss (311 ± 120.4ml vs 341.9 ± 123.9ml, ns), intraoperative transfusion requirement (15% vs 23.8%, ns), postoperative hemorrhage (10% vs 11.9%, ns) or any need for revision surgery (12.5% vs 11.9%, ns). The rate of favourable outcome (GOS 4-5) after three months was also comparable (39.4% vs 24.2%, ns). A subgroup analysis showed that only patients receiving a combination of treatments (thrombectomy, and intraarterial and intravenous lysis) had a higher incidence of any hyperdensity in postop CT imaging (n=6, 66.7%, p<0.01).
Conclusions: Presurgical recanalization (lysis or thrombectomy) does not negatively affect the perioperative risk profile of decompressive hemicraniectomy for impending malignant stroke. Future studies will have to reevaluate and substantiate indications for DHC in view of the efficacy of recanalization, but this will not be limited by anticipated alterations in the surgical risk profile.
