DECOMPRESSIVE CRANIECTOMY IN MALIGNANT ISCHEMIC INFARCTION OF THE MIDDLE CEREBRAL ARTERY. CASE REPORT.pdf

- Decompressive craniectomy is a surgical removal of a considerable part of the cranial vault, associated with a durotomy of the exposed area, with the purpose of increasing the volume of the cranial continent, decrease intracranial pressure (ICP) and relieve mechanical compression secondary to the displacement of Brain
structures

1. DR. DAMIAN LASTRA COPELLO. SENIOR CONSULTANT NEUROSURGEON. MD.
EMERGENCY AND CRITICAL CARE FELLOWSHIP.
SPINE SURGERY AND NEURO-ONCOLOGY TRAINING . LECTURER. RESEARCHER.
MEDICAL SCIENCES UNIVERSITY SANTIAGO DE CUBAAND HAVANA UNIVERSITY. CUBA
SHARAB MEDICAL CENTER. BANJUL. GAMBIA.
DECOMPRESSIVE CRANIECTOMY IN
MALIGNANT ISCHEMIC INFARCTION OF THE
MIDDLE CEREBRAL ARTERY.CASE REPORT

2. “…EVERY PATIENT
PROVIDE TWO
QUESTIONS
—FIRSTLY WHAT CAN BE
LEARNT FROM HIM
AND SECONDLY
WHAT CAN BE DONE FOR
HIM…”
.
Harvey Cushing
In: Robert Coope, The Quiet Art (p. 103), E.S. Livingstone Ltd. Edinburgh, Scotland. 1952

3. CONCEPT:
-Malignant middle cerebral artery infarction is defined as the
sudden obstruction of cerebral blood flow in the irrigation territory
of the Middle Cerebral Artery (MCA) of ischemic-thrombotic
etiology and cardio-embolic etiology.

4. EPIDEMIOLOGY. MALIGNANT INFARCTION OF THE MIDDLE CEREBRAL ARTERY
Epidemiological study that includes both types of CVD (ischemic and
hemorrhagic) revealed an annual incidence per 100,000 inhabitants
of 218 and 127 for men and women respectively.
-The crude mortality reported at 28 days after stroke was 36%, with
mortality occurring outside the hospital setting in 62.5% of cases
. Until a few years ago, it was considered a fatal and untreatable
condition, since the mortality associated exceed 80%.
In this unfavorable context, decompressivehemicraniectomyhas re-
emerged as an effective therapeutic alternative in selected cases,
with a reported decrease in mortality of between 15-40%.

5. CRITICAL CONDITION
Progressive increase in cerebral edema
Increase in intracranial pressure
Decreased cerebral perfusion
Progressive degradation of consciousness and death
Is associated with HIGH MORBIDITY AND MORTALITY

6. CONCEPT:
-Decompressive craniectomyis a surgical removal of a
considerable part of the cranial vault, associated with a
durotomyof the exposed area, with the purpose of
increasing the volume of the cranial continent, decrease
intracranial pressure (ICP) and relieve mechanical
compression secondary to the displacement of Brain
structures

7. HISTORICALPERSPECTIVE
-There is evidence that the philosophers Hippocrates and Galen had indicated craniotomies
for patients with traumatic brain injury.
-Marcottein 1886 describes a technique of expansion of the dura mater.
-Spiller and Frazier CH in 1891 examined the procedures of cerebral decompression that
had been performed until then.
-Kocher T in 1901 makes references to its use for the control of intracranial pressure.
-Cushing H. in 1905 publishes the results obtained with sub-temporal craniotomy in patients
with intracranial hypertension secondary to brain tumors.
-https://www.researchgate.net/publication/334773062_CRANEOTOMIAS_DESCOMPRESIVAS_Monografia.Lacerda , Angel. 2019

8. TECHNICAL REQUIREMENTS TO ACHIEVE THE EFFECTIVENESS
OF THE PROCEDURE AND AVOID SECONDARY
COMPLICATIONS
-Its extension must be greater than 12 cm or
exceed the margins of the causal lesion.
-Should include the anterior and middle cranial base to avoid
herniationsthrough the free edge of the tentorium.
-It should be accompanied by a duralextension (duroplasty),
preferably with autologous tissue. (FASCIA LATA OF VASTUS
EXTERNIUM MUSCLE)

9. MOST COMMONLY PRACTICED
TYPES OF DECOMPRESSIVE
CRANIECTOMY
1.UNILATERAL HEMICRANIECTOMY
2.BIFRONTAL CRANIECTOMY ( TONNIS OR MODIFIED )
3.BILATERAL FRONTO -TEMPORO PARIETO -OCCIPITAL
DECOMPRESSIVE CRANIECTOMY
4.TRAUMA FLAP
OTHER
. HINGE CRANIOTOMY

10. MAIN INDICATIONS
-AS PART OF NEURO-INTENSIVE SURGICAL TREATMENT FOR
PATIENTS WITH SEVERE TBI AND INTRACRANIAL HYPERTENSION
SYNDROME
( PRIMARY OR SECONDARY DECOMPRESSIVE CRANIECTOMY )
-MALIGNANT INFARCTION OF THE MIDDLE CEREBRAL ARTERY
-SEVERE INTRACRANIAL HYPERTENSION SECONDARY TO MASS
EFFECT DUE TO SPACE -OCCUPYING LESION

11. SURGICAL CRITERIA
-Patients with Grade IV and VI -Marshall imaging classification.
-ICP greater than 25 mm Hg, refractory to first level Neuro-Intensive
treatment measures
-Age less than 65 years.
-GCS greater than 3 points at the time of patient admission
-DISPLACEMENT OF MIDLINE STRUCTURES GREATER THAN 5 MM

12. CASE PRESENTATION:
-45 YEARS OLD
-SUDDEN AND PROGRESSIVE DEGRADATION OF
CONSCIOUSNESS
-HE IS RECEIVED IN THE EMERGENCY ROOM WITH GCS 8/15
POINTS
-FONDUS EYE: -PAPILLARY EDEMA
-TOTAL AND PROPORTIONAL RIGHT HEMIPLEGIA
-MOTOR APHASIA
-POSITIVE BABINSKI SIGN (DUPREE FAN SIGN)
-BRADYCARDIA, HYPERTENSION AND RESPIRATORY
DIFFICULTY( CUSHING TRIAD)

13. NEURO-IMAGING STUDY
BRAIN MRI:
-AN AREA OF ISCHEMIC CEREBRAL INFARCTION IS OBSERVED IN THE RIGHT
HEMISPHERE THAT INVOLVES THE TERRITORY OF THE MIDDLE CEREBRAL
ARTERY WITH AN EXTENSIVE AREA OF ASSOCIATED CEREBRAL EDEMA THAT
COMPRESSES AND DISPLACES MIDLINE STRUCTURES MORE THAN 5 MM WITH
ERASURE OF THE SULCUS AND GYRUS OF THE BRAIN.

14. BRAIN MRI

15. •-A LEFT UNILATERAL FRONTO-TEMPORO-PARIETO-OCCIPITAL HEMICRANIECTOMY
WAS PERFORMED
•(10 x 12 cm)-(The patient's craniometrics allowed us to be less aggressive)
•-DUROPLASTY WITH FASCIA LATA OF THE VASTUS EXTERNIUM MUSCLE
•-MARSUPIALIZATION OF BONY FLAP IN THE LEFT LOWER LIMB
•-NEURO-INTENSIVE TREATMENT WAS CONTINUED, ACHIEVING THE REMOVAL OF THE
OROTRACHEAL TUBE FROM THE PATIENT 72 HOURS AFTER THE OPERATION AND
STOPPING INVASIVE MECHANICAL VENTILATION
•-THE BONE FLAP WAS REPOSITIONED 11 MONTHS AFTER FIRST SURGICAL PROCEDURE

16. POST-OPERATIVE IMAGES.
(TAKEN WITH THE CONSENT OF FAMILY MEMBERS)

17. DUROPLASTY

18. POST OPERATIVE MRI

19. RESULTS
•-REGRESSION OF SIGNS OF INTRACRANIAL HYPERTENSION
•-REGRESSION OF MOTOR DEFECT (HEMIPARESIA WITH PREDOMINANCE OF
THE BRACHIAL STRENGTH)
•-THE PATIENT BEGAN TO PRONOUNCE SOME WORDS (CONSCIOUS AND
ORIENTED)
•-GCS: 15/15 POINTS

22. THANK YOU

23. BIBLIOGRAPHIC REFERENCES.
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Years of Quality Life or Mere Existence?. Neurology India 71(2):p 272-277, Mar–Apr 2023. | DOI:
10.4103/0028-3886.37543
 https://www.researchgate.net/publication/334773062_CRANEOTOMIAS_DESCOMPRESIVAS_Monografia
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