Masih penasaran dengan salah satu perdebatan dalam morning report pagi itu. “Bisakah mempertimbangkan decompressive craniectomy pada kasus ICH?”
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Decompressive surgical evacuation of a space-occupying cerebellar infarction is effective in preventing and treating herniation and brain stem compression (Class I; Level of Evidence B). (Revised from the previous guideline)
Decompressive surgery for malignant edema of the cerebral hemisphere is effective and potentially lifesaving (Class I; Level of Evidence B). Advanced patient age and patient/family valuations of achievable outcome states may affect decisions regarding surgery. (Revised from the previous guideline)
[Guidelines for the Early Management of Patients With Acute Ischemic Stroke, AHA/ASA, 2013]
Buat malignant edema kasus stroke iskemik, decompressive craniectomy punya level of evidence 1B. Bagaimana rekomendasi prosedur ini pada kasus ICH?
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Baca-baca sekilas guideline ICH 2010, tampaknya belum ada rekomendasi tentang decompressive craniectomy.
Oke, kalo gitu kita review sekilas riset-riset decompressive craniectomy pada ICH.
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Surgical options in ICH including decompressive craniectomy.
Mitchell P, Gregson BA, Vindlacheruvu RR, Mendelow AD.
J Neurol Sci. 2007 Oct 15;261(1-2):89-98. Epub 2007 Jun 4.
Abstract
Intracerebral haemorrhage (ICH) accounts for 15 to 20% of strokes. The condition carries a higher morbidity and mortality than occlusive stroke. Despite considerable research effort, no therapeutic modality either medical or surgical has emerged with clear evidence of benefit other than in rare aneurysmal cases. Intracerebral haemorrhages can be divided into those that arise from pre-existing macroscopic vascular lesions – so called “ictohaemorrhagic lesions”, and those that do not; the latter being the commoner. Most of the research that has been done on the benefits of surgery has been in this latter group. Trial data available to date precludes a major benefit from surgical evacuation in a large proportion of cases however there are hypotheses of benefit still under investigation, specifically superficial lobar ICH treated by open surgical evacuation, deeper ICH treated with minimally invasive surgical techniques, and decompressive craniectomy. When an ICH arises from an ictohaemorrhagic lesion, therapy has two goals: to treat the effects of the acute haemorrhage and to prevent a recurrence. Three modalities are available for treating lesions to prevent recurrence: stereotactic radiosurgery, endovascular embolisation, and open surgical resection. As with ICH without an underlying lesion there is no evidence to support surgical removal of the haemorrhage in most cases. An important exception is ICHs arising from intracranial aneurysms where there is good evidence to support evacuation of the haematoma as well as repair of the aneurysm.
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Decompressive craniectomy in addition to hematoma evacuation improves mortality of patients with spontaneous basal ganglia hemorrhage.
Ma L, Liu WG, Sheng HS, Fan J, Hu WW, Chen JS.
J Stroke Cerebrovasc Dis. 2010 Jul-Aug;19(4):294-8.
Abstract
We conducted a retrospective study to assess the effect of decompressive craniectomy on outcome of patients with spontaneous basal ganglia hemorrhage (SBH). A review of a hospital database was performed to search for patients with a diagnosis of SBH who received hematoma evacuation with (N=38) or without (N=46) decompressive craniectomy in our institute from January 2005 to January 2008. Descriptive statistics revealed that patients in the decompressive craniectomy group were in poorer clinical condition before surgery. Unadjusted analyses found no significant difference between groups in either 30-day mortality or 6-month functional survival (32% v 43%, P=.26, and 55% v 45%, P=.28, respectively). However, after severity adjustment the multivariate logistic regression analysis showed that decompressive craniectomy group was associated with improved 30-day mortality (Exp (B) 0.11, 95% confidence interval 0.02-0.60, P=.01) and 6-month functional survival (Exp (B) 26.97, 95% confidence interval 2.20-317.62, P=.01). In conclusion, our study suggests decompressive craniectomy in addition to hematoma evacuation might improve mortality of deteriorating patients with SBH. Larger, randomized studies are needed to verify this result.
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Decompressive hemi-craniectomy is not necessary to rescue supratentorial hypertensive intracerebral hemorrhage patients: consecutive single-center experience.
Shimamura N, Munakata A, Naraoka M, Nakano T, Ohkuma H.
Acta Neurochir Suppl. 2011;111:415-9. doi: 10.1007/978-3-7091-0693-8_71.
Abstract
OBJECTIVE:
A consensus on decompressive surgery for hypertensive intracranial hemorrhage (ICH) has not been reached. We retrospectively analyzed our single-center experience with ICH.
MATERIAL AND METHODS:
From January 2004 to August 2009, 65 consecutive supratentorial ICH patients underwent surgery in our institute. Supratentorial ICHs that exhibited a hematoma volume of over 50 mL according to the xyz/2 method were included in this study. We compared a hematoma removal plus decompressive craniectomy group (DC) and a hematoma removal group (HR) with regard to GCS, preoperative hematoma volume, shift from the midline, time from the ictus to surgery, post-surgical hematoma volume, brain swelling, hospitalization periods, and m-RS after 3 months. Statistical analysis was done using the t-test or χ2 test, and the odds ratio was calculated.
RESULTS:
Twenty-five patients participated in this study. The DC group included 5 male patients, and the HR group 20 patients (F/M=8/12). Mean DC group age was 44.2 years, and 56.8 years for the HR group (p<0.05). GCS, preoperative hematoma volume, shift from the midline, time from the ictus to surgery, and postoperative hematoma volume were similar between both groups. Brain swelling on post-operative [corrected] CT was demonstrated to be mild and delimited within the cranium in the DC group, similar to the HR group. Hospitalization periods increased in the DC group (p<0.05). The m-RS after 3 months was similar for both groups. The factors relevant for m-RS were age, postoperative hematoma volume, and GCS at 24 h after surgery.
CONCLUSION:
Decompressive craniectomy is not necessary for rescue in ICH if the hematoma can be removed completely.
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Decompressive Hemicraniectomy in Patients With Supratentorial Intracerebral Hemorrhage
Christian Fung; Michael Murek; Werner J. Z’Graggen; Anna K. Krähenbühl; Oliver P. Gautschi; Philippe Schucht; Jan Gralla; Karl Schaller; Marcel Arnold; Urs Fischer; Heinrich P. Mattle; Andreas Raabe; Jürgen Beck
Stroke. 2012; 43: 3207-3211
Abstract
Background and Purpose—Decompressive craniectomy (DC) lowers intracranial pressure and improves outcome in patients with malignant middle cerebral artery stroke. Its usefulness in intracerebral hemorrhage (ICH) is unclear. The aim of this study was to analyze feasibility and safety of DC without clot evacuation in ICH.
Methods—We compared consecutive patients (November 2010–January 2012) with supratentorial ICH treated with DC without hematoma evacuation and matched controls treated by best medical treatment. DC measured at least 150mm and included opening of the dura. We analyzed clinical (age, sex, pathogenesis, Glasgow Coma Scale, National Institutes of Health Stroke Scale), radiological (signs of herniation, side and size of hematoma, midline shift, hematoma expansion, distance to surface), and surgical (time to and indication for surgery) characteristics. Outcome at 6 months was dichotomized into good (modified Rankin Scale 0–4) and poor (modified Rankin Scale 5–6).
Results—Twelve patients (median age 48 years; interquartile range 35–58) with ICH were treated by DC. Median hematoma volume was 61.3mL (interquartile range 37–83.5mL) and median preoperative Glasgow Coma Scale was 8 (interquartile range 4.3–10). Four patients showed signs of herniation. Nine patients had good and 3 had poor outcomes. Three patients (25%) of the treatment group died versus 8 of 15 (53%) of the control group. There were 3 manageable complications related to DC.
Conclusions—DC is feasible in patients with ICH. Based on this small cohort, DC may reduce mortality. Larger prospective cohorts are warranted to assess safety and efficacy.
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Retrospective Comparison of Craniotomy and Decompressive Craniectomy for Surgical Evacuation of Nontraumatic, Supratentorial Intracerebral Hemorrhage
Seth B. Hayes, M.D., Ronald J. Benveniste, M.D., Ph.D., Jacques J. Morcos, M.D., Mohammad A. Aziz-Sultan, M.D., Mohamed Samy Elhammady, M.D.
Neurosurg Focus. 2013;34(5):e3
Abstract
Surgical evacuation of nontraumatic, supratentorial intracerebral hemorrhage (SICH) is uncommonly performed, and outcomes are generally poor. On the basis of published experimental data and the authors’ anecdotal observations, a retrospective chart review study was performed to test the hypothesis that large decompressive craniectomies (DCs), compared with craniotomies, would improve clinical outcomes after surgical evacuation of SICH. For patients with putaminal SICH, DC was associated with a statistically significant improvement in midline shift, compared with craniotomy. Decompressive craniectomies also resulted in a strong trend toward decreased likelihood of poor neurological outcome (modified Rankin Scale score > 3). For patients with lobar SICH, no associations were found between DC or craniotomy and clinical outcomes. For patients selected to undergo surgical evacuation of putaminal SICH, a DC in addition to surgical evacuation of the hematoma might improve outcome.
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Decompressive Craniectomy with Hematoma Evacuation for Large Hemispheric Hypertensive Intracerebral Hemorrhage
Satoru Takeuchi, Yoshio Takasato, Hiroyuki Masaoka, Takanori Hayakawa, Hiroshi Yatsushige, Keigo Shigeta, Kimihiro Nagatani, Naoki Otani, Hiroshi Nawashiro, Katsuji Shima
Acta Neurochirurgica Supplement Volume 118, 2013, pp 277-279
Abstract
Hemispheric hypertensive intracerebral hemorrhage (ICH) has a high mortality rate. Decompressive craniectomy (DC) has generally been used for the treatment of severe traumatic brain injury, aneurysmal subarachnoid hemorrhage, and hemispheric cerebral infarction. However, the effect of DC on hemispheric hypertensive ICH is not well understood. To investigate the effects of DC for treating hemispheric hypertensive ICH, we retrospectively reviewed the clinical and radiological findings of 21 patients who underwent DC for hemispheric hypertensive ICH. Eleven of the patients were male and 10 were female, with an age range of 22–75 years (mean, 56.6 years). Their preoperative Glasgow Coma Scale scores ranged from 3 to 13 (mean, 6.9). The hematoma volumes ranged from 33.4 to 98.1 mL (mean, 74.2 mL), and the hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. Intraventricular extensions were observed in 11 patients. With regard to the complications after DC, postoperative hydrocephalus developed in ten patients, and meningitis was observed in three patients. Six patients had favorable outcomes and 15 had poor outcomes. The mortality rate was 10 %. A statistical analysis showed that the GCS score at admission was significantly higher in the favorable outcome group than that in the poor outcome group (P = 0.029). Our results suggest that DC with hematoma evacuation might be a useful surgical procedure for selected patients with large hemispheric hypertensive ICH.
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Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis
Simon G. Heuts, B.S., Samuel S. Bruce, M.A., Brad E. Zacharia, M.D., Zachary L. Hickman, M.D., Christopher P. Kellner, M.D., Eric S. Sussman, B.S., Michael M. McDowell, B.S., Rachel A. Bruce, B.A., and E. Sander Connolly Jr., M.D.
Neurosurgical Focus
May 2013 / Vol. 34 / No. 5 / Page E4
DOI: 10.3171/2013.2.FOCUS1326.
Abstract
OBJECT
Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions.
METHODS
From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution’s ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients’ characteristics and outcomes of treatment were prospectively collected.
RESULTS
The patients’ median age was 43 years (range 30–55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5–9). The median ICH volume was 53 cm3 (range 28–79 cm3), and the median midline shift was 7.6 mm (range 3.0–11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5–4.6 mm), and the median change in GCS score was +1 (range −3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9–11), the median modified Rankin Scale (mRS) score was 5 (range 5–5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17–27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4–5), and 2 were functionally independent (mRS Score 0–3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5–9, ICH volume 28–79 cm3, age < 60 years) whose cases were managed nonoperatively (n = 5).
CONCLUSIONS
Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.
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Anyway, masi perlu studi lebih banyak tentang apilkasi teknisnya. Misalnya tentang ini nih..
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Cranioplasty after Decompressive Craniectomy: The Effect of Timing on Postoperative Complications
Patrick Schuss, Hartmut Vatter, Gerhard Marquardt, Lioba Imöhl, Christian T. Ulrich, Volker Seifert, and Erdem Güresir.
Journal of Neurotrauma. April 10, 2012, 29(6): 1090-1095. doi:10.1089/neu.2011.2176.
Abstract
Decompressive craniectomy (DC) due to intractably elevated intracranial pressure mandates later cranioplasty (CP). However, the optimal timing of CP remains controversial. We therefore analyzed our prospectively conducted database concerning the timing of CP and associated post-operative complications. From October 1999 to August 2011, 280 cranioplasty procedures were performed at the authors’ institution. Patients were stratified into two groups according to the time from DC to cranioplasty (early, ≤2 months, and late, >2 months). Patient characteristics, timing of CP, and CP-related complications were analyzed. Overall CP was performed early in 19% and late in 81%. The overall complication rate was 16.4%. Complications after CP included epidural or subdural hematoma (6%), wound healing disturbance (5.7%), abscess (1.4%), hygroma (1.1%), cerebrospinal fluid fistula (1.1%), and other (1.1%). Patients who underwent early CP suffered significantly more often from complications compared to patients who underwent late CP (25.9% versus 14.2%; p=0.04). Patients with ventriculoperitoneal (VP) shunt had a significantly higher rate of complications after CP compared to patients without VP shunt (p=0.007). On multivariate analysis, early CP, the presence of a VP shunt, and intracerebral hemorrhage as underlying pathology for DC, were significant predictors of post-operative complications after CP. We provide detailed data on surgical timing and complications for cranioplasty after DC. The present data suggest that patients who undergo late CP might benefit from a lower complication rate. This might influence future surgical decision making regarding optimal timing of cranioplasty.
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Decompressive craniectomies, facts and fiction: a retrospective analysis of 526 cases
Fernanda Tagliaferri, Giulia Zani, Corrado Iaccarino, Salvatore Ferro, Lorenza Ridolfi, Nino Basaglia, Peter Hutchinson, Franco Servadei
Acta Neurochirurgica
May 2012, Volume 154, Issue 5, pp 919-926
Abstract
Background
The aim of this article was to review the clinical practice of “bone flap decompression” in Regional Neurosurgical Units with no particular protocol in use.
Methods
From January 2005 to December 2008, a retrospective and multicentre study was conducted on patients who were treated with decompressive craniectomy (DC) in seven departments of neurosurgery in Italy. This study included patients with traumatic brain injury, stroke, aneurysmal subarachnoid haemorrhage and cerebral arteriovenous malformations. Data were retrieved from individual medical records.
Results
We identified 526 patients with DC. Age was the most significant predictor factor of survival, together with pupil reactivity, time of decompression and size of the bone flap. The effect of age in predicting survival was so important that in patients over 65 years old we did not find any other significant factor related to survival. In younger patients, the survival rate was much better with a large bone flap (p = 0.01). Unfortunately, 57% of patients were decompressed with a bone flap of less than 12 cm in diameter. This was probably due to the association in 80% of cases between haematoma evacuation and decompression.
Conclusions
The current practice in many centres is different from published papers. Decompression is common over the age of 65 years, is associated with haematoma evacuation and often the bone flaps are inadequate in terms of size.
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Ventriculomegaly after decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage
Satoru Takeuchia, Hiroshi Nawashiroa, Kojiro Wadaa, Yoshio Takasatob, Hiroyuki Masaokab, Takanori Hayakawab, Kimihiro Nagatania, Naoki Otania, Hideo Osadaa, Katsuji Shimaa
Clinical Neurology and Neurosurgery
Volume 115, Issue 3, March 2013, Pages 317–322
Abstract
Objective
The aim of the present study was to investigate factors associated with the development of ventriculomegaly suggestive of hydrocephalus (VSOH) after decompressive craniectomy with hematoma evacuation for hemispheric hypertensive intracerebral hemorrhage.
Methods
This study focused on 21 patients who underwent decompressive craniectomy with hematoma evacuation for hemispheric hypertensive intracerebral hemorrhage. The patients’ clinical and radiological findings were retrospectively reviewed.
Results
Eleven patients were male and ten were female, with an age range from 22 to 75 years (mean, 56.6 years). The preoperative Glasgow Coma Scale score ranged from 3 to 13 (mean, 6.9). Hematoma volumes ranged from 33.4 to 98.1 ml (mean, 74.2 ml). Hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. The presence of intraventricular hemorrhage was significantly associated with the development of VSOH (P = 0.023). The distance of the decompressive defect to the midline and the presence of meningitis showed a strong trend for association with VSOH (P = 0.051, P = 0.090, respectively).
Conclusion
Careful attention should be paid to the occurrence of VSOH after decompressive craniectomy with hematoma evacuation in intracerebral hemorrhage patients with intraventricular extension, meningitis, and/or a short distance of the decompressive defect to the midline.
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Cerebral Blood Flow, Brain Tissue Oxygen, and Metabolic Effects of Decompressive Craniectomy
Christos Lazaridis, Marek Czosnyka
Neurocritical Care June 2012, Volume 16, Issue 3, pp 478-484
Abstract
Decompressive craniectomy (DC) is used for patients with traumatic brain injury (TBI), malignant edema from middle cerebral artery infarction, aneurysmal subarachnoid hemorrhage, and non-traumatic intracerebral or cerebellar hemorrhage. The objective of the procedure is to relieve intractable intracranial hypertension and/or to prevent or reverse cerebral herniation. Decompressive craniectomy has been shown to decrease mortality in selected patients with large hemispheric infarction and to control intracranial pressure in addition to improving pressure–volume compensatory reserve after TBI. The clinical effectiveness of DC in patients with TBI is under evaluation in ongoing randomized clinical trials. There are several unresolved controversies regarding optimal candidate selection, timing, technique, and post-operative management and complications. The nature and temporal progression of alterations in cerebral blood flow, brain tissue oxygen, and microdialysis markers have only recently been researched. Elucidating the pathophysiology of pressure-flow and cerebral hemodynamic consequences of DC could assist in optimizing clinical decision making and further defining the role of decompressive craniectomy.
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Btw, nemu istilah untuk komplikasi DC (khususnya berkaitan dengan kasus SAH, TBI, infark) yang namanya CAPECTH..? (haduh, kok susah disebut sih)
Craniectomy-associated Progressive Extra-Axial Collections with Treated Hydrocephalus (CAPECTH): redefining a common complication of decompressive craniectomy.
Nalbach SV, Ropper AE, Dunn IF, Gormley WB.
J Clin Neurosci. 2012 Sep;19(9):1222-7. doi: 10.1016/j.jocn.2012.01.016. Epub 2012 Jun 20.
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