Decompressive Hemicraniectomy for Space-occupying Cerebral Infarction

Abstract

The development of a space-occupying hemispheric infarction occurs in a subset of patients with ischaemic cerebrovascular stroke. It is a life-threatening condition with a high mortality rate of up to 80% with medical therapy alone. Previous retrospective and uncontrolled case series have suggested that decompressive hemicraniectomy can significantly reduce mortality to 20–30% compared to conservative treatment. This evidence has now been confirmed by the data of prospective randomised studies. The data also indicate that the reduction of mortality is not accompanied by an increase in the number of completely disabled patients. However, the number of disabled patients depending on the assistance of others increases significantly, and the patients and their caregivers need to be comprehensively informed about the long-term consequences prior to surgery. Furthermore, questions concerning the optimal time point for decompression and the upper age limit at which patients still benefit from surgery remain unanswered. Thus the indication for surgery is to a great extent still dependent on the individual situation of the patient and the experience of the treating physicians. This review covers the indications, the surgical technique, the prognostic factors and the clinical outcome with this procedure based on the data of retrospective series and the results of the recently published prospective randomised trials.

Zusammenfassung

Ein kleiner Teil der Patienten mit ischämischem Schlaganfall entwickelt im Verlauf der Erkrankung einen raumfordernden Infarkt. Es handelt sich um einen lebensbedrohlichen Zustand, der bei alleiniger medikamentöser Therapie mit einer hohen Letalität in bis zu 80% der Fälle einhergeht. Retrospektive und nicht kontrollierte Studien erbrachten Hinweise, dass durch die dekompressive Hemikraniektomie die Letalität im Vergleich zur konservativen Behandlung auf 20–30% gesenkt werden kann. Diese Daten werden nun durch die Ergebnisse prospektiv randomisierter Studien bestätigt. Diese Studien weisen auch darauf hin, dass die Reduktion der Letalität nicht mit einer Zunahme der Zahl komplett pflegebedürftiger Patienten einhergeht. Allerdings steigt die Zahl behinderter Patienten, die zumindest teilweise auf die Hilfe anderer Personen angewiesen sind, signifikant an. Deshalb sollten Patienten und ihre Angehörigen vor der Operation eingehend über die möglichen Folgen im Langzeitverlauf aufgeklärt werden. Ungeklärt bleiben der optimale Zeitpunkt für die Dekompression sowie das Alterslimit, bis zu dem ein deutlicher günstiger klinischer Verlauf bei den Patienten zu verzeichnen ist. Die Entscheidung zur Operation hängt daher weiterhin zu einem nicht unerheblichen Maß von der individuellen Situation des Patienten und der Erfahrung der behandelnden Ärzte ab. Die vorliegende Arbeit gibt einen Überblick über die Indikationsstellung, die chirurgische Technik, prognostische Faktoren und das klinische Ergebnis basierend auf den Daten retrospektiver Berichte sowie den Ergebnissen der kürzlich publizierten prospektiv randomisierten Studien.

Key words

decompressive craniectomy - brain oedema - ischaemic stroke - cerebral infarction

Schlüsselwörter

dekompressive Kraniektomie - Hirnödem - ischämischer Schlaganfall - zerebraler Infarkt

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