Decompressive craniotomy at patients with malignant course of massive ischemic stroke

Objective. To conduct the comparative efficacy analysis of conservative and surgical treatment of patients with malignant course of massive ischemic stroke Material and methods. The analysis of examination and treatment results of 63 patients with malignant course of massive ischemic stroke was performed. All patients had midline shift more than 7 mm in first 48 hours from disease beginning. All patients were divided into two groups: 1st group - conservative treatment (42 patients) and 2d group - patients with decompressive craniotomy (12 patients - intracranial pressure (ICP) monitoring). Results. The lethality among patients of 1st group was 100% comparing with 48% among patients of 2d group (p<0,05). The 3 types of ICP hemodynamics at operated patients (with ICP monitoring) were determined: 1. Normal ICP without any requirements for correction - 1 type; 2. Progressive increase of ICP up to 20 mmHg and more, which is manageable by conservative therapy - 2 type; 3. Progressive increase of ICP up to 20 mmHg and more with development of refractory intracranial hypertension - 3 type. Conclusion. The surgical treatment (decompressive trepanation) at patients with malignant course of massive ischemic stroke with midline shift more than 7 mm during first 48 hours since disease beginning is accompanied by more than 2-fold lethality decrease. The ICP monitoring at such patients after decompressive craniotomy performing allows diagnosing intracranial hypertension and determing of its treatment strategy.

массивный ишемический инсульт, внутричерепное давление, внутричерепная гипертензия, декомпрессивная краниотомия, massive ischemic stroke, intracranial pressure, intracranial hypertension, decompressive craniotomy

1. Гусев Е.И., Скворцова В.И. Ишемия головного мозга: монография. М.: Медицина, 2001. - С. 12-13., С.105-112.

2. Крылов В.В., Никитин А.С., Буров С.А. и др. Декомпрессивная краниотомия в комплексе интенсивной терапии злокачественных форм массивного ишемического инсульта // Журнал неврологии и психиатрии. - 2013. - № 1. - С. 15-22.

3. Крылов В.В., Талыпов А.Э., Пурас Ю.В. Выбор трепанации в хирургии тяжелой черепно-мозговой травмы // Вопросы нейрохирургии им. Н.Н. Бурденко. - 2007. - № 1. - С.11-16.

4. Пурас Ю.В., Талыпов А.Э., Крылов В.В. Декомпрессивная трепанация черепа в раннем периоде тяжелой черепномозговой травмы // Нейрохирургия. - 2011. - № 3. - С. 19-27.

5. Пурас Ю.В., Талыпов А.Э., Ховрин Д.В., Крылов В.В. Селективная микрохирургическая резекция височной доли при хирургическом лечении дислокационного синдрома у пострадавших с тяжелой черепно-мозговой травмой // Нейрохирургия. - 2012. - № 2. - С. 43-51.

6. Adams J., Graham D. Twelve cases of fatal cerebral infarction due to arterial occlusion in the absence of atheromatous stenosis or embolism // J Neurol Neurosurg Psychiatry. - 1967. - Vol. 30. - P. 479-488.

7. Berrouschot J. et al. Mortality of space-occupying (‘malignant’) middle cerebral artery infarction under conservative intensive care // Intensive Care Med. - 1998. - Vol. 24(6) - P. 620-623.

8. Berry R., Alpers B. Occlusion of the carotid circulation: pathologic considerations // Neurology. - 1957. - Vol. 7. - P. 223-237.

9. Bounds J. et al. Mechanisms and timing of deaths from cerebral infarction // Stroke. - 1981. - Vol. - 12. - P. 474-477.

10. Brown M., Glassenberg M. Mortality factors in patients with acute stroke // JAMA. - 1973. - Vol.224. - P. 14931495.

11. Bruce D., Hurtig H. Incidence, course, and significance of cerebral edema associated with cerebral infarction // Cerebrovasc Dis. - 1979. - Vol. 11. - P. 191-198.

12. Cho D., Chen T., Lee H. Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction //. Surg Neurol. - 2003. - Vol.60(3). - P. 227-232.

13. Dohmen C. et al. Identification and clinical impact of impaired cerebrovascular autoregulation in patients with malignant middle cerebral artery infarction // Stroke. - 2007. - Vol. 38. - P. 56-61.

14. Hofmeijer J., Kappelle L., Algra A. et al. Surgical decompression for space-occupying cerebral infarction (the hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial [HAMLET]): a multicentre, open, randomised trial // The Lancet Neurology. - 2009. - Vol. 8. - P. 326-333.

15. Jüttler E. et al. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY) a randomized, controlled trial // Stroke. - 2007. - Vol. 38 - P. 2518.

16. Mitchell P. et al. Reassessment of the HAMLET study // The Lancet Neurology. - 2009. - Vol. 8. - P. 602 - 603.

17. Ng L., Nimmannitya J. Massive cerebral infarction with severe brain swelling: a clinicopathological study // Stroke. - 1970. - Vol. 1. - P. 158-163.

18. Shaw C., Alvord E., Berry R. Swelling of the brain following ischemic infarction with arterial occlusion // Arch Neurol. - 1959. - Vol. 1. - P. 161-177.

19. Subramaniam S. Decompressive hemicraniectomy for malignant middle cerebral artery infarction // The Neurologist. - 2009. - Vol.15. - P. 178-184.

20. Vahedi K. et al. DECIMAL, DESTINY, and HAMLET investigators Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials // Lancet Neurol. - 2007. - Vol. 6(3). - P. 215-22.

21. Vahedi K. et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial) // Stroke. - 2007. - Vol. 38(9). - P. 2506-2517.