Suboccipital Decompressive Craniectomy for Cerebellar Infarction

Suboccipital Decompressive Craniectomy for Cerebellar Infarction

Unlike the situation with supratentorial masses causing herniation, there are several reports of patients in a deep coma from direct brainstem compression who were operated upon quickly and made useful recovery.

Guidelines from the American Heart Association/Stroke Council’s Scientific Statement Oversight Committee from 2014 recommended suboccipital decompressive craniectomy (SDC) with dural expansion to be performed in deteriorating patients with cerebellar infarction failing maximal medical therapy 1).

However, no good-quality evidence is available to support this surgical practice, and the surgical timing and technique both remain controversial 2).

The evidence favoring suboccipital decompressive craniectomy in space-occupying cerebellar infarctions stems predominantly from retrospective, monocentric, uncontrolled studies. 3)

Criteria for patient selection and the timing of the operation are not yet established, although there are several reports that DSC is effective


For Suyama et al. early suboccipital decompressive craniectomy should be considered for treating cerebellar infarction in patients with GCS 13 or worse. A poor prognosis is inevitable in patients whose infarction is combined with other locations than the cerebellum but in those who already have obstructive hydrocephalus at the time of surgery 4).

The operation of choice is a suboccipital decompression to include enlargement of the foramen magnum. The dura is then opened and the cerebellar infarction tissue usually exudes “like toothpaste” and is easily aspirated. Avoid using ventricular drainage alone as this may cause upward cerebellar herniation and does not relieve the direct brainstem compression.


The patient is positioned prone on chest rolls with the head in a Mayfield head-holder or in a horseshoe headrest. Flex the neck to open the interspace between the occiput and posterior arch of C1. The shoulders is retracted inferiorly with adhesive tape. A midline skin incision from inion to ≈ C2 spinous process is made.

Open the dura in a “Y” shaped incision, and excise the triangular top flap.


Necrosectomy appears to be a suitable alternative, achieving comparable mortality and functional outcomes. Further trials are necessary to evaluate which surgical technique is more beneficial 5).

Suboccipital decompressive craniectomy (SDC) for cerebellar infarction has been traditionally performed with minimal high-quality evidence. The aim of a systematic review and meta-analysis from the UBC HospitalVancouver, was to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients with cerebellar infarctions.

systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalysesguidelines. The primary outcome was the proportion of patients with a moderate-severe disability after SDC. Secondary outcomes included mortality and adverse events. A sensitivity analysis was conducted to examine the roles of age, preoperative neurologic status, external ventricular drain insertion, and debridement of infarcted tissue on SDC outcomes.

Eleven studies (with 283 patients) met the inclusion criteria. The pooled event rate for moderate-severe disability was 28% (95% confidence interval [CI], 20%-37%) and for mortality, it was 20% (95% CI, 12%-31%). The estimated overall rate of adverse events for SDC was 23% (95% CI, 14%-35%).Sensitivity analysis found less mortality with mean age <60 years, higher rates of concomitant external ventricular drain insertion, and debridement of infarcted tissue. Several factors were identified for heterogeneity between studies, including follow-up time, outcomes scale, extent of infarction, and other neuroimaging features.

The best available evidence for SDC is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes 6).

Cerebellar infarction and associated brain edema due to brainstem compression or obstructive hydrocephalus cause consciousness disturbance. In such cases, the mortality rate is reported to be 84% 7) when decompressive suboccipital craniectomy (DSC) is not performed


The best available evidence for Suboccipital Decompressive Craniectomy is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes 8).


A poor prognosis is inevitable in patients whose infarction is combined with other locations than the cerebellum but in those who already have obstructive hydrocephalus at the time of surgery 9).


Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome 10).


Favorable clinical outcomes including overall survival can be expected after preventive Suboccipital Decompressive Craniectomy in patients with a volume ratio between 0.25 and 0.33 and the absence of brainstem infarction. Among these patients, preventive Suboccipital Decompressive Craniectomy might be better than the best medical treatment alone 11).

Suboccipital Decompressive Craniectomy for Cerebellar infarction Case series.

Suboccipital Decompressive Craniectomy for Cerebellar Infarction Case reports.


1)

Wijdicks EF, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M; American Heart Association Stroke Council. Recommendations for the management of cerebral and Cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Apr;45(4):1222-38. doi: 10.1161/01.str.0000441965.15164.d6. Epub 2014 Jan 30. PubMed PMID: 24481970.
2) , 5)

Hernández-Durán S, Wolfert C, Rohde V, Mielke D. Cerebellar Necrosectomy Instead of Suboccipital Decompression: A Suitable Alternative for Patients with Space-Occupying Cerebellar Infarction. World Neurosurg. 2020 Dec;144:e723-e733. doi: 10.1016/j.wneu.2020.09.067. Epub 2020 Sep 22. PMID: 32977029.
3)

Neugebauer H, Witsch J, Zweckberger K, Jüttler E. Space-occupying Cerebellar infarction: complications, treatment, and outcome. Neurosurg Focus. 2013 May;34(5):E8. doi: 10.3171/2013.2.FOCUS12363. PMID: 23634927.
4) , 9)

Suyama Y, Wakabayashi S, Aihara H, Ebiko Y, Kajikawa H, Nakahara I. Evaluation of clinical significance of decompressive suboccipital craniectomy on the prognosis of Cerebellar infarction. Fujita Med J. 2019;5(1):21-24. doi: 10.20407/fmj.2018-010. Epub 2018 Dec 6. PMID: 35111496; PMCID: PMC8766232.
6)

Ayling OGS, Alotaibi NM, Wang JZ, Fatehi M, Ibrahim GM, Benavente O, Field TS, Gooderham PA, Macdonald RL. Suboccipital Decompressive Craniectomy for Cerebellar infarction: A Systematic Review and Meta-Analysis. World Neurosurg. 2018 Feb;110:450-459.e5. doi: 10.1016/j.wneu.2017.10.144. Epub 2017 Dec 2. PMID: 29104155.
7)

Feely MP. Cerebellar infarction. Neurosurgery. 1979 Jan;4(1):7-11. doi: 10.1227/00006123-197901000-00003. PMID: 450221.
8)

Ayling OGS, Alotaibi NM, Wang JZ, Fatehi M, Ibrahim GM, Benavente O, Field TS, Gooderham PA, Macdonald RL. Suboccipital Decompressive Craniectomy for Cerebellar infarction: A Systematic Review and Meta-Analysis. World Neurosurg. 2018 Feb;110:450-459.e5. doi: 10.1016/j.wneu.2017.10.144. Epub 2017 Dec 2. PMID: 29104155.
10)

Lindeskog D, Lilja-Cyron A, Kelsen J, Juhler M. Long-term functional outcome after decompressive suboccipital craniectomy for space-occupying cerebellar infarction. Clin Neurol Neurosurg. 2018 Dec 1;176:47-52. doi: 10.1016/j.clineuro.2018.11.023. [Epub ahead of print] PubMed PMID: 30522035.
11)

Kim MJ, Park SK, Song J, Oh SY, Lim YC, Sim SY, Shin YS, Chung J. Preventive Suboccipital Decompressive Craniectomy for Cerebellar infarction: A Retrospective-Matched Case-Control Study. Stroke. 2016 Oct;47(10):2565-73. doi: 10.1161/STROKEAHA.116.014078. Epub 2016 Sep 8. PMID: 27608818.

Malignant middle cerebral artery territory infarction

Malignant middle cerebral artery territory infarction

The malignant middle cerebral artery territory infarction is a distinct syndrome that occurs in up to 10% of stroke patients, 1) 2) which carries a mortality of up to 80% (mostly due to severe postischemic cerebral edema → increased ICP → herniation 3)

Patients usually present with findings of severe hemispheric stroke (hemiplegia, forced eye and head deviation) often with CT findings of major infarct within the first 12 hours. Most develop drowsiness shortly after admission. There is progressive deterioration during the first 2 days, and subsequent transtentorial herniation usually within 2–4 days of stroke. Fatalities are often associated with: severe drowsiness, dense hemiplegia, age > 45–50 yrs, 4) early parenchymal hypodensity involving > 50% of the MCA distribution on CT scan,23 midline shift > 8–10 mm, early sulci effacement, and hyperdense artery sign (p. 1354) 5) in MCA. Neurosurgeons may become involved in caring for these patients because aggressive therapies in these patients may reduce morbidity and mortality. Options include:

  1. conventional measures to control ICP (with or without ICP monitor): mortality is still high in this group and elevated ICP is not a common cause of initial neurologic deterioration in large hemispheric stroke

2. hemicraniectomy (decompressive craniectomy):

  1. ✖ to date, the following treatments have not improved outcome: agents to lyse clot, hyperventilationmannitol, or barbiturate coma.

In patients with severe middle cerebral artery (MCA), intracranial atherosclerotic disease (ICAD), the mechanism of stroke is multifactorial, but hemodynamic insufficiency plays a significant role. This finding is important in selecting a subgroup of patients who may benefit from revascularization 6).

see Malignant middle cerebral artery syndrome.

Malignant middle cerebral artery territory infarction diagnosis.

Malignant middle cerebral artery territory infarction treatment.

Malignant middle cerebral artery territory infarction outcome.

A case of a child with serological evidence of SARS-CoV-2 infection whose onset was a massive right cerebral artery ischemia that led to a malignant cerebral infarction. The patient underwent a life-saving decompressive hemicraniectomy, with good functional recovery, except for residual hemiplegia. During rehabilitation, the patient also developed a lower extremity peripheral nerve neuropathy, likely related to a long-Covid syndrome 7).


A 39-year-old woman in the 24th week of pregnancy who suffered a right malignant MCA infarction that eventually required DC. The patient delivered a healthy baby and underwent a second surgery for cranioplasty 7 months later. 8).


1)

Moulin DE, Lo R, Chiang J, et al. Prognosis in Middle Cerebral Artery Occlusion. Stroke. 1985;16:282–284
2) , 3)

Hacke W, Schwab S, Horn M, et al. Malignant Middle Cerebral Artery Territory Infarction: Clinical Course and Prognostic Signs. Arch Neurol. 1996; 53:309–315
4) , 5)

Wijdicks EFM, Diringer MN. Middle Cerebral Artery Territory Infarction and Early Brain Swelling: Progression and Effect of Age on Outcome. Mayo Clin Proc. 1998; 73:829–836
6)

Dubow JS, Salamon E, Greenberg E, Patsalides A. Mechanism of Acute Ischemic Stroke in Patients with Severe Middle Cerebral Artery Atherosclerotic Disease. J Stroke Cerebrovasc Dis. 2014 Jan 11. pii: S1052-3057(13)00425-4. doi: 10.1016/j.jstrokecerebrovasdis.2013.10.015. [Epub ahead of print] PubMed PMID: 24424333.
7)

Scala MR, Spennato P, Cicala D, Piccolo V, Varone A, Cinalli G. Malignant cerebral infarction associated with COVID-19 in a child. Childs Nerv Syst. 2021 Jun 26. doi: 10.1007/s00381-021-05273-x. Epub ahead of print. PMID: 34175976.
8)

Fernández García A, Jiménez Zapata HD, de Lera Alfonso MC, Sánchez Fernández C, Jiménez Arribas P, Rodríguez Arias CA. Decompressive Craniectomy in Pregnant Women. J Neurol Surg A Cent Eur Neurosurg. 2021 Jun 2. doi: 10.1055/s-0041-1726108. Epub ahead of print. PMID: 34077979.

Malignant middle cerebral artery infarction outcome

Malignant middle cerebral artery infarction outcome

Malignant middle cerebral artery infarction is associated with high mortality and morbidity.

The mortality rate of patients with brain edema after malignant middle cerebral artery (MCA) infarction approaches 80 % without surgical intervention 1).

Over the past 10 years in Francedecompressive craniectomy (DC) has been increasingly performed for malignant middle cerebral artery infarction (MCI) regardless of age. However, in-hospital mortality remains considerable, as about one-quarter of patients died within the first weeks. For those who survive beyond 6 months, the risk of death significantly decreases. Early mortality is especially high for comatose patients above 60 years operated in inexperienced centers. Most of those who remain in good functional status tend to undergo a cranioplasty within the year following DC 2).


Three separate studies investigated the effectiveness of decompressive craniectomy after malignant MCA infarction in controlled trials with patients less than 61 years of age 3) 4) 5). These were demonstrated that hemicraniectomy reduced the mortality rate by 49% at one year after stroke when compared with conventional medical treatments. However, the question of how applicable the results are to patients older than 60 years of age still remains unanswered.

When neurosurgeons recommend decompressive surgery for patients with malignant infarcts, patients’ relatives often refuse the operation because of the patients’ age, past medical history or comorbidity. Such a situation occurs more frequently when the patient is older than 70 years of age 6).

References

1)

Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009; 8:949–958.
2)

Champeaux C, Weller J. Long-Term Survival After Decompressive Craniectomy for Malignant Brain Infarction: A 10-Year Nationwide Study. Neurocrit Care. 2019 Jul 9. doi: 10.1007/s12028-019-00774-9. [Epub ahead of print] PubMed PMID: 31290068.
3)

Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, 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. Lancet Neurol. 2009 Apr;8(4):326–333.
4)

Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007 Sep;38(9):2518–2525.
5)

Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial) Stroke. 2007 Sep;38(9):2506–2517.
6)

Yu JW, Choi JH, Kim DH, Cha JK, Huh JT. Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 70 years old. J Cerebrovasc Endovasc Neurosurg. 2012 Jun;14(2):65-74. doi: 10.7461/jcen.2012.14.2.65. Epub 2012 Jun 30. PubMed PMID: 23210030; PubMed Central PMCID: PMC3471258.
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